Promoting a Culture of Learning in EMS

There are approximately 826,000 emergency medical services (EMS) providers in the United States who deliver prehospital care through nearly 20,000 EMS agencies.¹ These providers are responsible for complex decision-making that relies on knowledge gained through completion of a limited foundational curriculum relative to the level of care they deliver. Given the public trust bestowed upon EMS providers, it is essential that they remain competent in all aspects of their profession’s core content and scope of practice. Further, these providers must be prepared to evolve their practice as new evidence is established. Such maintenance and advancement of professional knowledge is traditionally handled through local continuing medical education programs.

One of the great challenges faced by those who teach continuing medical education is a perceived lack of engagement among those students they attempt to teach. Educators who wonder why students are not committed to learning may pass judgment that students simply don’t value knowledge. There are numerous factors that can contribute to deficiencies in student engagement, making it reasonable to believe initiatives aimed at promoting engagement in continuing education must be comprehensive in their nature. Such initiatives should seek to align the culture of an organization with the value of learning.

Culture of Learning

In order to promote engagement in continuing education, we should strive to establish a culture of learning in EMS. Such a culture is characterized by intentional, independent and self-directed pursuit of knowledge driven by a desire to learn, not for the purpose of credentialing, but for the sake of learning itself. What follows is a series of four recommendations for increasing engagement in continuing education programs by establishing a culture of learning. The specific recommendations addressed include: promoting pride in performance, developing self-regulated learners, incorporating adult learning principles and instilling curiosity.

Promoting Pride in Performance

The EMS profession is full of dedicated and humble professionals; however, it is human nature to desire some level of recognition for a job well done. Nothing destroys morale faster than a group of workers who feel their efforts have been ignored, or that going above and beyond their job requirements simply doesn’t matter. Conversely, EMS providers tend to thrive when faced with challenges and often have a competitive spirit. This sets the stage with opportunities to motivate EMS providers through initiatives that recognize and celebrate performance. As noted by Marsee, recognition and celebration of accomplishments is an important step for promoting cultural change within an organization.²

EMS providers who find a source of extrinsic motivation in high-level performance will likely develop their motivation to engage in continuing education as a means to reinforce and enhance their performance. However, such improvement necessitates that employees receive feedback as to how well they are performing and in what areas they might be able to improve. The leadership of an organization should be prepared to evaluate available data sources in order to provide employees with measures of their performance.

When it comes to developing a culture of learning, organizations should capitalize on simple forms of recognition that can lead to a sense of pride in performance among the organization’s employees. Potential areas for recognition of performance are only limited by data collection capabilities. Some ideas include the achievement of response time goals or individual components of high-quality CPR (e.g., chest compression fraction). Recognition can range from an old fashioned pat on the back to public praise, such as highlighting employee performance on your organization’s Facebook page. Regardless of which approach best suits your organization, you should never waste an opportunity to recognize an employee for being awesome!

Developing Self-Regulated Learners

One of the great flaws of the American educational approach is the focus on teaching content rather than teaching students how to learn. This has led to a mindset among students that learning is a process that happens to them rather than one involving intentional, independent and self-directed effort.³ Unfortunately, this same mindset is noticeable among EMS providers in regard to continuing education. Dissection of this issue points to deficiencies associated with self-regulation.

Self-regulated learning encompasses “full attention and concentration, self awareness and introspection, honest self-assessment, openness to change, genuine self-discipline, and acceptance of responsibility for one’s learning.”⁴ Such learning does not arise from simply reading and listening, but requires activities that actively engage the cognitive, psychomotor and affective domains. Further, self-directed learning requires students to set goals, develop a plan to achieve those goals, and monitor their focus and motivation along the way.⁵

In addition to the previously described characteristics, self-regulated learning also requires the learner to be proficient with self-evaluation. This is an area that is seemingly deficient in younger generations of learners. These individuals are often chastised for growing up during a time when our society developed an aversion to singling out individual performance and began the tradition of awarding participation trophies for youth sports and other activities.⁶ While the intent of this trend was to avoid the possible detriment of social alienation among impressionable and developing young minds, this approach has instead created many challenges to our current educational efforts.

The EMS providers we seek to educate may have grown up during a time in which they lacked the opportunity to accurately compare their knowledge, skills and abilities against their peers. Instead, these individuals may have been cultured to believe they possess trophy-worthy abilities without any true measure of those abilities. One can easily imagine how this mindset might contribute to a lack of engagement among individuals now forced to participate in continuing education activities, despite their perceived existing level of knowledge.

In order to develop self-regulated learners, EMS agencies should seek to clearly communicate their educational values to their employees. Additionally, the individuals responsible for developing education and training initiatives should consider utilizing activities such as meta-assignments. These tasks are intended to help students monitor their thought processes and actions associated with learning.⁵ While such activities might not be practical for routine use, they can be incorporated into your organization’s employee performance review process. EMS providers can then hone their self-evaluation skills through repeated comparison among peer, supervisor and self-evaluation metrics.

Incorporating Adult Learning Principles

While self-regulation is essential for life-long learning, the EMS educator must also contribute to the learning process by embracing principles of adult learning in the development of continuing education activities. There are many aspects of adult learning that should be recognized, but a student’s need to understand why they must learn the material at hand is paramount.⁷ EMS educators should be prepared to help students make this connection. Instructors should not wait for someone to question this need to learn, but should come to class eager to help students understand why. If the instructor cannot provide appropriate justification then the topic should be reconsidered.

Another important component of adult learning is the principle of immediacy.⁷ In order to maintain engagement among adult learners we must provide content that is immediately usable. It is not advisable to present a course on protocol changes that won’t take effect for six months. Instead, focus educational content on topics that can be applied right away. Training on the rollout of new equipment should be timed as closely as possible with the actual deployment of that device. While a lack of immediacy is detrimental to how receptive learners are, delays with implementation can result in knowledge and skill degradation that might compromise future performance, thus limiting the benefit of the original educational effort.

It is also important to avoid common pitfalls of EMS continuing education. In this regard, educators must use caution with allowing quality assurance (QA) activities to influence continuing education. EMS providers are often aware of isolated clinical and operational errors that happen in their organization. Educators should avoid the temptation to deliver continuing education to the masses as a result of an individual error. This can not only create a negative association with the agency’s QA program, but EMS providers will likely tune out a class they feel they are being subjected to as a result of an error they didn’t make. Instead, EMS educators should attempt to give field providers a voice in helping to identify topics for future education sessions.

Those responsible for curriculum development should establish a formal means through which providers can make requests for specific training topics. You might also find it useful to occasionally conduct surveys of all personnel to inquire about topics of interest. This can be helpful in identifying trends that might be useful for large-scale sessions. This will promote a sense of ownership for the content and may promote engagement among providers.

Instilling Curiosity

Perhaps the most effective way to keep experienced EMS providers engaged in continuing education is to foster their sense of curiosity—one of the four sources of intrinsic motivation.⁸ Fostering this attribute can lead to the pursuit of knowledge, for the sake of knowledge itself. This can be accomplished by capitalizing on the use of novel approaches to involve EMS providers in the research process.

While the National EMS Education Standards⁹ require paramedic graduates to have a “fundamental depth and foundational breadth” of knowledge pertaining to research, it is believed many EMS educators are not adequately prepared to conduct research, let alone teach paramedics about research.¹⁰ As such, those responsible for the delivery of continuing education have the opportunity to capture the attention of EMS providers and enhance their engagement by providing them with the tools needed to take ownership of their profession. This doesn’t mean that your agency’s training officer needs to be an expert researcher, but that individual does need to be able to facilitate the process of inquiry.

A great way to approach the topic of research is to start by having students follow the trail of references in a pertinent text. This can help an EMS provider understand the process that leads to evidence formation and can help unravel those practices that are guided by anecdote. EMS providers may find a sense of empowerment in realizing there is a greater source of knowledge than the often conflicting, minimally cited, paramedic textbooks that tend to perpetuate EMS dogma. Once an individual realizes that questioning the status quo can lead to productive answers, their curiosity may lead them to pursue higher-level inquiry.

Conclusion

The development of a culture of learning in EMS depends on the ability organizational leaders to model the behaviors previously described. Our leaders must not only promote pride in performance among their ranks, but must also take pride in their own performance. These individuals should intentionally and independently pursue a path of lifelong learning and must foster a learning environment within their organization that supports adult learners. Further, it is essential that those leading a culture of learning seek to expand the knowledge of our profession through a process of formal investigation. This is an important component of breaking down barriers associated with research among field level EMS personnel.

Given the wide variety of potential reasons why experienced EMS providers lack engagement in continuing education, these four recommendations do not represent a one-size-fits-all approach. Individual agencies might find that these concepts resonate within their organization, but they should also ensure that their decision making is informed by an educational needs assessment. Several of the recommendations presented here do not represent evidence-based education practice; however, this can be attributed to a lack of literature focused on the scholarship of teaching and learning in the specific context of EMS continuing education. Nonetheless, these recommendations represent reasonable solutions to further enhance the engagement of experienced EMS providers in continuing education.

References

1. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment, https://ems.gov/pdf/2011/National_EMS_Assessment_Final_Draft_12202011.pdf.
2. Marsee J. 10 Steps for Implementing Change. Business Officer, https://www.virginia.edu/processsimplification/resources/Implementing%20Change.pdf.
3. Ruohoniemi M, Lindblom-Ylänne S. Students’ experiences concerning workload and factors enhancing and impeding their learning-a useful resource for quality enhancement in teaching and curriculum planning. International Journal for Academic Development, 2009; 14(1): 69–81.
4. Zimmerman BJ, Schunk DH. Self-regulated learning and academic achievement: Theoretical perspectives. Mahwah, NJ: Lawrence Erlbaum Associates, 2001.
5. Nilson LB. Creating self-regulated learners. Sterling, VA: Stylus Publishing, LLC, 2013.
6. Elliott D. How to teach the trophy generation. Chronicle of Higher Education, https://chronicle.com/article/How-to-Teach-the-Trophy/123723/?sid=pm&utm_source=pm&utm_medium=en.
7. Knowles MS, Holton EF, Swanson RA. The adult learner: The definitive classic in adult education and human resource development, 7th ed. Burlington, MA: Elsevier, 2011.
8. Lepper MR, Hodell M. “Intrinsic motivation in the classroom.” In Ames C, Ames R, Research on Motivation in Education, Vol. 3. San Diego: Academic Press, 1989, pp. 73–105.
9. National Highway Traffic Safety Administration. National Emergency Medical Services Education Standards, https://ems.gov/pdf/811077a.pdf.
10. Carhart E. Faculty Perceptions of Barriers to Conducting Research in Accredited EMS Education Programs. Original Research Presented at the National Association of EMS Educators 18^th Annual Educational Symposium, Washington, D.C., 2013 Aug.

Elliot Carhart, EdD, RRT, NRP, NCEE is an assistant professor in the Emergency Services program at Jefferson College of Health Sciences in Roanoke, VA. He earned his doctorate from Nova Southeastern University, where his studies focused on healthcare education. He is a former firefighter/paramedic and currently practices as a registered respiratory therapist at Carilion Roanoke Memorial Hospital. Contact him at carhart.elliot@gmail.com.