Introduction
Over the course of the last 20 years, the creativity and flexibility in the utilization of all the different tools associated with EMS education have allowed for EMS educators to personalize instruction and create meaningful learning experiences for all students. This, in turn, has helped to create more equitable learning environments and foster academic success.1 These approaches should be used in combination with one another in order to maximize learning for all.
Students who want to enter the profession take their entry-level EMT course with excitement, curiosity and varying degrees of trepidation. What we offer students in this regard to support them needs to be as varied as the people who enter the program. Building in time for study and practice is essential to student success. These should be communicated ahead of the start of the program and should be on the calendar for everyone.
Study groups, apps, extra time for practice are all are important, but not everyone will benefit from all of them. Variety is key because people acquire knowledge in different ways but build in the time for all of them and make sure the students are aware they are part of the commitment to the program.
For example, some students are voracious readers, they will download journal articles, read blog posts, books. Other students learn in the moment, scenario-based education and clinical experiences for example. Here they will not employ the skill and knowledge they have acquired, but they will ask probative questions or seek to have the concept demonstrated for them. Other students learn best from infographics, videos, or podcasts.
Differentiated Instruction
Educators should tailor instruction to meet the individual needs of every student. We do this by adjusting the content, process, and product of instruction in order to accommodate the diverse needs, learning styles, and interests of learners.1 We don’t do this on a single student basis, educators don’t devise individual lesson plans or plans of instruction for each student, but rather EMS educators should present different modes of content and process for the entire class in order to appeal to the way every different student learns, with an intent on allowing for different types of products to be displayed in response to the instructor efforts.
For complex topics, an educator could assign readings from the textbook or a journal article from JEMS in conjunction with a sim lab exercise or a student-led presentation and a video or podcast. For students who are kinesthetic, auditory, or visual learners – or some combination of all three – using a mixture of content and process modalities is essential to deliver the material effectively.
The basis of differentiated instruction seeks to identify and address the unique learning needs of each student in a classroom, by considering the student’s talents, skills, interests and individual learning style. There are three essential elements that compose differentiated instruction: content, process and product.2
Content
This refers to what the students are learning. Differentiating the content means providing multiple ways for students to access information and concepts. This can be done by providing different levels of complexity, different types of resources (YouTube and TikTok videos, for example), and different modalities of learning (VARK: Visual, Auditory, Reading/Writing and Kinesthetic). Regarding complexity we might transition from the patient who is having angina that resolves with nitroglycerin to the patient in cardiogenic shock with a plummeting blood pressure and rales that are bases to apices.
Process
This refers to how the students are learning. Differentiating the process means providing multiple ways for students to engage with the content. This can be done by offering different learning activities, providing different groupings of students, and allowing for student choice in how they learn. The act of writing out flash cards and then using them for yourself or others for example, works on multiple levels. Compiling and editing information and then writing it down for example works on two learning styles, kinesthetic and visual methods.
Using those same flashcards to quiz your colleagues enhances interaction and discussion, in this instance focusing on auditory and visual styles. EMS Jeopardy incorporates John Nash’s game theory, using incentive structures, a correct answer earns points, points earn a prize for example. It also leverages decision-making strategies in competitive situations. Competition and cooperation balance are another component of Nash’s game theory, explores the balance between competition and cooperation, in the context of learning, healthy competition can stimulate students to strive for excellence and push their limits. Strategically, they can enhance their problem-solving skills and promote effective learning approaches. This game theory approach uses all three learning styles to impart information.
Real-time simulation using manikins provide students with invaluable opportunities to apply their knowledge, hone their skills, and develop critical thinking abilities in a realistic and controlled learning environment. These simulations bridge the gap between theory and practice, preparing students for the challenges they may face. There is something surreal about initiating a scenario with a patient in severe respiratory distress, who needs immediate endotracheal intubation, and having the capability to stop the scenario and describe the pathophysiology or identify landmarks for intubation. In real life this would never happen, but just being able to put the patient ‘on hold’ while you walk through the scenario is incredible.
Product
This refers to how the students demonstrate their learning. Differentiating the product means providing multiple ways for students to show what they have learned. This can be done by offering different types of assessments, allowing for student choice in how they demonstrate their learning, and providing opportunities for students to create their own products. Written and practical exams are great, and sim manikins have changed the game in this regard, but they are limiting.
Be creative. For example, for the author’s EMT students, they might offer them the choice of writing a report on the treatment of asthma, creating a TikTok or some other type of digital presentation illustrating the signs and symptoms of asthma, or developing a scenario where they have an asthma patient exhibiting the signs and symptoms of distress in order to illustrate their understanding.
Practice Makes Perfect
Our moms used to say to me all the time “practice makes perfect.” This author spends more time in real-time skills scenarios and practice then in the classroom. By offering students a variety of options for completing tasks and assignments they can achieve success on their own terms.
In making practice effective, it is important to emphasize the importance of aligning practice activities with learning objectives and providing students with feedback and reflection opportunities. Educators should vary the types of practice used, based on students’ needs and the specific skills being taught.2
There are three factors in making practice effective:
Setting Clear Learning Objectives
Before starting the practice, it is essential to identify clear learning objectives that align with the curriculum. This helps learners to understand what they are expected to achieve and helps instructors to design practice activities that are relevant to the learning outcomes.
Structured Practice Activities
Practice activities should be well-structured and engaging to keep learners motivated and focused. The activities should be designed to challenge learners and provide them with opportunities to apply their learning in different contexts.
Feedback and Reflection
Feedback and reflection are crucial components of effective practice. Feedback helps learners to understand their strengths and weaknesses and provides them with opportunities to improve. Reflection encourages learners to think critically about their learning and to identify ways to improve their practice.
There are different types of practice, and they all have their place in EMS education. The types of practice include:
Deliberate Practice
This involves structured activities designed to improve specific skills or concepts. It is focused, repetitive, and requires feedback to identify areas for improvement. Your first CPR course is an example of deliberate practice.
The five principles of deliberate practice are:
1. Specific Goals: Deliberate practice requires setting clear and specific goals that focus on specific skills or aspects of performance.
2. Full Concentration and Effort: Deliberate practice involves pushing oneself beyond the comfort zone and engaging in focused, intense practice to maximize learning and skill development.
3. Immediate and Informative Feedback: It should be immediate, allowing individuals to adjust their performance in real-time. Feedback should also be informative, providing specific information about strengths and weaknesses.
4. Repetition and Repetition with Variation: Repetition allows individuals to refine their skills over time. Additionally, deliberate practice incorporates variation, introducing different challenges or contexts to promote adaptability and deeper understanding.
5. Mentally Challenging Tasks: Mentally challenging tasks that stretch one’s abilities are essential to the learning event. By tackling difficult problems or tasks, individuals can develop higher levels of competence and expertise.
The four steps to deliberate practice in EMS education are:
1. Breaking Down Skills: Here you identify the specific skills or knowledge areas that need improvement and break them down into manageable components.
2. Goal Setting: The EMS educator sets clear and specific goals related to the skills being developed. These goals should be challenging but attainable, providing a sense of direction and motivation.
3. Engaging in Focused Practice: This type of practice should involve full concentration, effort, and repetition. Learners should actively seek feedback and make adjustments to improve their performance.
4. Reflecting and Iterating: Reflection is a crucial component of deliberate practice. After each practice session, learners should reflect on their performance, analyze strengths and weaknesses, and identify areas for improvement. By incorporating feedback and making adjustments, learners can iterate their practice and continue refining their skills.
By following these steps, learners can engage in deliberate practice, which is a structured and intentional approach to skill development, leading to significant improvements over time.
Distributed Practice: Utilizing this technique involves spreading out practice sessions over time. It is useful for long-term retention of information and skills. We might devise deliberate practice scenarios that are scaffolded, one building upon another. The patient suffering a myocardial infarction who proceeds to go into cardiogenic shock, and ultimately into cardiac arrest. The diagnostics and treatment are complex, and as we move through learning about patients suffering cardiac emergencies we build on each scenario, developing competency along the way.
The four steps of distributed practice are:
1. Initial Learning: This step involves the initial exposure to the material or concepts. It can be in the form of reading, listening, or watching lectures. The benefit of this step is that it provides a foundation of knowledge and introduces the learner to the topic. However, one drawback is that the learner may not retain all the information after a single exposure.
2. Spacing: After the initial learning, the material is reviewed at specific intervals over time. The spacing can be customized based on the learner’s needs and the complexity of the subject matter. The benefit of spacing is that it allows for better retention and retrieval of the information. By reviewing the material at intervals, learners reinforce their understanding and memory. However, a drawback is that it requires more effort and time compared to massed practice (cramming), as it requires multiple study sessions.
3. Retrieval Practice: This step involves actively recalling the information from memory without referring to the study materials. It can be done through self-quizzing, practice tests, or discussions. The benefit of retrieval practice is that it enhances long-term memory and strengthens the connections between different pieces of information. It also helps identify gaps in understanding. However, a drawback is that retrieval practice can be challenging and may initially result in errors or incomplete recall.
4. Feedback and Revision: After engaging in retrieval practice, learners receive feedback on their performance and use it to revise their understanding. Feedback can come from self-assessment, peer assessment, or instructor feedback. The benefit of this step is that it allows learners to correct misconceptions and reinforce correct information. It also guides further learning and improvement. One drawback is that timely and accurate feedback may not always be readily available, which can hinder the learning process.
Interleaved Practice: Practicing different skills or concepts in a random order is referred to as interleaved practice. This type of practice helps learners to make connections between different concepts and to develop their problem-solving abilities. Ever have a situation on scene that was what some of us would call an absolute trainwreck? You are going from one catastrophe to another regarding a single patient? This is where interleaved practice is important.
In the context of EMS education, interleaved practice can have both benefits and drawbacks:
1. Enhanced Transfer of Learning: Interleaved practice promotes the ability to transfer knowledge and skills to different contexts. Paramedic and EMT students often encounter complex and unpredictable and interleaved practice helps learners develop the ability to apply their knowledge and skills in various scenarios.
2. Improved Long-Term Retention: By interleaving different topics or skills, learners are required to constantly switch their attention and retrieve information from memory. This active engagement enhances long-term retention and strengthens memory connections, leading to better recall of the material in the future.
3. Overcoming Illusion of Competence: Interleaved practice helps learners identify gaps in their knowledge or skills. It prevents the illusion of competence that can occur with blocked practice, where students may feel proficient in a specific topic but struggle when faced with a real-life situation. Interleaving challenges learners to continuously review and apply their knowledge, exposing areas that require further practice and improvement.
4. Cognitive Flexibility: Interleaved practice promotes cognitive flexibility, as learners need to switch between different topics or skills. This flexibility helps paramedics adapt to changing circumstances and make quick decisions in high-pressure situations.
The drawbacks of Interleaved Practice in EMS education include:
1. Initial Perception of Difficulty: Interleaved practice may initially feel more difficult compared to distributed practice. Since learners are frequently switching between different topics or skills, they may experience a slower initial progress and perceive the learning process as more challenging. However, this temporary difficulty can lead to better long-term learning outcomes.
2. Reduced Sense of Mastery: With distributed, learners may experience a sense of mastery over a particular topic after repeated practice. In contrast, interleaved practice can diminish this feeling of mastery since learners are constantly shifting their focus. However, it is important to note that the sense of mastery gained from distributed practice may not necessarily translate into effective application of knowledge and skills in real-world situations.
3. Increased Cognitive Load: Interleaved practice can place a higher cognitive load on learners due to the need to constantly switch between topics. This can be mentally demanding and may require additional effort and concentration. However, this increased cognitive load can also enhance cognitive skills such as attention, working memory, and decision-making abilities.
Massed Practice: this method involves practicing a skill or concept repeatedly in a short period. It is useful for short-term retention but is not as effective as distributed practice for long-term retention. Examples of mass practice for specific skills include:
1. Endotracheal Intubation: Advanced airway management is a critical skill for paramedics. Mass practice can be useful for paramedic students to focus intensively on the skill of intubation. They can dedicate specific practice sessions where they repeatedly perform intubations under the supervision and guidance of experienced instructors. This concentrated and uninterrupted practice allows learners to refine their technique, develop muscle memory, and gain confidence in performing this crucial procedure.
2. Cardiopulmonary Resuscitation (CPR): A fundamental skill in EMS education is CPR. Mass practice of CPR can be beneficial, particularly during initial EMT training, certification, and recertification courses. Students can engage in extended practice sessions where they repeatedly perform chest compressions, rescue breaths, and other components of CPR on training manikins. This concentrated practice helps learners develop the necessary rhythm, coordination, and effectiveness required for high-quality CPR delivery.
3. Medication Administration: Paramedics are responsible for administering various medications to patients. Mass practice can be beneficial for learning the proper administration techniques and protocols for different medications. Students can engage in concentrated practice sessions where they simulate medication administration scenarios, prepare and draw up medications, and practice the correct administration routes (e.g., intravenous, intramuscular, subcutaneous). This focused practice allows learners to become proficient in medication calculations, equipment handling, and safe administration practices.
Summary
Differentiated instruction focuses on providing different materials (content), activities (process), and assessments (product) based on student needs. Individual students may have learning gaps that need to be recognized and addressed, for example remembering the indications for specific drugs or the difference between heart blocks. Differentiated instruction is a great strategy to assist with this because you can vary the content and processes to improve the product.
Practice plays a crucial role in learning, and effective practice requires careful planning, clear learning objectives, structured activities, feedback, and reflection. The importance of differentiating practice activities based on student’s needs and providing support for struggling students is needed to ensure that they can benefit from practice activities.
EMS educators must consider the different types of practice and their respective advantages and disadvantages when designing practice activities for their students. Practice allows students to engage with new concepts and skills repeatedly, leading to deeper understanding and increased retention, thereby improving patient outcomes.
References
1. Foundations of Education: An EMS Approach, 3rd Edition. National Association of EMS Educators, July 29, 2019.
2. Price, K. M., & Nelson, K. L. (2018). Planning effective instruction: Diversity responsive methods and management. Cengage Learning.