The Five Phases of Preceptorship

In 1977 I graduated from a hospital-based paramedic program, which didn’t have a structured ambulance internship in the plan of study.

Since it was the only program around, I was happy to just have the opportunity to go to paramedic school. Furthermore, the paramedic profession was in its infancy during this timeframe, so ambulance services only had first generation paramedics to assist with the learning and orientation process. For all intents and purposes, these first generation paramedics utilized camaraderie to help each other learn the “street medic” way of doing business.

I have very fond memories of those early days, but to be honest my street orientation to the paramedic profession was nothing more than on-the-job training. Today, paramedic students transition from classroom to street via a rigid process known as the field internship, which documents competencies, outcomes, etc. However, does our profession mirror other healthcare professions such as nursing and medicine when it comes to clinical internships? Or, do we still rely on an on-the-job training mentality without looking at today’s research of clinical internship.

In 2011 I conducted in-depth, face-to-face, audiotaped and transcribed interviews with paramedic preceptors to gain a better understanding of ambulance preceptorship, and to assist with revising our current preceptor workshop.¹ What seemed obvious during the interviews was that it takes a unique individual to simultaneous care for a patient while educating and evaluating a student. Overall, this article will discuss the similarities these preceptors utilized to teach, mentor and evaluate students during the field internship.

Field internship, or ambulance preceptorship, should not be confused with ambulance orientation, since ambulance orientation teaches a new hire how the EMS organization handles business—policies/procedures—on a daily basis. Nor should it be confused with the credentialing process that medical directors utilize to validate clinical competencies of paramedics by the use of their clinical coordinator and field-training officers. However, preceptorship is a widely used teaching method by a number of healthcare professions that utilizes preceptors as the gatekeepers for their profession.^2,3 In other words, if a student wants to graduate and sit for their licensing examination, they must first successfully pass through a preceptorship before permission is granted.

When it comes to the field internship, preceptors utilize an array of theories, such as adult learning theory, transformational learning theory and mentoring theory, as the theoretical framework to assist with the learning process. The question is how do they do what they do to accomplish this, while keeping the patient safe and providing appropriate care in a timely manner? Overall, this requires a well-developed preceptorship curriculum, along with preceptors who have the ability to multitask beyond their normal daily patient care interaction.

Knowles⁴ defines the European term andragogy as the art and science of facilitating adult learning. He also identified five basic assumptions of adult learning: (a) adult learners have a need to direct their own learning, (b) adult learners bring life experience to the learning process, (c) adult learners have a readiness to learn that is aligned with changing their social roles, (d) adult learners need to see the importance of what they learn and wish to apply this new knowledge immediately, and (e) adult learners are internally motivated to seek knowledge.

In conjunction with the five basic assumptions of adult learning, Knowles⁵ describes the six elements necessary to the andragogical model of education: (a) establish an environment for learning, (b) create an atmosphere for mutual planning, (c) mutually formulate learning objectives, (d) develop learning plans that involve learning contracts, (e) conduct the learning experience with appropriate resources, and (f) evaluate the learning outcomes and learning needs.

Along with adult learning theory, preceptors utilize transformational learning theory, which attempts to describe and analyze how adults learn to make meaning of their experience.⁶ Transformative learning involves reflectively transforming the beliefs that constitute meaning perspectives or schemes. In other words, for an adult learner to change their beliefs and attitudes, they must first engage in critical reflection on their experience, which in turn leads to transformation. To accomplish this, the preceptor will help the adult learner focus and examine the assumptions they have on a specific patient scenario; assess the consequences of these assumptions; identify and explore alternative sets of assumptions; and test the validity of the assumptions through reflective dialogue.

Finally, preceptors utilize mentoring theory to assist with the presentation of cognitive, psychomotor and behavioral characteristics of a healthcare practitioner to the adult learner. According to Kram,⁷ mentoring are those aspects of a developmental relationship that enhance both individuals’ growth and advancement. Psychological mentoring centers on enhancing a protégé’s self-esteem and confidence, which builds a sense of competence, clarity of identity and effectiveness in a professional role. This type of mentoring consists of providing counseling, camaraderie and role modeling. Conversely, career mentoring centers on career-related support by exposure, visibility, protection and sponsorship.

Overall, a defining condition of being an adult is the need to understand the meaning of experience.⁸ Adults learn to make their own interpretations rather than act on the beliefs of others. Facilitating such understanding is the goal of adult education and developing autonomous thinking is the purpose of transformational learning theory. Mentorship assists with learning the ropes of the profession by utilizing the mentor’s experience and position. Mentoring links concepts and practices, and promotes reflection through the transfer of knowledge from one situation to another. Furthermore, the adult learner is motivated to gain fresh knowledge, reconsider ideas, and confront existing concepts of truth when learning experiences are individualized and flexible by a valued mentor.

The Five Phases of Preceptorship

For the most part, the paramedic preceptors I interviewed shared some commonalities, which in turn led to a revision of our preceptor workshop. Today, we utilize a five-phase approach in the field internship to facilitate learning for our paramedic students.

Pre-Shift Phase

The timeframe at the beginning of each shift is one of the most important components of the internship for the student. After preliminary duties (equipment check, etc.) the preceptor and the student should utilize this time to develop objectives for the shift, which correlates with how the student is performing and where the student needs improvement. Objectives are also dependent on the number of shifts the student has already ridden. Early shifts focus on psychomotor skills, assessment and history gathering. Shift objectives then focus on delegation, scene management, clinical judgment and differential diagnosis. Finally, shift objectives focus on radio reports, transfer of care patient reports and documentation.

To ensure both parties understand the daily clinical objectives, the use of learning contracts is extremely helpful. A learning contract is a two-part document that has an area for clinical objectives and an area for preceptor notes, which allows the preceptor to expand comment on individual objectives. There should also be a signature line for both the student and the preceptor. The learning contract is also a valuable document at the end of the shift when the overall shift evaluation is being filled out, since it helps compare objective versus outcome. Generally, it is extremely difficult to predict the type of patient encounters for any given shift, so listing a specific patient illness or injury is an unrealistic objective. However, listing “improve verbal communication when delegating tasks” is a good example of an overall clinical shift objective. Finally, the number of clinical objectives for each shift should be small, since the goal of the learning contract is to focus/highlight specific learning opportunities and not list all the tasks students are required to do.

Patient Care Phase

The role of the preceptor is a very significant but stressful position, since a preceptor has the unique position of taking care of both the patient and student simultaneously. Preceptorship allows the student an opportunity to practice assessments, skills and clinical judgment under the watchful eye of an experienced clinical practitioner. The preceptor makes the clinical environment safe for both the student and patient, but the value of the clinical experience will depend on the quality and willingness of the preceptor to teach in the clinical environment. In other words, a major asset to student learning is the preceptor’s knowledge and experience along with the preceptor’s attitude and approach.

Classes to street: Preceptors have the difficult position of transitioning students from the controlled environment of the classroom to the chaotic environment of the streets. Most students have not spent a lot of time on an ambulance prior to coming to a paramedic program, so they are initially overwhelmed by the sheer impact of the emergency setting. Preceptors struggle with getting students to gather information from different sources, prioritize care, delegate responsibilities and maintain control of the scene. However, with time students achieve competency in all of these “street smart” skills. Preceptors accomplish this transition to the street by role modeling, skill assignment, coaching and providing constructive feedback. By gradually delegating specific patient care tasks, preceptors provide a framework for learning until students are running the entire call.

Guardian of care: One of the problematic aspects of being a preceptor has to do with the dual role of clinical teacher and patient care provider. Preceptors provide a type of safety net for patient care by ensuring students that potential mistakes will be stopped and assistance is always at the ready. “Stepping in or staying back” is the method utilized to ensure the safety net environment. The preceptor will step in to protect the patient or will stay back to let the student learn. Most preceptors feel this is the most apprehensive part of the job and usually step in sooner than needed during the early stages of preceptorship. This usually happens due to unfamiliarity with the students’ performance and abilities. Overall, requirements for stepping in or staying back centers on the action or inaction of the student, which would cause harm or be detrimental to the patient.

If what a student was doing was not an appropriate intervention, was going to harm the patient, or if they had not recognized that this was a critical patient that needed appropriate interventions immediately, that is usually the line in the sand to step in. (Anonymous Preceptor)

When potential harm or lack of intervention was going to lead to harm, preceptors step in and get things handled, and then try and get the student to reengage the patient encounter after some stabilization and interventions. (Anonymous Preceptor)

Debriefing Assessment Phase

Education research shows effective clinical teachers ask questions to evaluate the learner and provide meaningful feedback in a timely manner. To accomplish this some preceptors utilize a five step mini run review process after each patient encounter. This allows the learner to discuss the call, allows the preceptor to ask questions and clarify information, and provides time for a teachable moment. The mini run review, which utilizes the one minute preceptor model employed in some residency programs, is based on the five microskills for clinical teaching: (a) get a commitment, (b) probe for supporting evidence, (c) reinforce what was done well, (d) give guidance about errors or omissions, and (e) teach a general principle.⁹

Get a commitment: Ask questions about what the student thought was going on. This invests the learner further into the patient encounter and allows the preceptor to assess problem-solving skills.

Probe for supporting evidence: Explore the basis of the student’s opinion and what they have committed to in the previous step. This is accomplished by asking what factors support their field impression and why they chose their specific treatment plan. These questions help determine if it was a lucky guess or was it a well-reasoned and logical answer.

Reinforce what was done well: Provide the student with some specific positive feedback since positive behaviors need repeated reinforcement to become firmly established. This also increases the likelihood that these behaviors will be incorporated into future patient encounters. However, “good job” is too vague and should not be utilized as a standard feedback answer.

Give guidance about errors or omissions: Correct the student’s mistakes by describing specifically what was not done correctly, what the consequences might be and how to correct it in the future. However, avoid negative labels such as “bad” or “poor,” or the student may see this as criticism rather than constructive observation.

Teach a general principle: An important and challenging task for any student is to take new information from one patient encounter and generalize it to others. However, not all patient encounters provide the opportunity to teach a general principle. Therefore, if the situation arises the preceptor should be prepared to discuss differential diagnosis, signs and symptoms, treatment options, and available resources. For example, “remember to obtain allergies, medications and past medical history prior to giving medications.”

Post-Shift Phase

The overall shift evaluation summary takes into account the student’s performance over a specific period of time ranging from 8–24 hours. Some preceptors also document individual patient encounters in conjunction with the shift evaluation summary to assist with assessing the student’s overall shift performance. When providing shift summary feedback, preceptors should present information that helps the student decide whether their actions had the intended desired effects. Positive feedback reinforces behavior and encourages repetition of those behaviors by communicating they had the intended desired effects. Negative feedback discourages behavior by communicating they did not have the intended desired effects. Areas of the overall shift evaluation should include interview, exam, treatment, skills, leadership, professionalism/attitude, radio communication and patient care reports.

When preceptors review the shift summary with the students they should attempt to maintain a positive learning environment and adhere to the laws of learning. Furthermore, new preceptors and even some veteran preceptors need to be aware of potential evaluation bias that they may unintentionally bring to the evaluation process.

Student Advising Phase

Throughout the field internship, the paramedic program director or field internship coordinator should try and meet with each student every 10–15 shifts to review the student’s progress by appraising their documentation (learning contracts and shift evaluations) and terminal competencies pertaining to their prehospital clinical performance. Furthermore, monthly preceptor meetings should also be scheduled throughout the internship to validate individual student performance and to evaluate the overall effectiveness of the program.

Microskills Summary

• Get commitment (Assess)—“What do you think is going on?”
• Probe for rational (Assess)—“What led you to that conclusion?”
• Reinforce what was correct (Feedback)—“You did an excellent job of…”
• Correct mistakes (Feedback)—“Next time this happens, try this…”
• Teach general rule (Instruct)—“When this happens, do this…”

Positive Learning Environment

• Provide guidance, support, and encouragement
• Be fluid and flexible
• Acknowledge there is more than one way to accomplish a task
• Attempt to respond to student’s needs

Laws of Learning

• Individuals accept and repeat responses that are pleasant
• First Impressions are lasting
• Repetition yields habit
• Skills not practiced are forgotten
• Dramatic experiences leave lasting impressions

Preceptor Evaluation Errors

• Contrast effect: Evaluate a student relative to other students rather than the standard
• First Impression: Make a first favorable or unfavorable judgment and ignore or distort any further information
• Halo effect: Evaluate a student utilizing one part of their performance and extending it to all other areas of performance
• Similar to me effect: Evaluate a student more favorable if he or she has a similar personality to the preceptor
• Blanket approach: Evaluate a student in regards to their need to be liked or by playing it safe “everyone meets standard”

Summary

Clinical teaching has been one of the most important but problematic areas of professional education.¹⁰ Clinical knowledge rarely corresponds with the theoretical knowledge that students acquire in the classroom and lab setting, contributing to a theory-practice gap for the patient care provider. This gap leads to the difficulty and disillusionment experienced by students during their field internship. To assist students with transitioning to the prehospital environment, paramedic preceptors are a necessity. However, regardless of their prehospital experience, paramedic preceptors may not have had proper education in the teaching–learning process and may not have been provided a quality preceptor training program. At present, there is no nationally sponsored preceptor program that effectively prepares field internship preceptors as clinical instructors even though accreditation now requires education for all paramedic preceptors. It is my hope that this article may be useful in the development of quality preceptor workshops, which will enhance the overall field internship experience to better prepare future paramedics.

References

1. _{Gurchiek DJ. The meaning of ambulance preceptorship: Paramedics’ lived experience of being a field internship preceptor (Doctoral dissertation). ProQuest Dissertations and Theses database, UMI No. 3460482, 2011.}
2. _{Ashurst A. Career development: The preceptorship process. Nursing and Residential Care, 2008; 10(6): 307–309.}
3. _{Yonge O. Meaning of boundaries to rural preceptors. Journal of Rural Nursing and Health Care, 2009; 9: 15–22.}
4. _{Knowles MS. The adult learner: A neglected species, 3rd ed. Houston, TX: Gulf Publishing, 1990.}
5. _{Knowles MS. Andragogy in action: Applying modern principles of adult learning. San Francisco, CA: Jossey-Bass, 1985.}
6. _{Mezirow J. Transformative dimensions of adult learning. San Francisco, CA: Jossey-Bass, 1991.}
7. _{Kram KE. Mentoring at work: Developmental relationships in organizational life. Glenview, IL: Scott Foresman, 1985.}
8. _{Imel S. Transformative learning in adulthood. ERIC Document Reproduction Service No. ED423426, www.ericdigest.org/1999-2/adulthood.htm.}
9. _{Gordon K, Meyer B, Irby D. The one minute preceptor: Five microskills for clinical teaching. Seattle, WA: University of Washington, 1996.}
10. _{Mantzorous M. Preceptorship nursing education: Is it a viable alternative method for clinical teaching? Nursing, 2004; 19: 1–10.}

David Gurchiek, PhD, NRP, is the director of the Paramedic Degree Program and department chair for Nursing, Health and Public Safety Programs at Montana State University–Billings. Dr. Gurchiek has over 38 years of experience in emergency services, serves as a legal expert witness and consultant for prehospital emergency medicine, and is an accreditation site visitor for CoAEMSP. As a nationally recognized speaker, he has lectured at over a 100 state and national EMS conferences throughout the United States. He can be reached at dgurchiek@msubillings.edu.