Undergraduate paramedic students and interpersonal communication development: a scoping review

The objective of this review is to examine the current literature related to interpersonal communication skill development within undergraduate paramedicine. Interpersonal communication is a vital paramedic skill, with evidence demonstrating it leads to improved patient outcomes and satisfaction and reduces medical errors. Interpersonal communication is a core capability set by paramedicine regulatory bodies, and it is the responsibility of accredited universities to ensure graduates are ready for industry and possess all required skills and attributes. In order to be included in this scoping review, all articles were required to meet a pre-determined ‘population, concept, context’ (PCC) framework. The population was undergraduate paramedic students within the context of their undergraduate paramedicine programs, and the concept was interpersonal communication education/teaching/training. In June 2021, a search was conducted using CINAHL, Medline, Emcare and ERIC. The articles had to be written in English and published between 2011 and 2021 and non-research sources were excluded. 176 articles were identified in this search and after screening for duplicates and relevancy, 15 articles were found to be eligible. The literature highlighted 4 key themes, including graduate perception of ‘work readiness’, and a variety of learning experiences including alternative work integrated learning (WIL), interactions with specific patient groups and professional learning experiences. The literature demonstrated that interpersonal communication skills are fostered through human interactions, WIL and simulation, within undergraduate paramedicine programs. Findings from the literature review indicate that practising communication through human interactions, afford an increase in confidence, awareness of ability and empathy, and an increased awareness of preconceived biases. Intraprofessional and interprofessional simulation teaching methods demonstrate the potential to build students confidence in communication and awareness of what is required to function well in a team.


Introduction
Paramedics communicate for many reasons, including connecting and engaging with patients in their care, gathering information from patients and people on the scene, imparting professional knowledge regarding treatment and care, and working effectively and collaboratively in a team of other healthcare professionals (HCP) (Ahpra, 2021b). Paramedics are required to be proficient communicators because they interact with a variety of people, including patients across the life spectrum, from a multitude of social and cultural backgrounds, their family members, bystanders, emergency services and other HCPs . Furthermore, a paramedic's working environment is unpredictable, busy, noisy and often emotional, which can be barriers to effective communication (Ross, 2021). Effective interpersonal communication can be considered an essential skill for any paramedic and a requirement for safe practice (Ahpra, 2021b).
In its simplest form: ''Interpersonal communication is the verbal and non-verbal interaction between two (or sometimes more than two) interdependent people'' (DeVito, 2015, p. 18). Hargie (2016) adds that communication is also a transaction, with individuals interchangeably taking on the role of both communication sender and receiver, thus influencing the response and reaction of one another. O'Toole (2020) proposes that this transactional conceptualisation of communication applies well to the healthcare context, whereby the HCP and the patient send and receive verbal and non-verbal messages and interpret what they mean. In addition, O'Toole outlines the possible barriers to communication, such as cultural difference, language, age, gender, and life experience, and suggests these barriers need to be recognised and considered in order to have a successful interaction. Ineffective communication, then, can be considered to arise when paramedics do not overcome barriers, or have a poor understanding of effective communication skills and attributes (Willis & Mellor, 2020). O'Toole (2020) proposes that effective communication requires a mutual understanding, whereby both parties understand the verbal and non-verbal messages being sent, as well as understanding all internal and external factors which could be influencing the responses. For example, if you are communicating with a patient who is scared and in pain, and this is not considered when communicating with them, you may not have a successful interaction. Furthermore, mutual understanding in healthcare requires respect, empathy and trust and it is these attributes that ensure the patient knows they are valued and understood and this, in turn, leads to a positive connection, known as a rapport (O'Toole, 2020). Providing attention, interest and actively listening to the patient further builds this rapport and establishes further trust, which leads to the patient feeling more inclined to interact and collaborate with the HCP (Arnold, 2020). Establishing a good relationship with the patient will then assist with information gathering, which will help the clinician to understand the patients complaint better, make an accurate diagnosis and lead to better decision making by the paramedic Ross, 2021). Furthermore, these skills are important in empowering the patient, ensuring the interaction is a positive experience (O'Toole, 2020). Establishing a rapport, being respectful, gaining trust and active listening are all skills a paramedic must possess according to the Australian Health Practitioner Regulation Agency (Ahpra, 2021b).
Effective communication with patients is associated with improved satisfaction and better patient outcomes (Henderson, 2019), whereas poor communication can lead to patient complaints and medical errors (Pilbury & Lethbridge, 2019). More specifically, effective communication leads to a better understanding of the care being provided, and of the

Research aim and question
This literature review aims to examine current literature regarding interpersonal communication learning and teaching within undergraduate paramedicine. The research question therefore is -What current evidence base exists to inform universities to prepare their undergraduate paramedic students to be competent communicators?

Eligibility/inclusion criteria
In order to be included in this review, all evidence needed to meet the population, concept, context (PCC) inclusion criteria (Peters et al., 2021). The population to be examined was undergraduate paramedic students and the concept was the teaching and/or learning of interpersonal communication. This must have taken place within the context of an undergraduate paramedicine course. The literature review by Ross (2012) found no evidence of interpersonal communication education within undergraduate paramedicine prior to 2012, so a date range was added to the inclusion criteria in this scoping review meaning only articles published between 2011 and 2021 were to be included. Non-research sources were excluded in this study, as the inclusion of such, can impact the replicability of the research (Adams et al., 2016). Evidence not published in English was also excluded. These criteria were agreed by the whole team prior to the search.

Search strategy
A search was conducted using the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Emcare and Education Resources Information Centre (ERIC), accessed via the Charles Sturt University (CSU) online library between the 30th of June and the 1st of July 2021. Search terms were chosen based on the PCC framework already established (Table 1).

Evidence selection
This search identified 176 articles. Sixty-seven of them were duplicates, leaving 109 articles. The abstracts were initially assessed by JS to determine relevance using the PCC framework and 58 were removed. The full texts were then examined by JS and a further 36 were removed, leaving 15 articles (Fig. 1). Reference lists from those 15 articles were scanned to identify any missing articles. Furthermore, each article was searched for in SCOPUS to identify any articles citing them, which may have been relevant. No further articles were identified during this process. Authors JS and DJ independently assessed the quality of the articles using the Hawker et al. (2002) tool before then assessing the quality together to conclude each articles rating. The Hawker et al. (2002) tool was created due to a need for a robust way of assessing the quality of qualitative and disparate research. As such, due to the variety of methodologies used in the articles presented in this review, the Hawker et al. (2002) tool was appropriate. The tool highlights areas of strengths and weaknesses within each study by investigating 9 keys areas, such as abstract, method or ethics, etc. and rates them on a scale of 'good', 'fair', 'poor' and 'very poor' (Appendix 1). All articles included in this review were graded 'good'. Although not always considered necessary for scoping reviews (Levac et al., 2010), this was conducted to add a degree of rigor to the conclusions drawn from this study (Brien et al., 2010).

Extracting and charting the evidence
Data were extracted by two authors (JS and DJ) and both were in agreement that the articles were relevant to the PCC framework. The data regarding aims or objectives, sample and setting, method, outcomes, and conclusion and limitations were charted in a table form (Appendix 2). This enabled the evidence to be captured and recorded, while maintaining transparency and limiting errors and bias (Peters et al., 2021).

Data analysis
The research presented in this review took place within the context of a variety of university settings in multiple countries, including 10 from Australia, 2 from the United Kingdom (UK), 1 from the United States (US) and 1 from Poland. The remaining article was a literature review, which extracted data from the UK and US. The experience of the undergraduate population varied between articles with 7 articles indicating students were either in their 3rd year, final year, or a senior student, 4 articles referred to 2nd year students, 2 articles referred to 1st year students and 1 article did not specify the student's level of experience. Furthermore, there were a variety of research methods used, with a large proportion using a mixed methods approach. Every article demonstrated examples of the development interpersonal communication; however, this was not a primary aim in all studies.
Extraction of the data in line with the research question identified 4 major themes: 1. Interacting with a specific patient group 2. Professional communication experiences 3. Alternative work-integrated learning placement 4. 'Work ready' graduates and undergraduate communication education

Interacting with a specific patient group
In 4 publications, students had the opportunity to interact with various people within the elderly population, including people who are under palliative care and people with dementia. Lucas et al. (2015) and Stratton et al. (2015) utilised a mixed method approach to investigate a 5 day WIL experience in a residential aged care facility (RACF), with final year paramedic students. Both student groups had a variety of structured learning activities and opportunities to interact with aged care residents, many of which had dementia Stratton et al., 2015). This experience improved the student's knowledge of dementia and the communication barriers it can cause, as well as providing the opportunity for students to develop new strategies to communicate effectively and build a rapport with this particular patient group Stratton et al., 2015). Furthermore, students reported an increased confidence in their communication ability and an increased awareness of how they might transfer these skills into the pre-hospital setting Stratton et al., 2015). Building a rapport with a specific patient group was also investigated by . This study was limited by its small, self-selected sample, as well as the fact that the questionnaire used was not psychometrically tested and was based on self-reported data. However, the results were positive, with students reporting a significant improvement in their ability to build a rapport after the students had interacted one on one with an elderly person. Self-reflection demonstrated further improvements in the students' learning. Results also demonstrated an increase in the students confidence and empathy levels, which was further reflected in the work by Ross et al. (2018). In this study, communication skills improved in all students who practiced communicating with an older person, however those who had more one on one time, developed more empathy towards this patient group.
By providing students with this experience, they have been able to practice and develop key interpersonal skills such as rapport and empathy, as well as develop communication strategies to overcome communication barriers.

Professional communication experiences
In 3 publications, students experienced professional interactions with other students, in simulated emergency settings. Johnston et al. (2014) and Furseth et al. (2016) used a simulated patient handover, between nursing students and paramedic students, with the aims of overcoming barriers to interprofessional education (IPE) and improving interprofessional communication between the respective students during this crucial interaction (Furseth et al., 2016;Johnston et al., 2014). Johnston et al. (2014) gathered their data in group debriefing sessions and concluded that the students found it valuable to practise handovers and then take part in a debrief alongside other HCP students. Whilst this demonstrated how universities were teaching communication, it was not clear what the students learnt from the experience. Furseth et al. (2016) found high levels of self-confidence after the handover activity, stating that by increasing students' confidence with a certain task through the means of simulation and other learning activities, students may be more likely to complete these tasks successfully when required to do so in real life. It may have been beneficial for this research to have included a pre-intervention assessment of the students' confidence level, to better understand the merit of this learning activity. Similarly, Ford et al. (2014) used an intraprofessional learning activity with the aim of developing student's relational competence, which includes attributes such as being non-judgemental, trustworthy, empathetic, compassionate, and respectful. Students took part in a 3-day simulation activity and data were gathered through field diaries and focus groups (Ford et al., 2014). The students reported a better understanding of teamwork-based communication skills and a recognition of their own personality types when it came to communication (Ford et al., 2014).
In addition to these simulated professional interactions, Ross and Bertucci (2014) investigated student learning after being part of a peer-assisted learning (PAL) program. Paramedic students mentored high school students with an interest in a career in paramedicine and it was found that the program supported the development of interpersonal communication skills (Ross & Bertucci, 2014). The research unfortunately provided no more detail than that, as communication was not the primary outcome of their study. One might speculate that this type of activity may have merit in developing experience in interacting with teenagers and practicing tailoring medical language to a younger person.
Within 3 articles examples were provided of an interpersonal communication learning activity being used which provided students with the opportunity to practice communication. Only within the Ford et al. (2014) publication did authors provide evidence of exactly what communication skills the students were developing. But promisingly, all 4 publications were evidence of universities prioritising communication experiences within undergraduate programs. Simulated professional interactions appear to be enjoyed by the students and allow students to practice working in a team, highlight their own communication skills, and build confidence.

Alternative work-integrated learning (WIL) placement
Non-ambulance work-integrated learning (WIL) experiences within the community (Ross & Kabidi, 2017;Prakash et al., 2020), and in hospital (Credland, et al, 2020) were examined in 3 publications. Whilst communication was not the primary outcome under investigation, it was an area of development reported by students. On community-based WIL placements, students were exposed to areas of the community they had not interacted with before and this led to the development of empathy and led students to recognising unconscious biases that they may have held prior to the placement (Prakash et al., 2020;Ross & Kabidi, 2017). In 12 interviews, Ross and Kabidi (2017) discovered that this opportunity to practice communication led to an increased confidence and the development of new communication strategies. Similarly, the focus groups conducted by Prakash et al. (2020) highlighted that students immersed in this environment were afforded the opportunity to practice and hone communication skills such a rapport building. Furthermore, semi-structured interviews conducted by Credland et al. (2020) regarding a hospital-based WIL placement, highlighted that students were able to observe and practice various communication strategies with multiple patients, as well as gain experience with inter-disciplinary communication. These publications are examples of how non-ambulance WIL experiences have the potential to develop students' communication skills. Students were immersed in these new and often unfamiliar environments where their technical paramedic skills were not necessarily required, and students were encouraged to focus on their interpersonal skills as a priority. However, Credland et al. (2020) did provide evidence of students not always feeling welcome or supported whilst taking part in this WIL activity, as well as a lack of understanding from staff as to why paramedic students were there. This could have negative implications for the amount of learning that could take place, if it is not considered when creating non-ambulance WIL.

'Work ready' graduates and undergraduate communication education
The preceding publications provide examples of interpersonal communication educational experiences and teaching methods. The remaining publications investigate the university experience as a whole and how prepared students were in terms of interpersonal communication when entering the workforce. Włoszczak-Szubzda et al. (2013) analysed the interpersonal communication training within the syllabuses of 20 paramedicine education centres in Poland. Authors found that although communication education was present, there was a lack of job specific communication education, as well as interprofessional communication, with a greater focus on general communication knowledge (Włoszczak-Szubzda et al., 2013). Whereas Twinley (2012) used a mixed methods approach with a self-designed questionnaire in the UK and demonstrated that paramedic students felt they had been adequately taught verbal, non-verbal and written communication skills, but would like more practical experience to further develop their skills. Furthermore, the research showed a trend in the student's preparedness for WIL placement, whereby they felt less prepared for their first and more prepared for their most recent WIL placement (Twinley, 2012). Whilst the evidence is positive, caution should be exercised as this study was conducted with a small sample and it is unclear in both studies if the evidence is transferable internationally. Undergraduate paramedicine education facilities may differ in course structure, including required ambulance-based WIL hours leading to registration, as well as differences in cultural norms of communication.
An Australian study by O' Brien et al. (2013) investigated 23 final year paramedic students' perceptions of their work-readiness, using a mixed method survey. Quantitative data demonstrated that students feel 'somewhat adequately to adequately' prepared by their degree in terms of general interpersonal skills and communication with HCP's (O 'Brien et al., 2013). Students felt that WIL placements were an activity which could develop their patient communication further, with the authors postulating that paramedicine training could be improved through more WIL opportunities, including more diverse WIL placements, within a variety of healthcare sectors (O' Brien et al., 2013). However, since this publication, Australian paramedicine degrees have become subject to professional accreditation, so information about how prepared students feel to enter the workforce requires updating.
The final article identified by this review is a literature review by Ross (2012). This article demonstrated that before 2012 there was no research conducted concerning interpersonal skill education within undergraduate paramedicine. This article therefore supported the use of a search limitation based on year of publication when conducting the literature search for this scoping review (Ross, 2012).

Discussion
Providing opportunities to practice interpersonal communication with patients, peers and other disciplines was a prevalent teaching method described in the literature. Practise in this manner appears to build students comfort and confidence in their interpersonal communication skills (Credland et al., 2020;Furseth et al., 2016;Johnston et al., 2014;Lucas et al., 2015;Ross & Bertucci, 2014;Stratton et al., 2015). Through this interaction, students are able to discover their own weaknesses and strengths in their current communication ability (Ford et al., 2014;Prakash et al., 2020;Ross & Kabidi, 2017;Ross et al., 2018) and students consider more opportunities to obtain practical experience as a way to develop their communication ability further (O' Brien et al., 2013;Twinley, 2012). Additionally, in the literature review by Ross (2013), a similar conclusion was drawn, that the use of 'real patients' to develop interpersonal communication skills, when introduced early and purposefully within a HCP training, can lead to an increased confidence and ability to build rapport thus supporting the findings from this review. Furthermore the research shows that practising communication with specific patient groups, or with new groups of people that students had not interacted with before, appears to highlight unconscious biases that students may have held and encourages them to question stereotypical ideas they may have felt (Prakash et al., 2020;Ross & Kabidi, 2017;Stratton et al., 2015). These interactions lead to students developing empathy Prakash et al., 2020;Ross et al., 2018). These findings are similar to those found by Perlman et al. (2017), where undergraduate nursing students interacted with a particular patient group during a WIL placement. Perlman, et al. (2017) found that after this experience students were able to recognise and address preconceived biases and discovered the importance of communicating in a meaningful and caring way. Developing these caring attributes such as being kind and non-judgemental are key to being proficient at building rapport (English et al., 2021). Furthermore, Norfolk et al. (2007) reports that empathetic motivation, the ability to empathise, and possessing the communication skills to demonstrate to the other person that someone is empathetic to their situation, are all vital components of establishing rapport. Providing students with the opportunity to interact with specific patient groups, appears to be a beneficial teaching method to foster these attributes O'Brien et al., 2013;Prakash et al., 2020;Ross et al., 2018).
WIL has been explored in a number of the publications presented in this scoping review and appears to be a prevalent teaching method offering students many opportunities to interact with a variety of people (Credland et al., 2020;Lucas et al., 2015;Prakash et al., 2020;Ross & Kabidi, 2017;Stratton et al., 2015).This learning is often assisted by working alongside and with the support of mentors or supervisors (Credland et al., 2020;Lucas et al., 2015;Stratton et al., 2015). For example, research by Stratton et al., (2015) and Lucas et al., (2015) demonstrated that structured learning workshops provided during a WIL placement, alongside interactions with the residents supported student learning. However, only 1 study included in this review provided data regarding the role of the mentor or supervisor during WIL, and the barriers to effective mentorship (Credland et al., 2020). Wongtongkam and Brewster (2017) proposed that a good working relationship between mentor and student is beneficial to the students overall learning while participating in WIL. In addition, Wongtongkam and Brewster (2017) investigated paramedic students' clinical and non-clinical skill development during an ambulance placement where students have direct support from a mentor and found students improved in all aspects surveyed, which included history taking and questioning, handovers, giving clear communication and building rapport. Michau et al. (2009) discussed that student paramedic skill development is reliant on the mentor encouraging and/or allowing the student to use a skill and ensuring the student feels supervised. This sentiment was reflected in nursing placements too, whereby positive relationships between the nursing students and the professional staff, lead to an increased sense of belonging, motivation, confidence, and growing sense of professional identify, which all support student learning (Levett-Jones et al., 2009). Of course, WIL in a healthcare setting will inevitably expose students to a variety of patients, but supportive mentorship is a vital component to consider when using this as a teaching and learning method. Furthermore, WIL will not expose students to all patient groups, and in order to address these learning gaps, additional learning opportunities on top of WIL need to be considered (Michau et al., 2009).
Simulation was found to be another useful learning method for preparing students to be proficient communicators (Ford et al., 2014;Furseth et al., 2016;Johnston et al., 2014). Simulation offers the students an experience similar to the real thing, where the scope or level of the task can be controlled and with no risk of adverse events to patients (So et al., 2019). Professional interactions, through simulation, appear to lead to an increase in student's confidence regarding interprofessional communication (Furseth et al., 2016;Johnston et al., 2014), whilst highlighting the importance of team collaboration and effective team communication (Ford et al., 2014). Similar results were found in the review of literature conducted by Granheim et al. (2018), where IPE simulation was found to have a positive effect on communication skills and team collaboration skills. Granheim et al. (2018) highlighted that these IPE experiences encourage student communication development as any weaknesses come to the foreground and can be addressed.
Paramedic to patient communication was simulated using older people in the study by Ross et al. (2018), however it was used to assess the communication ability of the students, not as the learning strategy. Nevertheless, it was likely to be the leading cause of why all the communication scores of all students in the study improved, thus still promoting it as a learning strategy, although not potentially intended as one. Using students as simulated patients, to role-play interpersonal paramedic to patient communication, was not found in the literature, however Twinley (2012) proposed communication development activities such as role-play may have merit if incorporated into paramedicine education as a method of developing key communication attributes. Likewise, developing communication skills required to interact with children or developing skills related to difficult conversations with patients or their loved ones was not found in this review. Anderson et al. (2019) found that difficult conversations relating to terminating resuscitation to be one of the student's greatest concerns, with the student's suggesting simulation and role play may be beneficial learning and teaching techniques. Although the use of simulation appears to be beneficial for communication practice, there is no consensus to the level of fidelity required to facilitate interpersonal communication skill development or the potential benefits of more emerging simulation methods within paramedicine such as immersive technology media (Birtill et al., 2021). Exploring the use of technology, Barr and Foster (2017), proposed that the type of immersive technology used in their study, offered a more engaging and authentic learning environment, where a plethora of technical and non-technical skills, including communication were able to be practiced. Furthermore, a literature review by Birtill et al. (2021) exploring the use of immersive technologies in paramedicine concluded that while the role it could play in educating paramedic students is still unclear, it is an area that could benefit from further research drawing from its use and efficacy within other health disciplines.
It appears the overarching method of preparing undergraduate students to be proficient communicators is through experience. Kolb (2014) proposes that for knowledge to be created through experiential learning, the learner is to reflect on the experience and derive new concepts and ideas based on these reflections, to inform the next experience. Many of the studies presented in this review involve an experience and reflection, and in addition, many of the researchers encouraged or facilitated student reflection to gather data, which may have led to additional knowledge and learning by the participants (Ford et al., 2014;Johnston et al., 2014;.

Limitations
Scoping reviews explore the literature over a certain period of time, and there is the potential, more data has become available since this review was conducted, which is a limitation of scoping reviews (Brien et al., 2010). There is the potential, as not all databases were searched, that some articles were missed during this scoping review. Also, paramedicine has many interchangeable names, so there is a potential that the search did not include all paramedicine terms, and this may have afforded some articles being missed. In addition, with the terms focused on undergraduate paramedic students, it should be acknowledged that not all countries have tertiary education as a requirement for paramedic practice. Furthermore, many of the studies used in this review are investigating broader topics as opposed to specifically investigating communication development.

Conclusion
This scoping review has provided evidence of the teaching methods being used to develop undergraduate paramedic student's interpersonal communication skills. This review demonstrates that interpersonal communication development is valued by universities, with many offering opportunities for students to practice communication as a priority. Opportunities to practise interpersonal communication whilst taking part in WIL or through interactions with specific patient groups afford increased confidence and ability. These interactions also lead to an increase in empathy and a decrease in preconceived bias, all promoting a better rapport building ability with the patients in their care. In addition, professional simulation activities have the potential to offers student's the opportunity to build confidence in communication and develop teamwork skills all while in a supportive environment, with the opportunity to reflect and debrief.
Whilst this area of research is still growing, it is promising to see there is an evidence base beginning to emerge to inform universities on how best to support their students. There is strong support for the use of WIL and creating opportunities for students to interact with patient groups to support communication development, but little evidence into the true potential of simulation. Further research is recommended into the role simulation can play in developing student's interpersonal communication skills. Research is recommended into the various styles of simulation, including role-play, use of standardized patients and immersive technology. This review has demonstrated a growing value and interest in this important area of study.   Revealed three items to be statistically significant and have a large effect size: Confident (p < 0.01, r = 0.55), Empathetic (p = 0.03, r = 0.48) and Overall ability to develop rapport with the elderly (p < 0.01, r = 0.58). Two items trended positively with medium effect size; Humane (p = 0.16, r = 0.30) and Thorough (p = 0.08, r = 0.37) Themes emerging from the students -Assertiveness, communication, attitudes, rapport, and transferable skills Themes emerging from the elderly participants -Respect, Communication, empathy, rapport, and transferable clinical skills Limitations: Selection bias Small sample size Self-report data from the RQ was not necessarily indicative of improvement in rapport building skills, RQ not psychometrically tested Conclusion: Student's recorded improved confidence, empathy and overall ability to build rapport with older people through this engagement activity. In addition, students who received guided self-reflection displayed greater improvements in the above three areas than their control counterparts Funding Open Access funding enabled and organized by CAUL and its Member Institutions.

Appendix 2 Charting the evidence
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