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How caring assessment is learnt –

reflective writing on the examination
of Specialist Ambulance Nurses in
Sweden
Birgitta Wireklint Sundström a & Margaretha Ekebergh b

a
School of Health Sciences, Research Centre PreHospen ,
University of Borås,The Prehospital Research Centre of Western
Sweden , Sweden
b
School of Health Sciences , University of Borås , Sweden
Published online: 30 Oct 2012.

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

To link to this article: http://dx.doi.org/10.1080/14623943.2012.732944

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

How caring assessment is learnt – reflective writing on the

examination of Specialist Ambulance Nurses in Sweden
Birgitta Wireklint Sundströma* and Margaretha Ekeberghb
a
School of Health Sciences, Research Centre PreHospen, University of Borås,The
Prehospital Research Centre of Western Sweden, Sweden; bSchool of Health Sciences,
University of Borås, Sweden

This paper presents a research study that aims to describe and analyse how car-
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ing assessment is learnt in the Specialist Nursing, Prehospital Care Programme

for educating specialist ambulance nurses. The study is based on a contextual
and didactic model for learning. The focus was on the final course, Prehospital
Emergency Care, with clinical studies and clinical practice amounting to 15
credits, plus one of two theoretical examinations. We are testing the model to
explore what characterises the students’ learning when the model is applied.
The informants were 37 students (registered nurses). Written data from all 37
examinations were analysed by means of the phenomenological Reflective life-
world research approach. The results stress the significance of a didactic model
constructed according to the specific circumstances prevailing in the learning
context. With the help of the model an attitude of reflective awareness is
adopted, showing that knowledge in caring science and medical science are
equally valuable and, are applied simultaneously. Furthermore, the model gener-
ates knowledge that underlines the significance of the encounter with the patient
in the care-giving context of the prehospital environment, in order for the
student to be able to develop understanding and to learn caring assessment in
prehospital emergency care. Thus the result reveals that it is the encounter with
the patient that is most effective for the student’s learning process.
Keywords: didactic model; reflections; reflective awareness; specialist
ambulance nurses; nursing training

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

*Corresponding author. Email: birgitta.wireklint.sundstrom@hb.se

© 2012 Taylor & Francis

 272 B. Wireklint Sundström and M. Ekebergh

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

Credits

Courses Theory/practice Credits

Caring
Science,
40 credits
Caring Assessment in Prehospital Theoretical studies 10
Emergency Care
Prehospital Emergency Care Clinical studies and 15
clinical practice
Master’s Degree Project, Prehospital 15
Care

Medical
Science,
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20 credits
Emergency Theoretical 12
Medicine studies
Prehospital Care of patients with Theoretical and clinical 8
Trauma studies

addition, this programme can be complemented with a further year’s study resulting
in a two-year Master’s Degree in the subject.
Specialist ambulance nurses constitute a rather new profession in the Swedish
Emergency Medical Services (EMS), and the discipline of Prehospital Emergency
Care is becoming established and recognised as an important part of the patient’s
total care (Suserud, 2005; Wireklint Sundström & Dahlberg, 2011). Many studies
have focused on resuscitation skills and out-of-hospital survival (Axelsson,
Axelsson, Svensson, & Herlitz, 2007; Berdowski et al., 2011; Shin, Ahn, Song,
Park, & Lee, 2011). However, very little attention has been paid to how specialist
ambulance nurses learn to integrate a caring science approach with all the medical
knowledge needed in everyday work in prehospital emergency practice. This
question is of crucial importance in the EMS where there is a movement towards a
more flexible guidelines approach involving reflective practice, and away from the
traditional approach of training for and following strict protocols.
This paper presents a research study that is carried out within a caring science
approach (Dahlberg & Segesten, 2010) and aims to describe and analyse how
caring assessment is learnt in the Specialist Nursing, Prehospital Care Programme.

The process of learning caring assessment

The specialist ambulance nurse needs a broad knowledge base and skills to apply
to the care of patients in different settings (Suserud, 2005) with support from both
caring science and medical science. That the two perspectives should complement
each other is stressed by Wireklint Sundström and Dahlberg (2011). It has been
shown that care-givers’ openness to patients’ lifeworlds is an essential part of
assessment in prehospital emergency care. Assessments that are based on an
encounter and dialogue between patient and care-giver are characterised by inviting
the patient to participate. This approach is caring assessment which adds further
dimensions to the objective data. The inclusion of the patient perspective relieves
 Reflective Practice 273

suffering and leads to greater accuracy and safety in decision-making. Compared

with the work of paramedics this everyday work has been described as unrecogn-
ised and silent until Campeau (2008) developed the space-control theory and
described how paramedics establish social control at a scene through interaction.
Hubble, Paschal and Sanders (2000) wrote that looking for the best solution for
patient’s care needs is one of paramedics’ skills of practicing. However, the issue is
still how students can learn this caring science approach.
Thus, it is unclear how the students’ academic and clinical learning in prepara-
tion for specialist nursing in the EMS can best be achieved. The difficulty is to
know what kind of support they need for this learning. The process of learning
caring assessment in prehospital emergency care is preceded by giving the student
the opportunity of problematising the information from the emergency medical dis-
patch centre. Problematisation involves a discussion between the student and her/his
supervisor concerning what the assignment may bring with it, before meeting the
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patient. After the assignment has been completed, the student can evaluate her/his
newly acquired knowledge in relation to the assignment and its actual results. The
supervisor’s experience thus meets the student’s less experienced lifeworld.
Reflection is frequently mentioned as a complement to protocols, and guidelines
(Jones, 2008) and Ekebergh (2009) underline the necessity of recognising the stu-
dents’ lifeworlds in the supervision process. Gustafsson, Asp and Fagerberg (2007),
in their meta-synthesis study of qualitative research in nursing, conclude that
assumptions about reflective practice are predominantly based on theory. However,
there is still a demand for conceptualising reflective practice in clinical contexts
(Gustafsson et al., 2007) based on the urgent requirement for discipline-specific
research (Jones, 2008; Campeau, 2008; Wireklint Sundström & Dahlberg, 2011).
Jones (2008) highlights the need of adapting programmes for paramedic students
to the right educational level and to have a clear conceptual and contextual focus
for reflective practice. The lack of critical thinking has been demonstrated, and also
that paramedic students emphasise ‘technical reflection’ grounded in practical prob-
lem-solving. These results agree with Wireklint Sundström (2005) on EMS, and
also with Elmqvist, Brunt, Fridlund and Ekebergh (2009) using the concept of
‘doing’ when describing care in acute contexts, that should be understood as
carrying out a systematic course of actions. We underline the risk that the patients’
lifeworlds can be forgotten in practice with such a treatment-orientated approach.
Therefore studies are lacking on how the integration of the caring science approach
in the area of Specialist Nursing could be developed and learnt. Consequently we
call for didactic research focusing on reflective practice for continuing professional
development in the EMS with increased requirements for reflective thinking and
decisions when it comes to the care of individual patients. Ekebergh (2007) wrote
that the lifeworld perspective allows a new and deeper understanding of the role of
reflection in nursing students’ learning processes and also in students’ abilities to
integrate caring with caring practice.
A previous study (Wireklint Sundström, 2005) based on Ekebergh (2001)
presents a didactic model for the EMS, which is intended for the supervision of stu-
dents at different educational levels, both for RN and paramedics, during clinical
studies. In this model both students and other care-givers are seen as learning
persons, i.e. they are under constant and continuous development and therefore
“growing”. As its starting point, the didactic1 model takes the prehospital care
 274 B. Wireklint Sundström and M. Ekebergh

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

The didactic model for prehospital emergency care

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

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

medical knowledge.

Caring science constitutes the basis of the didactic model. Thus supervision and
other teaching activities take as their starting-point an approach where the patient is
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always understood to be an integrated part of the whole caring context. Caring

science clarifies for that reason how prehospital emergency care and its didactics
can develop, grounded in a patient perspective that recognises an interdependence
of caring science knowledge with medical knowledge.

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

In order for students to be able to assimilate the knowledge that is needed to carry
out prehospital emergency care, it is necessary for the supervision to emphasise
reflection and its importance for preparing the encounter with the patient’s individ-
ual care needs. The overall purpose of reflection is to prepare for keeping an open
mind in the face of the unknown and the uncertain, in each new assignment. The
aim of didactics in this respect is to guide the student towards an attitude involving
never really knowing what the next assignment or care situation will be like, which
is the actual situation for care-givers in the EMS.

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

To be able to relate to prehospital emergency care in a didactic way also entails rec-
ognising a highly variable caring context that leaves the care-giver with a sense of
vulnerability. The didactics must therefore include the care-giver’s need to create a
sense of temporary stability and control in the mobile care given in the EMS where
the care-giver also has to create his/her own care environment and make space for
caring on each occasion. Didactics that give prominence to flexibility can help to
clarify but also problematise the tension that exists between being sensitive to what
is unique and for example using standardised assessment forms.
The present study is based on this contextual and didactic model (Figure 1). We
are testing the model in the Specialist Nursing, Prehospital Emergency Care
Programme to explore what characterises the students’ learning when the model is
applied. The research questions were as follows:

• How are students learning caring assessment?

• How is their learning process formed?
• What characterises their reflection?
 Reflective Practice 275
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Figure 1. The overall research question to explore students’ learning process in prehospital
emergency care when the didactic model presented in the form of three didactic ideas is
applied.

Methods
This study design is based on a reflective lifeworld approach within the caring sci-
ence context (Dahlberg, Dahlberg, & Nyström, 2008; Dahlberg, Todres, & Galvin,
2009) and reflective practice in nursing education (Ekebergh, 2007; 2009).
Reflective lifeworld research (RLR) is characterised by its search for meaning. In
order to make this approach possible we need to adopt a reflective stance to our
usual attitudes and things we take for granted in everyday life, i.e. the EMS in rela-
tion to the learning process, and describe the phenomenon as it is experienced. The
phenomenon referred to is how the students experience the learning of caring
assessment with its focus on the ability to meet the patient in need of prehospital
emergency care.
The method refers to Husserl’s philosophy (1973) and is founded on his concept
of lifeworld theory. The starting-point of the method is a lifeworld-based under-
standing (Gadamer, 1995). This approach meets the criterion of studying students’
learning processes with openness and flexibility, based on the students’ own
experiences.

Setting and sample

The study was carried out at the School of Health Sciences, a University in Western
Sweden, as part of the year 2008 programme in Specialist Nursing, Prehospital
Care, for educating specialist ambulance nurses. The focus was on the final course,
Prehospital Emergency Care, with clinical studies and clinical practice amounting to
15 credits, plus one of two theoretical examinations.
The first author is supervising in Master’s Degree Projects and the second author
is teaching in Caring Science theory. Both authors are also registered nurses but
neither of them has been working in the EMS. The pre-understanding was due to
further research that points out that there could be difficulties in the integration of
the caring science approach in emergency oriented settings.
 276 B. Wireklint Sundström and M. Ekebergh

Examination in Prehospital Emergency Care, clinical studies and clinical

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

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

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

How did this contribute to your possibility to meet the patient’s and next-of-kin’s
care needs?
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(b) Give examples of situations when learning was hampered on account of your
being unprepared and not having had time to reflect on the situation
(Didactic idea 2)!

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

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

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

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

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

Sex
Male 22
Female 15

Age
Average age = 34 years old
24–34 years old 24
35–45 10
46–55 3
 Reflective Practice 277

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

Data collection
Approximately ten weeks were allowed between the day the students received their
examination papers and the day that they had to hand in their papers. The two
course teachers, neither of them one of the authors of this paper, assessed the indi-
vidual examinations. After completing their assessments and informing the students
of the results, the students were offered the opportunity of refusing to participate in
the study, which nobody did. The papers were then handed over to the first author.
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Data analysis
Written data from all 37 examinations was analysed by the phenomenological RLR
approach (Dahlberg et al., 2008). Such data analyses are characterised by a tripartite
structure and described as a movement between whole–parts–whole. They entail
understanding the data as a whole, then dividing it into parts before returning to a
new whole. In order to be able to do this the researcher has to move between
different abstract levels during the process of analysis. The analysis can thus be
seen as a process of understanding with a movement between different abstract
levels, instead of an analysis in separate stages.
By an ongoing dialogue throughout the data analyses both researchers main-
tained a dialectical process with a sensitive and reflective stance and tried to be as
open as possible in order to understand something that was completely new, which
means that tradition as well as pre-understanding became challenged. The decisions
of the meaning changed a lot through the process of analysis. The first author made
the first drafts and the second author read and gave suggestions of changes. During
meetings we then discussed ‘faithfulness’ to the data as well as depth of
understanding in relationship to the phenomenon (Dahlberg et al., 2008).
Data from the examinations was read several times by both researchers so that
all data were considered as ‘a whole’. Subsequently, the search for meanings began.
We moved back and forth between the parts and the whole in order to uncover
similarities and discrepancies in the data and we were able to identify clusters of
meaning. These clusters could be seen as themes describing how caring assessment
is learnt.
Each of the five themes has its own characteristics with a distinctive meaning in
relation to the others. Thus, each theme can be seen as ‘isolated’ in order to present
prominent learning features. However, at the same time the learning process is a
complex phenomenon and the meanings from the five themes overlap.
The learning process of caring assessment manifests itself in different ways and
our findings consist of the following themes of meaning: 1. The learning process is
challenged by care inadequacies; 2. The learning process goes through participation
in caring; 3. The learning process is in close relationship with the patient; 4. The
learning process is influenced of the unpredictable caring encounter; 5. The learning
process relies on support from the supervisor. We have included quotations from the
examinations in order to illustrate the meaning with individual students’ reflections.
 278 B. Wireklint Sundström and M. Ekebergh

When we use the term ‘students’ we are referring to RN undergoing education

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

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

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

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

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

The learning challenge is also described as containing feelings of inadequacy in rela-

tion to treatment, when the ambulance nurse cannot help patients in need of care
despite doing everything that the treatment guidelines permit, e.g. in connection with
pain control. One student writes in the following way about his shortcomings in the
care of a patient with chest pains and how he experienced learning caring assessment:

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

2. The learning process goes through participation in caring

When students are allowed to be present and to participate in caring experience
makes the learning process easier. One such situation concerned a patient with dia-
betes. The student writes in the following way about how good she felt when her
supervisor made her part of the caring:
 Reflective Practice 279

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

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

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

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

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

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

Caring situations involving closeness to a patient can also be experienced in the

company of a supervisor. The student will then be instructed to stay with the patient
to carry out supportive conversations. One student writes about one such caring
situation in the following way:

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

Caring situations in which caring science knowledge and medical knowledge are
simultaneously combined and integrated are also experienced as opportunities for
learning, e.g. as when the assignment concerns a female patient with a suspected
heart infarction. The student writes about this as follows:
 280 B. Wireklint Sundström and M. Ekebergh

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

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

The preparations for every new assignment include decisions as to which equipment
must be taken along to the caring encounter, in order to prevent the lack of impor-
tant equipment, e.g. equipment for cardiopulmonary resuscitation in a situation with
cardiac arrest. The unpredictable caring encounter can lead to impractical behavior
since students may be extra careful and include far too much extra equipment. One
student writes about her/his learning process in the following way:
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My lack of experience makes me tend to want to take along more equipment than experi-
enced people would. My load is much heavier than the others’ [ambulance personnel’s]!

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

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

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

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

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

They [the ambulance personnel] soon understood that I was uncomfortable in that
situation and they gave me plenty of time to think. For me in my role as a student,
this situation was a totally different experience from that of the ambulance personnel.
They did not experience the assignment as being as hard as I did. Through reflecting
 Reflective Practice 281

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

5. The learning process relies on support from the supervisor

Support and guidance by the supervisor are essential to the student’s learning and
they are described as decisive for both the student and the patient, especially in caring
situations where the patient’s condition is difficult to assess. One such caring situation
concerned a dying woman in a nursing home. There was a prior decision that CPR
would not be carried out. The ambulance personnel were only there to establish that
the patient was dead. However, when they arrived, the patient was still breathing and
had a pulse. The student describes how two supervisors wanted to make two different
decisions. The learning situation was thus confused as is clear below:
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I thought that it was a very difficult situation for everyone concerned. We were only
supposed to establish that the patient [a woman] was dead, but now the situation was
different! We could drive her to the emergency department and risk the possibility of
relatives not being able to share a good farewell with her, or we could let her remain
in her bed in the home. It was an ethical dilemma for us. My supervisors were of
different opinions on the matter and that made things even more confused. It felt as
though we would have to start CPR if the patient’s heart stopped while we were there.
That did not feel right. I had a lot of unanswered questions.

In this caring situation no supervision was given, the student’s questions remained
unanswered and the patient’s situation remained uncertain. In other words, the
patient’s situation and the student’s learning are parallel processes. A student writes
below about a different caring situation, in which the student and the supervisor
were on a collision course in relation to each other concerning the care of a patient
with chest pains:

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

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

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

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

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

Discussion
Our results show that the contextual model has been fruitful during clinical praxis
in prehospital emergency care so that learning has been highlighted in a nuanced
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way in relation to the students’ experiences. The results also show that caring sci-
ence and medical knowledge have manifestly been merged in the learning process.
This result is especially obvious when the students describe emergency situations.
An attitude of reflective awareness is adopted under those circumstances, showing
that the different types of knowledge content are equally valuable and that they are
applied simultaneously. An awareness of the difference between these two types of
knowledge is also apparent, i.e. caring science knowledge is paramount in the car-
ing relation with the patient and medical knowledge is especially dominant when
applying treatment measures. However, a caring relationship is required at the same
time in order to explain the aim and effects of the treatment to the patient and the
next-of-kin. The focus is thus simultaneously upon both types of knowledge, as
noted earlier by Elmqvist, Fridlund, and Ekebergh (2008), Holmberg and Fagerberg
(2010), and can also be compared with Leachasseur, Lazure, and Guilbert (2011)
who wrote about knowledge mobilisation. In addition, Janing (1996) noted that
medical conditions often present as ill-defined problems, which practitioners best
are prepared for by problem solving and reflective-thinking skills. According to
Ekebergh (2009), the findings in this study can be understood as a form of didactics
where theory and practice and different kinds of knowledge, i.e. knowledge in
caring and medicine, are merged though reflection.
In accordance with Sullivan and Chumbley (2010), the result can be understood
as a new approach to patient care and makes it clear that didactics must be based
on the concept of the patient’s perspective. This is demonstrated for example by the
students’ descriptions of their active participation in caring and influencing the
patients’ medical conditions. At the same time our results underline the important
fact that the patient and his/her experiences and condition are the foundation for
learning in prehospital emergency care.
According to our findings, we suggest in accordance to Berg and Kisthinios
(2007) that the supervisor should not emphasise one perspective at the cost of the
other, but should instead demonstrate by means of skilful didactics that both are
equally valuable. The didactics of prehospital emergency care offer the opportunity
for mutual learning in which the supervisor’s attitude, by counteracting the
polarisation of different kinds of knowledge, communicates instead that the patient’s
perspective constitutes both the structure and the content. The main point is that the
relationship to the supervisor simultaneously reflects the learning environment as
well as the caring environment.
 Reflective Practice 283

However, one challenge that has been demonstrated in the learning process con-
cerns caring situations that are particularly dominated by medical emergency, when
the student’s learning does not meet an approach with the interweaving of knowl-
edge types and adaptation to the patients’ perspective, i.e. caring science is missing
in such care situations. This challenge exposes the students to difficulties in the
learning process involving how to relate to strongly emotional experiences including
guilt and inadequacy. These findings underline just how important it is for supervi-
sion to meet the students in their own lifeworlds and with their specific needs for
support and supervision. In other words, supervision must be adapted to the fact
that the students’ previous experiences of caring with severely ill patients can vary.
We should note that not all students (RN) have been employed within the EMS
before their specialist education.
Based on the didactic model and the findings in this study, learning environments
can be created within the caring praxis of prehospital emergency care so that the
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merging of caring science and medical science is focused upon, problematised and
communicated to the students. This merging makes a critical analysis of theory and
praxis possible. For students to learn reflectively together with experienced supervi-
sors in direct contact with various ambulance assignments is a way to create such
learning environments. This form of didactics prepares students to meet human suffer-
ing in different types of caring situation. Caring in prehospital emergency care is thus
a type of caring that must be learnt in the company of supervisors and patients. The
supervisor’s role appears thus to be decisive for learning, a conclusion that is in
agreement with earlier research (Ekebergh, 2009; Johansson, Kaila, Ahler-Elmqvist,
Leksell, Isoaho, & Saarikoski, 2010). These findings make it clear that the
relationship between student and supervisor is the central factor influencing learning.
Based on these findings and in order to counteract the exclusion of students
from learning situations, we suggest that students should be invited into the caring
context with the patient and also into the professional fellowship of the prehospital
emergency care team. Learning is stimulated by the students’ active physical partici-
pation in caring measures that affect the wellbeing and medical condition of the
patient. On the other hand, it is also clear that without the support of the supervisor,
the student becomes invisible and her/his learning is downgraded priority-wise. In
that situation, the student abandons caring, at the same time abandoning the caring
relationship with the patient. Both the student and the patient are put in an exposed
position. The student loses confidence in the supervisor and it is probable that the
patient loses confidence in the student as a care-giver. It would appear that
supervision should be aimed at making students into active participators in actual
caring situations, in other words that the patient and his/her experiences constitute
the foundation for learning.
However, in this context one particular challenge to the learning process has
been shown. The findings also show that even the supervisor may constitute an
obstacle to learning, when the student with her/his own professional responsibility
as a registered nurse and the supervising nurse do not share the same approach to
caring. This particular finding is in accordance with Berg and Kisthinios (2007)
who report that only three-quarters of supervisors stated a use of theoretical nursing
perspective. Further, our findings show that the student abandons her/his own con-
victions in that kind of situation, to adopt instead the approach of the supervisor,
even though this may be less appropriate to the patient’s lifeworld. Consequently, a
shaky relationship with the supervisor can complicate and perhaps even prevent a
 284 B. Wireklint Sundström and M. Ekebergh

caring relationship with the patient. The learning process in caring relationships
involves handling powerful feelings characterised by competence and strength but
also with ingredients of incompetence and ineptitude.
We suggest that this challenge should receive more attention in the EMS, seen
in the light of our findings and the fact that specialist ambulance nurses’ caring
work is naturally enough independent and relatively solitary. Specialist ambulance
nurses’ particular responsibility concerning caring assessment has special implica-
tions in prehospital emergency care. It is thus of central importance in prehospital
emergency care for learning to be a process of preparation for autonomous caring
with great responsibility for assessing the patients’ needs. It is therefore of the
greatest possible significance to choose supervisors who can not only supervise but
who also have a caring approach, grounded in caring science.
Furthermore, the findings show that this didactic model can be seen as critical
thinking in education (Pithers and Soden, 2000), and supports a learning process
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whose ultimate goal is that the student will be able to be prepared for the unpredict-
able, by which is meant an openness to the uniqueness of the patient and her/his
need for prehospital emergency care (Wireklint Sundström and Dahlberg, 2011).
Thus the preconditions of prehospital emergency care with their character of unpre-
dictability in the caring encounter make demands of openness in the encounter with
every new patient. A didactic balancing act can enable a student to develop a
capacity for rapid, action-based behaviour, i.e. to be able to provide medical help
with a caring science approach when the patient is suffering from a life-threatening
condition. This didactic model means that preconditions can also be created for a
person of ability to encounter the patient with thoughtfulness on an existential level.
It is thus clear that the unpredictability of the caring situation creates awareness
about the need for openness when confronting the patient’s care needs.
However, one specific challenge to the learning process was demonstrated
regarding openness in prehospital emergency care. It became evident that the emer-
gency medical atmosphere and fixed routines for making rapid decisions can
obstruct the possibilities of maintaining an open approach. Based on these findings
we suggest that students need training in how to maintain an open approach to
information from the dispatch centre and, if possible to, creating conditions under
which they can listen to the patients’ stories – before any decisions about caring are
made. This has been shown to be a significant part of the didactic model. Supervi-
sion in situations involving closeness to patients is based on the experiences of the
patients, and this creates possibilities for encounters between the students’ and
patients’ lifeworlds. The supervisor is thus seen to be a significant factor in creating
balance in the dialogue so that it will become a meaningful encounter for both
student and patient. The student who is learning must be trained to have a caring
approach that will affirm the patient’s participation, and simultaneously reject any
approach that is merely routine and unreflective during caring assessment.
Earlier research discusses the effects of reflection on the learning process in rela-
tion to the student’s lifeworld (Gustafsson et al., 2007; Ekebergh, 2009), in relation
to the context (Jones, 2008; Campeau, 2008), and in relation to self-reported medi-
cation errors (Vilke et al., 2007). This study, which tests a didactic model based on
the prehospital context, demonstrates that the students had developed a reflective
attitude as described by Ekebergh (2007). Consequently it becomes apparent that
the student’s lifeworld is decisive for the learning processes that occur in intimate
conjunction with it. And finally, this result is a unique addition to further research
 Reflective Practice 285

on the development of knowledge in caring science and the nursing profession as

specialist ambulance nurses.

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

Recommendation for future research

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To make further advances in the knowledge about the learning process in

prehospital emergency care, more research is needed in the future. One of the most
important questions to continue with is: “How can the caring science perspective in
acute and emergency-dominated care be developed even more markedly and
strongly?” This research question is of extra importance since simulated clinical
scenarios and simulation learning are undergoing intensive development as a new
didactic model, a development partly at the cost of clinical practice.

Implications for learning practice

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

• in order to acquire an open approach to information from the dispatch centre,

and in order never to take anything for granted before the caring encounter
with the patient
• for an inclusive approach allowing caring science knowledge and medical
knowledge to be applied in a natural way at the same time and in all caring
situations
• for applying an explicitly patient-orientated/lifeworld-orientated perspective
even in medically advanced emergency situations.

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

• the co-operation with the EMS, their chiefs and their specialist ambulance
nurses;
• the supervisor’s approach and support in caring situations and
• education for supervisors.

Acknowledgements
The authors gratefully acknowledge the agreement given by the students and the two course
teachers to this study and their co-operation in gathering in the examination papers.
 286 B. Wireklint Sundström and M. Ekebergh

Note
1. In this paper “didactic” is used with the meaning of “learning support” as implies a con-
frontation between the student’s lifeworld, the caring science and the patient’s lived world.

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

Margaretha Ekebergh, RN, PhD, is a professor in caring science at University of Borås,

School of Health Sciences and a visiting professor at Linnaeus university, School of Health
and Caring Science. She is the head of the Centre of Health, Learning and Reflection in
Heath Care. Within this centre, her research focus is on the intertwining process of caring
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theory and caring praxis with the learner’s lifeworld. An overall theme is, Creating
innovative environments that bridging the theory – practice gap: the interaction between
caring and learning.

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