Most students attend classes either because they want to improve their performance or someone else wants them to. Someone’s not performing well with their endotracheal intubations? Back to training! Education is often the first tool wielded to solve performance problems, even when the problem isn’t a lack of education. Part of your job as an educator is to be able to identify when more education is not the solution.
Begin by identifying the desired competency. You can do this using a four-part question: Who (audience) must do what (behavior) where and when (conditions) and how well (degree)? This is the classic audience, behavior, condition, degree (ABCD) format used to identify desired performance goals.
Then ask the same question about who’s doing what, where/when, and how well right now. This is your current performance. The answer may not be readily available. Don’t assume. Collect data. Interview the people connected with the problem. Observe what you can of their real-world performance. The difference between where you are right now and where you want to be is the performance gap. Just teach them to be better, and you’ll close that gap, right?
As you probably guessed, not so fast.
Let’s say the desired performance is for paramedics (audience) to be able to endotracheally intubate (behavior) in the field using the supplied intubation kit (conditions) with 90% first-pass success (degree), but current first-pass success is only 60%. Is it time for an intubation update class? Maybe. What if the paramedics are skilled but don’t have tools such as bougies and video laryngoscopy to improve their success rates? What if the paramedics have the equipment and were taught how to use it but intubate so infrequently they may not remember or have the confidence to perform when the patient’s crashing? What if only paramedics attended intubation classes, so their EMT partners don’t know how to help position the patient or otherwise facilitate the intubation? What if paramedics think using these tools and techniques is a sign of weakness?
Many factors may contribute to a performance gap. Paramedics may lack the knowledge, skills, or attitudes needed to achieve the desired level of performance. If so, education in some form may help. Other key factors to consider include supply, situation, and system problems that may keep paramedics from achieving their goal no matter how much education they receive.
If you still need to reduce the performance gap, consider solutions that reduce or eliminate these key factors. In our example this would mean making sure all necessary intubation tools are consistently available and easily accessible for field use; realistic airway management practice opportunities are frequently available; and perhaps EMTs could be included in future difficult-airway programs to improve teamwork and coordination. Debriefing and constructive feedback should be an inherent part of these opportunities.
In addition, consider checklists and job aids to help build confidence and improve the consistency of first-pass intubation success. If commercial airline pilots can use these tools to keep aircraft from crashing, surely we should consider them for our patients. Respected lead paramedics and informal group leaders might be recruited to promote effective use of tools and techniques and help change attitudes like, “Real paramedics only need a tongue depressor and a garden hose, and they can intubate anyone!”
As educators we’re inclined to play to our strengths. When presented with a performance problem, we tend to try to educate our way out of it. Most times a great educator will be able to move the needle, but to really close those performance gaps we need to consider the key factors for which education is not the solution. It can be easier said than done, but the first step to solving these more complicated problems is to stand up and say, “We need to do more than have another class.”
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.