Paramedic Preceptor: Teacher and Evaluator
The paramedic preceptor is a significant factor in how and what students learn during practicum placements. Paramedic preceptors are considered both teachers and evaluators for the student1 within the paramedicine clinical education model2. This signature pedagogical approach3 is considered the primary point of connection between theory and practice for students where preceptors have the unique opportunity to transition the student from the controlled classroom environment to the chaos of practice. It is in this space that preceptors have a direct influence on the safety, quality and culture of the EMS system through their informal and formal shaping of the student’s learning opportunities. While the student experience of learning with their preceptors is known to be formative4 there is a significant evidence gap in the understanding of how paramedics construct knowledge and learn5 which leads to the preceptor navigating the teaching and learning with students without much system support or underpinning theory. If pedagogy is considered the enactment of the curriculum, where the learner interacts with others or with self in the learning moment or sequence of learning moments6 then preceptors are part of the pedagogical equation.
Much of the work of teaching and evaluation of students in paramedic programs is done by the preceptor in the practice setting during practicum placements, up to forty-five percent of program hours over 4 semesters is allocated to on-car placements with a specific preceptor. This is a significant workload for preceptors to commit to while still responsible for the care of themselves and the patient. The student-preceptor space in the back of the ambulance is where the learning and evaluation are intended to occur, this classroom area is known to be very contested places where positional power, legitimacy and contradictions are the norm and must be navigated by both the student and preceptor7. It is unknown how preceptors determine the difference between workplace standards and learning and evaluation objectives of the education program, as most likely preceptors are evaluating expectations of the workplace8 and not the educational objective.
How the preceptor determines when the student has progressed from the novice to competent or at what stage are they intended to become not just competent, but proficient in their practice is not well known. The significance of how preceptor evaluation impacts the student is somewhat known in that each evaluation and engagement on the topic of competence influences how the student understands their competence, how they come to know what professionalism behaves like, and what practical skills and tacit knowledge is valuable in the setting9. Paramedic students suggest that preceptors without any formal teacher education often will mean inconsistent teaching that may not follow the educational objectives and subjective evaluations that result in questionable and varying competency levels10. Some of this follows through in the evidence which indicates that even though up ninety percent of paramedic students graduate, they have high stress and anxiety in the first year of work11 and are often unsure of how to do the job or how to be a paramedic.
We now know that paramedic preceptors may benefit from better insight into their ways of knowing and learning and the ability to teach others. Having insight into their metacognition and ways of decision making5 enables the preceptor to ensure they are enabling students to develop good decision-making and reflective practice understanding. In the beginning, even the expert, veteran paramedic becomes a novice preceptor left to their own devices, unless or until there are supports in place that develop the teaching and evaluation competence of the preceptor. Students indicate that they can recognize the novice educator and evaluator even when the preceptor is a well-experienced clinical expert in the art of paramedicine10. Novice facilitators or evaluators generally lack formalized teacher trainer insight that can interfere with teaching and learning opportunities that provide guidance to students on developing reflective and reflexive capacity12.
Preceptors are expected to provide support to students in the moment of practice and to evaluate the outcomes according to the program requirements and competencies achieved. The time preceptors give to this is unknown and likely highly variable. Current education programs have a narrow curriculum focus on learning technical skills and procedural approaches to assessment and treatment that follows an educator-led model. In this model, paramedics are the educators, and they are considered experts in clinical practice who share their knowledge and assess the extent to which students can perform. This approach assigns to the preceptor (as a teacher) the full responsibility for making all decisions about what will be learned, how it will be learned when it will be learned, and if it has been learned. It is teacher-directed education, leaving to the learner only the submissive role of following a teacher’s instructions13.
A new understanding14 is emerging about common evaluation mistakes paramedic preceptors can make when teaching and evaluating students. This includes evaluating students relative to other students instead of against the learning objective. Leaning on the impression of the first introduction or the location of the student in the practicum placement, such as initial or repeat or final, where bias based on these assumptions changes how or if evaluation is completed. Preceptors need to remain vigilant to the halo effect and the familiar similar to me effect, both of which take intentional work by the preceptor to ensure evaluation is meaningful and complete. There are many types of learning and evaluation opportunities and the difficult aspect of this is to align them to meet the needs of both the student and preceptor within the expected progression of the student from learner to a novice. This notion of progression underpins the program approach to practicum experiences however more work to lay this out for both student and preceptor would improve the lived experiences and outcomes. Many students are unclear after multiple patient events on exactly which parts of the interaction were successful for them according to the preceptor. It can be very difficult for both the student and preceptor when navigating the complexities of patient care and teaching, learning and evaluation at the same time. Further it can be difficult to relate these aspects of teaching, learning and evaluation to the patient outcome when the treatment was misguided or mistakes are made.
Preceptors must engage with students in a relational way where this social aspect of practice, the interactions are negotiated through and bound within cultural and social norms15. Learning for practice does not occur in isolation from other aspects of experience, such as relationships between self and others, the influence of context and EMS system, or where an experience is placed in relation to other experiences16. All these aspects of experience, both the preceptor’s and the student implicate how the learning is situated and subsequently reflected on, during and after the practicum. Both the preceptor and students must learn to employ reflection in their practice to some extent, however it is difficult to ensure there is enough time to develop reflective practice understanding and skill and further little time during events to reflect on what they are doing and make relevant and timely changes. Some attempts can be recognized in the preceptor-led “what you want to do now” or “what do you think is the problem”. Although a powerful opportunity for learning reflective practice, these processes are challenging given preceptors are not able to pre-select cases that are appropriate to the student’s abilities and learning needs, and for the same reason difficult to link very different or emergent events to deepen the reflective process. Further, because both student and preceptor are required to participate in all patient care events as they occur this constant evaluation and reflection approach can be and is exhausting for both.
Most paramedic education programs provide a preceptor orientation to their specific program to ensure evaluation of the student occurs according to the program standards. The preceptor orientation is designed to identify the timing of the practicum placement in relationship to the theoretical aspect of the education program, and help the preceptor to understand if the student is on their very first practicum, have already completed a practicum and embarking on the midstream, repeat or final practicum. It is a challenge for both the educational programs and the supporting paramedic service to provide enough structural supports to enable adequate clinical placements for paramedics. Often preceptors are forced by time and location to take on a student and can be as likely as not to be paired with a student with similar communication or learning styles. Further challenges for preceptors include navigating call volume and event type to meet the student’s need and preceptor experience, where this mismatch is left to the preceptor to innovate ways for student achievement and patient safety.
Most paramedic preceptors vividly recall their own learning experiences during practicum placements, either as the student or preceptor, however, the understanding of how these preceptor-student experiences impact the teaching and evaluation that happens in the practicum placement is yet to emerge. There is much to understand how the continuum of the student to graduate to preceptor implicates how paramedics develop their identity, knowledge, and skills to practice. My own experiences as a student and preceptor, and continually as a learner, are closely linked to my experiences with both incompetent and expert preceptors, where the imprint of their words and actions remain.
So we need to develop an understanding of the skills and knowledge the preceptor can employ to provide safe learning spaces, supervision, guidance and oversight of the student within the context of practice. How and when a preceptor comes to understand the different learning and evaluation styles, setting mutual expectations and learning goals to support safe practice and education achievements for and with the student needs to be incorporated into educational supports for preceptors. How can the preceptor move safely from the aspect of patient safety to student advocacy and what are the bumps in these spaces. The educational and delivery agencies must move to consider the preceptor role as an instructional method and look to develop meaningful supports through education, evaluation and certification of preceptors. While the opportunity for contextual practice-based learning is a significant strength of the education system for paramedics and this educational design dependency is widespread much more work is needed to understand how to better support the preceptor in their important role.
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