Administration and Leadership, Training

Paramedic Hybrid Education Programs Brings Learning Opportunities to Everyone

Issue 11 and Volume 40.

In the lobby of the National Medical Education & Training Center in West Bridgewater, Mass., hangs a large map of the world peppered with red dot stickers. (See photo above.) The stickers represent the places our paramedic students come from— Qatar, Australia, Switzerland, the Philippines, Iraq, Afghanistan, Germany, Ireland, St. Croix, the Cayman Islands, the Turks and Caicos Islands and points throughout North America.

Each dot tells a story about why the student couldn’t attend a local paramedic program and what drove them to enroll in nontraditional education. Their personal journeys are long with many obstacles, including the constant need to overcome the negative connotation that surrounds attending a hybrid paramedic program.

For more than 30 years, brick and mortar classrooms have been the only way EMS education was delivered in many parts of the world, so why change the model?


Our profession had begun to dabble in online continuing education classes, but most initial paramedic programs still continued with the same traditional delivery model they’d used since the 1970s with students and an educator in a physical classroom, where technology isn’t used for any part of the course, and quizzes and exams are taken using paper and a writing tool.

I began to question my own teaching methods years ago after an EMT approached me to see if there was an alternative way she could attend paramedic school. She was divorced and taking care of five children while working full-time for a private ambulance service.

Listening to her story, I could feel the passion she had for her chosen vocation. She wanted to take her patient care and career to the next level. I asked myself how I could help her and wondered how many others had similar stories and barriers to becoming a paramedic.

Today, there are many new education models that embrace modern technology and they have many different names—online, hybrid, blended, Web-enhanced, synchronous, asynchronous, e-Learning, Web-based, distance education, or Web-facilitated course.

In a Web-facilitated course, 1–29% of content is distributed with Web-based technologies but it’s still essentially a face-to-face course. It may bring in the use of a learning management system (LMS) or a content management system (CMS)—the online area where handouts, syllabi and ancillary materials are stored for student access. An LMS can also be used to deliver quizzes and exams, and can have graded discussion questions where students interact with their peers in the class.

We didn’t create any new technology, choosing instead to license products accessible to any educator or school.

An online course is defined as 80% or more of the content delivered online, typically using Web-based discussion boards, and has a reduced number of face-to-face meetings, if any.1 It’s asynchronous, independent learning that can be accessed from anywhere in the world and conducted at your own pace.2 A blended or hybrid course has 30–79% of the content online; the rest is face-to-face delivery.

In 2005, hybrid education—blending technology-assisted distance learning with face-to-face traditional education—wasn’t a new concept to colleges and universities, but it was for EMS education. In my research, I was only able to find three hybrid paramedic programs in the country: a program at Bulverde Spring Branch EMS, PERCOM, and the Training Division, all located in Texas.


I felt an entirely online program wouldn’t work well for those who needed an alternate delivery model to traditional paramedic education. The subject matter would be too challenging for the average student to teach themselves. Paramedic educators are intricate and valuable links between curriculum content, street experiences and student learning, and serve as mentors to not only pass on experiences, but instill core values and the ethos of our profession.

Inspiration came from my wife Kim, who had navigated the digital hallways of the University of Massachusetts and graduated with her BSN through the university’s hybrid education program. I knew if universities could incorporate online learning into educating nurses, we could certainly do something similar in educating paramedics. Plus, study data showed hybrid courses could produce similar if not better results than traditional delivery.2


An LMS allows distribution of content to the entire class at once. It’s a place to put all handouts that would normally be given to students in traditional classes. It delivers quizzes and exams, allowing parameters such as timed questions, seeing only one question at a time, and not allowing back tracking of questions. The quizzes and exams can be automatically graded, giving students instant gratification of seeing their grade as well as annotated answers for each test item. Students have instant access to their grades and they can track their progress in their personal grade book.

After meeting with the EMT who sought a better education model, I contacted an LMS salesperson I’d met in the exhibit hall at an EMS conference, told her my idea, and asked plenty of questions. She put me in touch with Leslie Hernandez, an instructor who was using the Evolve LMS to teach a hybrid program.

Leslie’s hybrid class was a combination of independent online content study with live campus classes at her training center. Leslie shared her experiences and gave me a tour of her online content. She encouraged me to learn the intricacies of the LMS to create a design that would fit our program’s needs. She suggested I learn how to set up a course, build files, import quizzes and exams, and set the evaluation tools. She challenged me to understand how a student would view the course and how the content I added would impact the student’s learning. The LMS became the backbone of the course.

Our hybrid program uses Canvas as our LMS and Adobe Connect Pro for the virtual classroom. Both can be accessed using any Web browser and each has a mobile app that allows students to access their course content from their tablet or smartphone.

The virtual classroom allows us to deliver live real time lectures accessible from anywhere in the world a student has an Internet connection. One of the biggest advantages I saw in virtual classrooms was the software recording and ability to archive every session. All lectures and session recordings could be linked in the LMS so students could watch the recorded classes as many times as they needed.

This feature makes a difference for any learner who might otherwise struggle in a traditional classroom environment and enables all students to better understand concepts and think critically.

We didn’t create any new technology choosing instead to license products accessible to any educator or school. This made the development of the program easier because we didn’t have to hire anyone to build anything or write any code. It also ensured we didn’t have to store any content within our school’s server.


Once the course was fully built, the next hurdle was to secure approval from the Massachusetts Department of Health’s Office of EMS (OEMS).

In a meeting with the director and other OEMS staff, I presented the pre-built content in the LMS and a salesperson met us online to demonstrate how the virtual classroom worked. The OEMS staff had plenty of questions, but the most vital was how we would know the student wasn’t cheating during online tests and that the student taking the online evaluations was the person enrolled in the course. I told them we couldn’t know for sure, but our course capstone exam was a validated test product produced by Health Education Systems Inc. (HESI) and proctored at the school. Students must prove cognition and competency in the didactic phase as well as in the lab by passing the HESI and a psychomotor exam similar to NREMT’s. Students also have to show competency managing case-based simulations using live actors and a Laerdal ALS Sim Man, Sim Child and Baby. Students must show acceptable understanding of the medical problem presented, formulate a treatment plan, execute the treatment correctly and deliver a radio report to the hospital or interact with a medical control physician.

Some of the staff at OEMS were skeptical but accepted that we had sufficient controls in place to ensure student competency. I proposed a local pilot program study in which students would go to class two nights a week in the live, interactive virtual classroom and attend skills training on Saturdays.

Figure 1: Mean scores for traditional vs. hybrid paramedic programs

Mean scores for traditional vs. hybrid paramedic programs

We asked OEMS to approve two full classes so we could produce data to compare and study the cohorts. I wanted to ensure this delivery model would work and students would be successful, both in the course and on the state certification exam. It’s important to note that at that time, Massachusetts had its own paramedic exam and didn’t use the NREMT for testing. This was changed July 1, 2013, and we now use the NREMT as the testing company for all levels of providers.


Two full courses were completed with a 100% first-time pass rate by all graduates on the certification exam. I had proven to myself and, in turn, to the state OEMS office that hybrid education for initial paramedic education wasn’t only valid, but top-notch. It’s difficult to argue with success.

During the two years of the pilot programs, a number of out-of-state students began asking if they could join the next class. Working with OEMS, we developed a new model: Students who enrolled from out-of-state would complete the entire didactic portion online first. Once they passed the cognitive portion they would travel to our school in Massachusetts, where they would complete a 10-day “skills boot camp.” The HESI paramedic exit exam would then be given to evaluate the cognitive portion prior to entering the clinical phase of the program.

Once students passed their skills training, they would return home to complete clinical and field internships. If their state and/or local regulations prohibited internships, students would return to Massachusetts to complete their internships at our contracted sites. After a student completes the clinical internship, they’d be enrolled in the capstone field internship course.

To complete the course and our program, students would return to our school for a final evaluation consisting of a case study presentation from the student’s internship, adult and pediatric simulations in which student performance is evaluated by our medical director, program director and program coordinator, and the final capstone cognitive exam.


Following the launch of our hybrid paramedic education program, we conducted a multi-year study using the exit exam from HESI. The study was a comparative analysis between our hybrid students vs. our campus students from 2010–2012, and the final exam was an independent, validated paramedic exit exam that uses questions with varying degrees of difficulty and are vetted for reliability based on the national EMS education standards.

A total of 27 traditional students and 77 hybrid students were enrolled in the study. The mean HESI score of traditional students was 626 (standard deviation [SD] = 97) vs. a mean of 690 (SD = 114) for hybrid students (p = 0.007).

The data was expanded in 2012–2014. A two-tail student t-test with unequal variances was used to conduct a data analysis comparing hybrid vs. traditional HESI results. This allowed testing of the hypothesis that hybrid education is as good as traditional paramedic program models and a null that traditional education programs have better cognitive outcomes than hybrid education programs. The expanded data included 290 students: 68 traditional students and 222 hybrid students.

The mean HESI for the traditional students was 639 (SD = 105) vs. 679 (SD = 98) for hybrid students (p = 0.006). (See Figure 1.) Since the p value is < 0.05, we must reject the null and accept that hybrid education has outcomes as good as traditional education programs. In fact, we see a slight edge in our hybrid students over our traditional students.

Our certification rates are high overall and very similar between both programs, which proved our hypothesis that hybrid education for paramedic programs is as successful as traditional brick and mortar classroom delivery.


From the first quarter in 2012 to the second quarter in 2015, our paramedic program has a 90% first-attempt pass rate for students taking the NREMT paramedic cognitive exam.

Students who have chosen our hybrid model may have no other options to becoming paramedics. Our distance hybrid learners seem to have an edge over our local hybrid and even our campus programs. As told time and time again in the stories below the red dots of the map in our lobby, our hybrid students’ commitment to education is rooted in their personal motivation to becoming a paramedic. Despite the odds, they persevere to reach their goal.


1. Allen IE, Seaman J: Class difference, online education in the United States 2010. Babson Survey Research Group: Babson Park, Mass., 2010.

2. Bain LZ. Behind the final grade in hybrid v. traditional course: Comparing student performance by assessment type, core competency and course objective. Infor Syst Educ J. 2012;10(1):47–60.

3. Black G. (2002.) A comparison of traditional, online and hybrid methods of course delivery.Journal of Business Online. Retreived March 14, 2015, from