EMS Field Instruction: Part 3--How to Be an Effective Field Instructor
The first article in this four-part series, Elements of an Effective Field Instruction Program , was written for managers who want to start or improve a field instructor (FI) program. Part two Adult Learning addresses leading theories about how adults learn. This month we look at what it takes to be an effective field instructor.
Congratulations! You have chosen to pursue one of the most difficult specialties there is. As if running an EMS call isn’t complicated enough, you now have to direct, teach and monitor someone else trying to do the same thing. You will be part coach, part encyclopedia, part mentor and part Obi-Wan Kenobi. Doing so will require use of all your EMS and teaching skills, but seeing your trainees grow into this job and perform confidently and competently is one of the most satisfying things you will experience.
Being Part of an FI Program
Hopefully, your boss is providing numerous tools and support to help you do your job. Some things you should be receiving are:
- A raise or differential. You are working way harder than just running calls, and you have more skills than the average staff employee. In addition, you are directly affecting the present and future course of the agency.
- Status. Since you are acting in a leadership role, both to new people and current staff, your pay and status should be equal to that of supervisors.
- A clear chain of command.
- Quality people to train. You can't teach EMS to a rock.
- Clear guidelines. Very clearly defined skills, performance levels and times for reaching goals.
- Effective documentation. If documentation isn't user-friendly and effective, it doesn't get used.
- Solid support for your decisions. It is vital that management listen to and respect your opinions, especially when you think a trainee should pursue some other passion, like heating and air conditioning.
The FI Program
One of the largest benefits derived from an organized program is consistency in employee performance; however, this only occurs when FIs stick closely to the training program. If you find yourself "wandering" during training, focus on changing the training program so all FIs are doing the same things. A mission statement can help keep everyone focused on the same goal.
Being thorough means verifying knowledge and experience that the trainees may not get to see during their FI tour. It is easy to simply run calls, observe and talk about them afterwards. But what if they go through their whole program and never see a uterine inversion, tension pneumothorax or foot degloving? Could that happen?
It's guaranteed they won't see everything. Your documentation ensures that they are competent in all areas of operations and medicine for which they are responsible. It is too easy to allow things to slip through the cracks. If a trainee runs a call a year and a half after training and completely messes it up because you didn't verify he knew how to treat crush syndrome, it is not fair to the patient who might get substandard care, even if this employee has done well in all other situations.
Training vs. Evaluation
You have two main jobs: to teach and to evaluate. Balancing those functions will often be a challenge, so begin as approximately 80% teacher and 20% evaluator and slowly transition throughout training to the opposite. By the time students reach the end of field instruction they should be acting completely independently.
Early in training, be relaxed and forgiving. Inform students as your focus shifts. In the last few weeks, tell them you are evaluating them carefully and they should be at their best. By then, they will be comfortable with you and your program, so the pressure will be more tolerable and they will perform better.
Paperwork
Documenting all the things you have verified your trainee knows can involve a lot of paperwork. Using downloaded forms from the publisher or creating your own will save lots of time and make documentation possible. If the paperwork is too difficult, it won't be used properly. You should have:
- Trainee questionnaire (to record their previous experience)
- A single call assessment evaluation
- A daily evaluation (goals for the day and week)
- Knowledge review
- Competency checklist (the master list of all required skills)
- Tour evaluation form
- Special report form for any issue that requires extra documentation. It is like a mini-version of the FI process. State the problem or goal, create a plan, evaluate results.
- FI instructor evaluation (for the trainee to evaluate you)
- FI program evaluation (for the trainee to evaluate the program)
- Quality assurance form. This is used to track 100% chart review for a period of time after they clear field instruction.
Whew! Let's get started! It's your first day with a new trainee. Hopefully you've had a chance to review his file so you are familiar with his background. After introductions, immediately lay out your expectations and goals for the day. Reassure him that you are his partner in training and you will work together at a speed that works well for both him and the field instruction program.
The first day it is best to just let him observe and keep it low pressure. One of your jobs is to make the trainee comfortable. Frequently assess his stress level and comprehension. "Am I going too fast?" "What do you think you need today?" "Let me know if a situation makes you uncomfortable."
Information overload
Decide on your goals for the day and stick to them as much as possible. The million little details that are locked in your vault should be doled out appropriately. If you bombard your trainee with a billion bits of information, his eyes will glaze over after a few hours, he will not remember them, and he'll eventually tune you out. You must allow for some silence in the ambulance during the day.
The importance of honest feedback
Throwing a trainee to the wolves, putting him in high-pressure situations so you can have the satisfaction of watching him sweat, and then chewing him out later might be fun for some people, but it has no place in a professional training process.
The more honest feedback you can give your trainee, the better. If he is failing at something, don't sugarcoat it, but put it in perspective. "You haven't verbalized the need to give Solu-Medrol. Let's give it now and we'll talk about why after the call." Don't forget to point out the things he did well.
Goals
It is most effective to create goals for the shift, the week and the tour. There is a place for this on the daily evaluations. Goals should, of course, be evaluated and adjusted often. This quickly tells you if the trainee is keeping pace and lets both of you directly see his progress.
An example of some good goals for the first day are to go through the ambulance to learn location and type of equipment, observe customer service, take a tour of the base and pay attention to major roads.
Begin Day 2 with more focused goals like driving nonemergent, talking on the radio, cot operations and introduction to mapping. Let the trainee take responsibility for his participation in training. For example, rather than going through the ambulance to show him where everything is, having him go back and find everything will be more effective. You must make it clear immediately that he will not be a passive participant in training. We are not there to "spoon feed" training. Adult learning theory shows that the more involved someone is in the learning process, the more effective it will be. (The Adult Learner, 6th Edition, Knowles, Holton and Swanson, Elsevier 2005.)
Tell the trainee that at the end of three shifts you will quiz him on equipment, and he will have to know where everything is kept. Leave it at that. After three shifts, if he hasn't spent any time on this or can't do it, let him know he is falling behind and not living up to expectations. If he expresses a legitimate reason for failing, give him a new deadline with a mutually arrived-at plan to overcome the problem.
If a trainee is having trouble meeting deadlines, notify your director. If he is failing at simple things, he will probably fail other more important skills later if his attitude or training is not adjusted. And, the FI period could drag on past normal limits if you allow it.
Mapping
This may be simple or complex, depending on city planning in your area. Hopefully you have a resource sheet of information for the trainee that includes coverage area, address scheme, major roads, neighborhood information (e.g., an area has street names that follow a pattern), exceptions to addressing, a list of major facilities (stadiums, jails, nursing homes), how to use maps and alternative ways to map. The complexity of your district will directly affect how complex this segment of training is. Create a mini-course if needed. Prepare a list of addresses and have the trainee practice mapping until fluent. Remember, learning by doing is best.
It is much more effective to teach trainees how to map well than to focus on "showing them around." First, you can't show them everything. Second, they can't remember everything. Third, new buildings will be constructed and others torn down after their training. If you teach them mapping fundamentals, they will always be able to find any address in your area.
Knowledge assessment
It's true that book knowledge is no substitute for running calls, but book knowledge is still required in our job. Although knowledge is assessed during school and certification with written tests, there are limitations. Multiple-choice tests are easy to fudge and do not necessarily truly gauge knowledge. Fill-in answers provide a much more accurate picture, but are more time-consuming to create and grade. And there are people who have the knowledge but have difficulty transferring it in a written environment. The knowledge course that accompanies this series is a very good alternative.
One of the main reasons for the knowledge review is to find gaps in the student's training. Maybe he was sick during that component and never really got it. Unlike many other disciplines, EMS doesn't have a section that is disposable. If your trainee got an 80% in class, which 20% is he missing? This scares me. Obstetrics or pediatrics are each less than 20% of the curriculum. Let's hope it's not those. The knowledge review covers the entire curriculum and will expose any important gaps.
These courses (with versions for EMT and paramedic) assess knowledge and teach in an interactive format and are designed to be used in the ambulance during down-time. The instructor verbally asks the trainee questions and grades his answers on a sliding scale. It allows the instructor to teach what might be lacking and refer the trainee to books or to assign homework. Their answers are graded and can be referred to later to assess progress. The advantage to this process is that it is fluid and adapts to the speed and needs of the trainee. There are many degrees of "right" answers. If I ask you to explain the pathophysiology of CHF, there is more than one right answer, but I can tell if you get it or not by what you say.
Driving
Driver training can be fun and rewarding. Hopefully, your agency includes a driving course, which should take place before trainees show up on your rig. However, you might be their first point of contact for driver training.
The trainee should be comfortable driving nonemergent in your vehicle. If you assign driving, don't add other training (like knowledge review) while this is going on. If he is concentrating on driving (as he should), other training will not be effective. If he already knows the coverage area, this can be quick. Let him drive around for a couple of hours. Point out that he should be a courteous driver during nonemergent driving, always leave space to maneuver if there is an emergent call, and swing wide on turns to avoid the "curb check."
Once he is comfortable with the vehicle, orient him to all emergent systems before he has to use them. Make sure he knows all applicable local laws, and always tell him he must stop and clear all intersections. (If you fail to do this and he crashes, he could claim ignorance and blame you.)
We do many things automatically while driving emergent. For example, staying to the left side of your lane helps "push" traffic to the right. If your trainee isn't doing the right things, think about the underlying principles involved before you try to redirect his actions. Obviously, if he isn't safe, tell him to pull over. Try to go over appropriate parking ahead of time. Diagrams will help.
Running calls
Once your trainee has had a chance to observe a few calls, let him transition to doing more. I usually start inexperienced trainees on skills like BPs, IVs, history, physical exam, and so on. It is vital to have the trainee verbalize everything he needs. Since we can't read trainees' minds, if they think something but don't say it, we can't document that it was done. If they protest when you write "failed to do X today," you tell them, "If you don't tell me, I can't know if you thought of it or not." They will next time.
If you are training with three people, be careful not to start running calls as a three-person crew. Once in the back of the ambulance it is easy to help your trainee, but he has to get everything done once he is cleared, so at some point you have to stop helping and see how he does.
Your partner
Being a third on an instructor ambulance can be stressful for your partner, who may lose the chance to perform procedures he likes doing and may be relegated to a secondary role. It is important to keep his needs in mind and try to compensate for the inconvenience. Let him run a call from time to time, not only to keep him in the game, but to give your trainee a break.
Remind your partner to not offer too much help to a new trainee. The trainee must be able to recognize things independently without help. This is very important for his evaluation. If your partner jumps in to pick up the slack, you will never know the trainee's ability.
Teach trainees how to treat their future partners. New paramedics sometimes treat their EMTs like personal valets, and nobody deserves to be treated poorly on the job. Spending a little time showing trainees how to make their partners feel appreciated will lead to a much happier work environment for everyone.
Nuggets
A nugget is a piece of information that is objective, recordable and pertinent. You should always actively look for them. In addition to teaching, your job is to verify that your trainee is capable of certain things without being told, prompted or helped. For example, you are called to a trauma scene. Before you step out of the ambulance you can see your patient qualifies for a full trauma team activation. As the trainee approaches the patient, step out of earshot, call the trauma, but don't tell him you've done so. Hopefully, he will realize it soon after and verbalize the need. Bing! You have your nugget. If you call the trauma, you will never know if the trainee would have done it himself. This is what makes you a professional.
If the trainee starts treatment and doesn't say anything about a trauma-team activation until you pull into the ER, you have a different type of nugget. If he failed to recognize or verbalize the need, this is a crucial piece of data.
One habit to develop is, at the moment you realize the need for something, hold that thought for a minute or two. If your trainee still doesn't get it, you can "suggest" it to him. Many times he will "get it" but just need a little more time. Obviously, if it's something like chest compressions, waiting isn't appropriate.
Once the trainee is able to put together major components of running a call, disappear into the background as much as possible. You can direct him if he seems to be getting off track without taking over the call. If he is running long on scene time, ask "What is your goal for scene time?" He might have a legitimate reason that you are unaware of. Tapping your watch with a disapproving look is condescending and contrary to our goal of positive, supportive training.
Have fun
Make a conscious effort to crack an (appropriate) joke at least once a day. Being in training is very stressful, and the trainee might see you as a stern, serious taskmaster with no discernable sense of humor (especially if you are). Jokes will go a long way toward making your trainee relaxed, comfortable, and more able to absorb material and work hard.
Taking over a call that is not going well
There are two ways to take over a bad call. First is the stealth method, where you start directing your trainee but leave the impression he is in charge. A colleague had an excellent way to do this. On their first day, he told trainees if he ever said anything prefaced by "how about…" that meant do whatever followed. So if you said, "How about we do an ECG?" they would ask for the ECG. This allowed continuity for the patient and pointed out to the trainee what he was missing, but still allowed him to be in a leadership role. Or, just hand them the ECG cables and they will get the idea.
The second method should be the last resort. Simply say, "I'm taking over the call" and move into that role as discreetly as possible. If you make the switch while moving the patient to the ambulance, it's possible no one will even notice. It's very important not to embarrass or humiliate your trainee. After the call, discuss the failure and explain clearly why you took over. Don't take over a call just because it isn't going smoothly. Take over only when patient care is in serious jeopardy and there is no other way to direct your trainee.
Personality conflicts
Let's face it, not everyone gets along with everyone else. You must be able to separate your training style from your personality to some degree. Your trainee may not be your cup of tea, or vice versa, but stay objective. If he is working hard, has a good attitude and listens to what you say, his taste in music doesn't really matter (until he becomes your permanent partner).
If a trainee rebels because of you, you need to adjust your teaching style. Tell him up front, "We seem to be having a tough time, and I think it might be because of me. What can I do differently to make this smoother?" This is how you will learn to be a better instructor. It can also be a back doorway to make him realize that he is the problem.
If the trainee has a bad attitude or is lazy, don't tell him that directly, but point out that he doesn't seem to be taking your direction well. Then ask him why. If he is simply not taking his fair share of incentive to study, say "I've noticed that when we have a moment free you are reading a magazine instead of studying mapping. Do you feel this is a waste of time?" If he says "yes," you have easy documentation on attitude. Once again, lay out goals and expectations. If you have been documenting goals daily, you can easily scrape this barnacle off your organization. Avoid becoming too familiar with your students. Even if it's someone you really like, save the friendship for after training. Hold a high standard to avoid offending your trainees. If they don't respect you for something you said, it will be hard for them to respect you as an instructor.
Patient reaction
What do patients think about the field instructor program?
Patients often notice that you are directing your trainee. If they ask, explain that this person is training and you are a field instructor. Tell them if the trainee isn't doing everything the way he should, you will do it. That usually reassures them that they are getting the best care possible.
Being a field instructor can be extremely challenging and rewarding at the same time. I know it will improve your practice. You will learn things about EMS that you never thought of from trainees' questions and participation. Having a desire to teach and learn is a great way to keep your love for this business alive and avoid call burnout, as it gives you a whole new perspective on EMS.
Related:
Chris Hendricks was a field instructor at Pridemark Paramedic Services for five years and has trained over50 EMTs and paramedics. He currently works as a nurse, paramedic, author and educator in Colorado. He welcomes your questions and comments at medic2033@hotmail.com.
