It would be unreasonable to demand every EMS student get 100% on every exam or be kicked out of their program. If a prehospital provider forgets to ask when the patient last ate or leaves the bandage a little loose when placing a board splint, you can say they have room for improvement, but it’s unlikely the patient will die as a result. And yet nobody wants an EMT who is “pretty good at stopping hemorrhage most of the time” or a paramedic who “can usually get a tube within the first few tries.” Sometimes mere competence is not enough. These skills demand mastery.
The American Heart Association recognized this in its 2018 scientific statement on resuscitation education. The very first education strategies it identifies are mastery learning and deliberate practice. While these strategies go together to help learners perform identified skills at a mastery level, the trick is to use them the right way to achieve the desired results.
It can be argued that only experienced practitioners can achieve true mastery of a skill, and this may be true of some definitions of mastery. However, students of all stripes must be able to perform some skills at a high level of expertise straight out of the gate because lives will truly depend on it.
Identify skills that require mastery—The first step is to identify the knowledge, skills, or attitudes (KSAs) that must be achieved at a mastery level. These are the KSAs that will have the most positive impact on patient outcomes. Both the educator and student must be able to articulate why the EMS provider must be able to perform these skills, above others, correctly without fail. Quick examples include the ability to identify immediate life threats on the primary survey as well as the ability to perform lifesaving interventions.
Set performance objectives—Determine what the student (the audience) must be able to perform as KSAs (the behaviors), in what contexts (the conditions), and how well they must be demonstrated (the degree). These “ABCDs” of objectives should focus on the outcomes you’re trying to achieve, rather than the ways in which you’re trying to achieve them.
For example: The student will endotracheally intubate the patient on the floor with 90% first-pass success. This example objective specifies the audience, behavior, conditions, and degree but does not demand the provider use a gum bougie, video laryngoscopy, head-up/elevated positioning, etc. These tools and techniques may be helpful to the student or preferred by the instructor, but if the objective is to place an endotracheal tube to secure the airway, then the instructor should not arbitrarily restrict student resourcefulness in meeting the objective. If it is desired that the student be able to effectively use certain equipment or techniques, they can be addressed in separate lessons, but if the goal is for the student to be able to use their available skills along with critical thinking to solve a clinical problem, it defeats that purpose to mandate specific steps for them to do so in the final mastery-level evaluations.
Use purposeful practice—The performance objectives you have set define what you will need for the student to practice the skill until they achieve mastery. They (the audience) will need to perform the actual skill (the behavior) under actual or simulated circumstances (the conditions) until they can meet the requirements (the degree). To be clear, there is no way a student can achieve mastery of any task without actually performing it. In fact, they will need one more “secret ingredient” to do so.
Provide external feedback—In addition to the ABCD objectives, students will also need EF, external feedback. This can be provided by peer students, instructors, or automated feedback devices. The important thing is that when students practice, they receive constructive evaluation on their performance. Practice without this feedback is worse than no practice at all. At least a student who has not practiced may have a chance at performing correctly, whereas a student who has practiced incorrectly without external feedback has reinforced improper behavior and will almost certainly perform incorrectly.
Feedback must be centered around the performance objective. While other references can come into play, many well-intentioned educators find themselves providing students with “tips and tricks” that are based on educator preferences rather than objective feedback on the student’s pursuit of the objective. Furthermore, this kind of feedback can easily slide into a minilecture that takes valuable time from student practice. Yes, some students may benefit from a bit of brief review or correction, but whenever you are tempted to re-explain something during a practice session, ask yourself: Do you want the student to be able to talk about the skill or actually perform it? If the answer is the latter, let them get back to purposeful practice.
Employ overlearning—Mastery learning has been described as training students not just until they get it right but until they can’t get it wrong. For EMS this means not stopping the purposeful practice and external feedback as soon as the student can perform the skill up to standards.
Another applicable phrase is that when the situation is critical, you do not rise to the occasion, you fall back on your training. This is why critical skills that demand mastery learning will require overlearning—practice even after you’ve gotten it right. In addition to our ABCD and EF, I might add G for Go try it another way. While the additional practice of overlearning can have some value in establishing “muscle memory,” even greater value is gained by varying the conditions or degree of performance objectives or the scenario and tools provided. The goal is not to have a student practice under every imaginable condition or with every possible challenge; the goal is to build the student’s comfort with the tools and techniques, increase confidence in their abilities to adapt, and enhance their critical thinking skills to be able to perform lifesaving interventions under suboptimal and dynamically changing conditions.
Rommie L. Duckworth, LP, is a dedicated emergency responder and award-winning educator with more than 25 years working in career and volunteer fire departments, hospital healthcare systems, and public and private emergency medical services. He is currently a career fire captain and paramedic EMS coordinator.