Practicum is an important part of every paramedic program, providing students a learning environment to develop new skills and adjust their previous practice. At the same time, it is also seen as a final exam, a chance to see if the student is ready for practice outside of the classroom setting. This occurs under the watchful eyes of their preceptors, who serve as teachers and adjudicators at the same time. These diverging objectives can cause confusion and challenges for both the student and the preceptor. It is thus necessary to clarify the point of practicum and the role of the preceptor.
Practicum is meant to provide students a bridge between the classroom and the practice environment they will soon enter. The students are expected to learn how to assess and treat patients based on the knowledge developed during their schooling. At the same time, students adapt skills to live patients rather than classmates and mannequins. It is a challenging situation. The rigid structure developed in school as a foundation is challenged by the more fluid practice environment. Students must ask patients about their symptoms and interpret physical signs rather than receive verbal prompts. These assessments may be further complicated by a lack of personal experience of clinical presentations and the subtle hints that may indicate a patient is stable or deteriorating. Rigid scenario-based approaches are challenged by managing multiple priorities at the same time.
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At the same time, practicum is seen as a final exam, as the student’s performance is evaluated by the preceptor. Skills must be performed in an appropriate, timely and effective manner. The practicum has a time limit and minimum expectations attached to determine success. Practicum is, for many, the final step to be completed in the program, lending it further unofficial status as a final exam.
Merging these two objectives into a single practicum causes several challenges. On the foundational level, it is not appropriate to be testing a student while at the same time trying to teach them. A teaching environment differs greatly from a testing environment. If the practicum is meant to facilitate learning and skill development, it must be welcoming. The student should feel safe to take chances, trusting that the preceptor is there to identify and prevent errors. In such an environment, skills can be developed, good habits can be formed, and the student can grow as a practitioner.
A practicum meant to serve as a final exam does not allow this flexibility. Its focus instead is on demonstrating proficiency rather than developing it. A testing environment does not provide the safety to learn; a mistake might result in an unsuccessful practicum. A preceptor testing a student must also remove themselves from the environment as much as possible, to best assess the student’s practice. With this approach, a student will likely select a more conservative approach based on what they already know, in order to maximize their chances of success.
Since these two options are mutually exclusive, the learning environment emerges as the preferable option. A student completing the didactic portion of their education must still be taught how to put the pieces together in the practice environment. The student can still be evaluated in this environment, but the end goal should not be pass or fail, but readiness to operate at the prescribed level. Minimum expectations can still be maintained, such as minimum hours, call volume, or competencies completed. The preceptor may also provide their thoughts on the student’s progress at the end of the practicum. Issues can be resolved through more constructive means, extending the duration of practicum or transferring the student to a busier station.
The Preceptor’s Role
The preceptor’s role directly relates to the objective of the practicum. Preceptors can be welcoming teachers imparting wisdom and best practice or the final gatekeepers of the program weighing the student’s skills and knowledge against a standard. Since practicum is intended to be more of a learning experience, preceptors should aspire to the former, striving to bring out the best in the student, and equip them with skills to thrive for the duration of their careers.
Based on these objectives, preceptors must possess qualities beyond clinical skills. Teaching is a separate discipline and requires different skills than those prioritized in paramedicine. A preceptor must have a knowledge base beyond the average practitioner and the ability to effectively communicate ideas and knowledge to students in a welcoming and non-judgmental learning environment. A preceptor must be openminded and supportive of the student’s strengths while identifying and improving weaknesses. Prior experience with adult education and learning styles is crucial to being an effective preceptor. Paramedic students are adult learners, requiring a personalized learning approach that expands on their previous experience. Adult learners must also respect and trust their preceptor in order to want to learn from them. These are skills and traits that preceptors must develop independently, through training or supplementary education.
This is especially important in the early stages of a student’s career. Preceptors represent the first experience many students have with EMS. A positive preceptor who guides with respect will leave a different impression on a student than one who is rigid and dismissive. The student and preceptor should meet before practicum begins to discuss their learning styles, teaching styles and expectations for practicum. If there is significant disagreement between them, a different preceptor should be selected to facilitate the student’s learning. There should be no judgment if either party feels there are personality issues. Practicum is challenging enough for both student and preceptor without having to deal with personality conflicts. A learning experience like practicum may be an ideal time to learn how to manage personality issues, but not when the preceptor and student are the source of that conflict.
The expectations of the practicum must be clearly delineated by the school, specifying the role of the preceptor, and objectives of the student. Similarly, the preceptor’s employer should also provide information regarding the expectations of preceptors and students during operational hours. Further questions are easily raised. How should preceptors be selected? Should preceptors be compensated for the extra time, effort, and skills necessary to take on this role? If so, is it the duty of the school or the employer to provide the training and compensation?
What Should Students Learn on Practicum?
The following are most visible in daily practice and are the natural focus for practicum.
- Communication skills: Effective communication should involve non-judgmental communication with patients and closed-loop communication with practitioners. Active listening skills allow paramedics to gain accurate information from a patient, guiding further assessment and treatment skills. This is likely the single most important skill a paramedic can develop; good rapport significantly improves a patient’s perception of the response and their patient care.
- Good clinical practice: This is the core of the practicum. The focus should be on a thorough assessment of patients to provide the information necessary to determine differential diagnoses and treatments. Students can then determine whether to treat immediately, prepare for potential treatment, or monitor the patient. Critical thinking skills should be developed in concert with practical skills, giving students an understanding on when their practical skills are necessary or when careful monitoring is sufficient.
- Hands-on experience and training: The goal is to develop practical experience with the specific equipment and tools in the practice environment. Creating a regular steady process for skills such as medication administration will mitigate errors, especially during more stressful periods. These skills are less visible, but provide an important intellectual foundation to the practitioner as they proceed through their career.
- Self-teaching: Students should be able to ask as many questions of their preceptor and colleagues as possible. They should also be given the skills to perform their own research and come to their own conclusions. They must understand that skills and knowledge must be refreshed and updated to keep current with best practice. It falls upon their own initiative to maintain this knowledge.
- Bridging the gap between school learning and street practice: This must be done in a respectful manner. Disparaging knowledge developed in school can create a disrespect for learning and an overreliance on experience in the practice environment. Even if the knowledge is not commonly used, it can help the practitioner guide patients through their care.
- Positive mentality: Preceptors should be mindful of negative tendencies, biases, or experiences developed throughout a paramedic career and try to foster a more positive perspective. For many students, this is their first consistent experience with EMS and this first impression can permanently color their point of view. A positive mentality will help develop resiliency as students face difficult situations throughout their career.
- Self-reporting/safety-consciousness: A double-edged sword, this requires a work environment already dedicated to a fair response to errors. Paramedics (and students) should feel safe to self-report their errors in order to minimize ill effects to the patient and work to identify the systemic causes that may lead to future errors. Students should be taught the ability to identify potential sources for errors before they make them, as well as different means to prevent these errors from occurring.
The author would like to thank his preceptors, Josh Becker and Brian McAdam, for the positive examples they provided during his practicums.