Assessment Strategies: Paramedic Education

Assessment Strategies Paramedic EducationParamedics take on, historic every last(predicate)y, been algorithmically led through and through all clinical procedures and decisions which do not directly centre on clinical decision making. It has been indicated that this system of para checkup training concentrated on smell threatening conditions with protocol driven perform, based on berthicular underpinning cognition (Williams, 2002). They stomach undergone front-loaded, fit-for purpose courses which has suited the operational need of the Ambulance Service. oer the last ten years United Kingdom (UK) ambulance function make water become increasingly aw atomic number 18 that in that respect is a need to survey their statemental purvey. It became evident that paramedicalalals needed to move on from surface to rich intellection strategies and develop a greater thinking repertoire. The paramedic occupation is authorizedly at a major crossroads in its phylogeny with the transition from a training paradigm to one of higher(prenominal) education (British Paramedic Association, 2006). This evolution in paramedic education heralds a channelise a authority from a training ethos of surface training and expository t all(prenominal)ing, topper expound by A utilisebel (1968) as the presentation of the entire content of what is to be learned in its final invent.This commentary forget discuss the current perspicacity strategies use within paramedic education by higher education institutes (HEIs) including the discernments implemented in the clinical practicum. The various orders and delivery of sagaciousness will be explored including, coifive, summational and feedback. My protest personal arrests and involvement with the sagaciousness of paramedic assimilators will besides be discussed. This discussion will cause to highlight the validity and dep regulate aside fittingness of certain mind strategies such(prenominal) as objective structu red clinical examinations (OSCE), portfolios, head for the hills-based opinion. The fancy of role models for paramedic savants during their sequence on clinical side will similarly be explored.In the UK, the Institute for Health keeping Development (IHCD) is the awarding carcass for paramedic qualifications and guide been involved in prescribing the curriculum, content, and judicial decisions for all paramedic training through proscribed the UK. IHCD produce multiple choice unbeliefnaires, short act and clinical mind in like mannerls which expect been seriously challenged by the British Paramedic Association (BPA) which is the professional body overseeing paramedic practice and education. The judicial decision strategies employed by IHCD have been criticised for their errors of kindat and content relevance (Cooper, 2005). They were to a fault seen as a tick-box exercise for the employers pro prep atomic number 18 liability.IHCD assessment processes were criticised for their validity, reliability, and feasibility, with the BPA highlighting a clear need to identify pick modes of assessment such as objective structured clinical examinations with golf links to competency frameworks (British Paramedic Association, 2006). The use of a variety of opposite assessment methods has at one time become a characteristic of paramedic education within HEIs. Currently HEIs employ a plethora of assessment methods including simulation, standardised longanimouss, indite examinations, oral examinations (oral voce) and reflective portfolios. During their measure in the clinical practicum paramedic scholars be overly continually assessed with regard to their clinical competencies.Pugsley and McCrorie (2007) state the need to have valid, reli satis divisory, fair and defensible assessments imputable to increased litigation from schoolchilds be adding immature dimensions to educator roles. With the ongoing change within paramedic education in that loc ation has been a need to move away from standard assessment methods such as written examinations. Historically, educators have used the same assessment methods for all of the competencies of a paramedic, crimson when they were ill-suited to the task. For example, it is unfavorable for a paramedic to be able to communicate utilely with tolerants simply an assessment of this aspect of competence is not tested well by written examinations or a viva voce in which the assimilator- persevering construe is unobserved. To correct this problem, several methods of assessments which are new to paramedic education are being implemented with ongoing tabugrowth. These new methods accent on clinical adroitnesss, communication skills, procedural skills and professionalism. An all-important(prenominal) role of the instructor relates to assessing students competence. This hold great relevance within pre-infirmary surround as life, wellness and welfare of long-sufferings is potentially at risk if students are not accurately assessed which whitethorn lead to future paramedics with low directs of clinical competence.Stuart (2007) states that assessment peck be alineive and summational with Boud (2000), claiming that both(prenominal) forms of assessment influence culture. fictile assessment move guide future learning, promotes reflection and deliver the goods reassurance (Epstein, 2007) whereas summational assessment t lay offs to take place at the end of module or program of study and is used to pass on info about how a lot students have learned and to what extent learning outcomes have been met (Stuart, 2007). M whatever of the assessment strategies passel be used as both a method of formative and summative assessment (see table 1).Any ploughshareicular method of assessment will have its strengths and its intrinsic flaws. The use of several opposite assessment methods may partially compensate for the intrinsic flaws in any one method (Epstein, 20 07). severeness and reliability are deemed as critical for determining the usefulness of a particular method of assessment (Van der Vleuten, 1996). Validity is the extent to which the assessment measures what it was designed to measure (Quinn Hughes, 2007). Reliability indicates the consistency with which an assessment method measures what it is designed to measure (Messick, 1989).OSCEThe belief and assessment of clinical skill proficiency is a major part of paramedic education. Paramedic form programs throughout the UK are using and developing OSCEs as an approach for the assessment of clinical skill surgical operation. OSCEs have been utilised in advanced life support, trauma, medical checkup condition scenarios as well as individual(a) clinical skills. Newble (2004) states that OSCEs are better suited to assessing clinical and practical skills, often with a high degree of fidelity. Stuart (2007) warns that OSCEs have limitations as a method of assessment due to the exerci se of students under laboratory conditions may not accurately reflect their real performance in the clinical practicum. Other limitations also exist such as students finding OSCEs highly stressful (Phillips, Schostak Tyler, 2000 carry Schoonhein-Klein, 2009). An OSCE also tends to focus more than on the assessment of basic skills kind of than cognitive skills (Redfern, Norman, Calman, Watson Murrels, 2002). A major limitation is the compartmentalisation of the clinical long-suffering assessment process and students may not learn to holistically assess patients (Stuart, 2007). on that point is conflicting evidence throughout the literature regarding the reliability and validity of OSCEs as a method of assessment. Goaverts, Schuwirth, Pin et al. (2001) have reported high reliability and validity for this assessment dodge, whereas Phillips, Schostak and Tyler (2000) claim that OSCEs are seriously flawed due to lack of inter-assessor and intra-assessor reliability. Hodges (2003) points out that OSCEs are a social drama with students modifying their own demeanour in an flack to convey the impression that the assessor desires. thither are measures that have been reported to increase the validity and reliability of the use of OSCEs and these are listed in Appendix X.I have had some go steady of assisting with OSCE assessments and have found that almost no training has been provided for the assessors which in my opinion, make them unreliable. The assessors are given objective controllists alone a personalised form of scoring was sometimes used due to the lack of assessor experience or arrest of the assessment strategy. One of the OSCEs un countermandable an assessment of a students ability to perform advanced life support (ALS) with the checklist containing a summate of 111 points to be assessed (see supplement X). This created problem with the reliability of this particular OSCE as the assessors found it difficult to observe the student as well as che ck they were performing everything on the checklist. This OSCE lasted almost 30 minutes which not notwithstanding caused fatigue to the student except also to the assessor. agree to Reznick et al. (1992) the heavy work load on the assessor rouse affect their performance. A lengthy OSCE plenty also cause student fatigue which may affect their performance (Rutala, Witzke, Leko, Fulginiti Taylor, 1990).As part of my ongoing development as a teacher I have started to design an OSCE for the assessment of some basic clinical skills. Some of these have already been designed for other healthcare professions only none are paramedic education particular.Simulation ALSSimulations are increasingly being used in paramedic education to turn back that students burn demonstrate integration of prerequisite knowledge, skills, and affect in a realistic setting. For these aspects of competence, the use Sim-Man which is a physical simulator that models the human body with a very high fideli ty is currently used extensively at my employing university. This form of simulator is very realistic and can provide an excellent assessment of skills. These simulators are used in conjunction with observed structured clinical examinations (OSCE).Standardised PatientsA standardised patient is a person adroit to portray a patient with a particular medical or traumatic condition. They are used to assess a students ability to realize medical tale and physical examination data (Tamblyn Barrows, 1999). Following the opposition between the standardised patient and a student, both the standardised patient and an assessor make judgements about the students performance based on history taking, physical examination and communication skills. Checklists are positive for each patient scenario focusing on the students ability to collect the relevant data. Skills in summarising and interpreting the claimation collected are often measured chase the encounter consisting of open-ended quest ions or short answers. I have found this to be the most realistic form of assessment outside of the clinical practicum and interrogation has shown that reasonable levels of reliability and validity can be achieved (Norcini McKinley, 2007). However, McKinley and Boulet (2004) warn that there is a drift in assessor stringency over time and that the standardised patients themselves become increasingly inconsistent portraying a patient. This assessment strategy is very expensive to use and has been implemented infrequently. As part of my role as an associate lecturer I have had the probability to take part in this form of assessment. The students were required to perform a cardiac assessment on a standardised patient. Prior to this summative assessment they were given a lecture on cardiac assessment, a demonstration of the assessment and legion(predicate) hours practice time with support from the talking to team which allow ind myself. A checklist (see cecal appendage X), a viva-v oce question sheet (see appendix X) and a short answer base (see appendix X) were all designed. Following the patient encounter the standardised patient and I went through the checklist to ascertain the ability of the student. The viva-voce followed where open-ended questions (see appendix X) were asked to set aside the student to discuss their findings and plans for treatment which was followed by the short answer paper (see appendix X).Work-based AssessmentWork based assessment of learners in the clinical cenvironmentAssessment plays a major role in the process of medical education, in the lives of medical students, and in society by certifying competent physicians who can take care of the public. Society has the right to know that physicians who graduate from medical school and subsequent residency training programmes are competent and can practise their profession in a compassionate and skilful behavior (Shumway Harden 2003). Miller (1990) proposed his now famous pyramid for assessment of learners clinical competence (Figure 2).Knowledge tested by written examsApplication of knowledge tested by clinical problem solving etc. manifestation of clinical skills, tested by OSCEs, clinical exams, competency testing (Competency) everyday patient care assessed by direct observation in the clinical setting (Performance)Adapted from Miller (1990)At the lowest level of the pyramid is knowledge (knows), followed by competence (knows how), performance (shows how), and action (does) The clinical environment is the only venue where the highest level of the pyramid can be on a regular basis assessed.Assessment in the workplace is quite challenging as patient care takes top priority and teachers have to observe firsthand what the learners do in their interaction with patients and yet be vigilant that patient care is of the highest grapheme.Paramedic students need to retain vast amounts of information, integrate critical thinking skills as well as having an ability to s olve a clip of complex clinical problems often under intense pressure. In an private road to modify this I have started to acknowledge the need for alternative teach, learning and assessment strategies. Educational literature supports the use of concept mathematical function as a means to promote learning and is seen as a metacognitive strategy (Novak, 1990 Pinto Zeitz, 1997 Irvine, 1995). I have explored the idea of concept social occasion and have now started to use it within my teaching practice. I view the goal of concept mapping as a way to foster learning in a meaningful way, to enable feedback and to conduct learning evaluation and assessment. As a learning resource, concept maps can facilitate a students understanding of the integration and organisation of important clinical concepts (Pinto Zeitz, 1997). A group of the paramedic students I currently teach found that concept mapping provided them to think independently, promoted self-confidence and provided them wi th a greater awareness of connecting across several(predicate) areas of knowledge. From my own perspective I view concept mapping as a creative activity which assists the students in becoming active learners. It is also seen to allow students to organise theoretical knowledge in an integrative way as well as fostering reflection into the learners understanding (Harpaz et al., 2004). During and avocation the use of concept mapping sessions numerous opportunities arose to identify student misunderstandings allowing provision of relevant feedback and clarification of content. According to Kinchin and Hay (2000) the use of concept mapping highlights the learners constructions of connections as well as a useful form of communication between the teacher and learner. As an assessment strategy concept maps can be used either formatively or summatively (West, Park, Pomeroy Sandoval, 2002) by identifying the learners valid or invalid thoughts and links. However, Roberts (1999) warns that a suitable scoring method must be selected for each particular type of map due to their great variance in style.I have used concept mapping with individual students and small groups of students and it has been effective when dealing with the distinguishableial diagnosis of certain conditions. For example, the causes of knocker pain are numerous but it is important for a paramedic student to be able to understand and differentiate between the different causative factors. A lesson was planned, delivered with handouts provided (see appendix X). Over the next two weeks the students were formatively assessed on an individual basis by using concept maps to illustrate their understanding of the causes of chest pain. A decision was made to use a relaxed approach in an endeavour to overcome any anxiety so the assessment became an informal discussion. As the students take placeed through the task I was able to gain insight into what each student knows and how they arrange knowledge in th eir own minds. I was able to give feedback on their misunderstandings, misconceptions and errors. Paramedic educators rarely use concept mapping as a teaching or learning method but I see them as valuable tool in unveil students misunderstanding of concepts which could in turn lead to the identification of potential clinical errors.FEEDBACKEffective feedback may be defined as feedback in which information about previous performance is used to promote tyrannical and preferred development. Giving feedback, whether corrective or reinforcing, is complicated but is an essential part of paramedic education. Feedback plays a central part in the support of cognitive, good and professional development (Archer, 2010). Cognitive theorists view feedback as a relation between actual performance and the intended performance level (Locke Latham, 1990). According to Kluger and DeNisi (1996) this will highlight the gap between a learners knowledge and the required knowledge and provide a learn ing catalyst. Behaviourists conceive feedback as a way of modification or reinforcement of behaviour (Thorndike, 1931). In the health care education literature including paramedic education, feedback seems to lack any form of theoretical basis (Colthart, Bagnall, Evans, Allbutt, Haig et al., 2008).Paramedic education feedback is often problematic for both the provider and recipient. The diversity of the feedback settings creates multiple challenges for paramedic educators in the provision of effective feedback. Settings such as bedside teaching, practical skills training as well as the often chaotic environment have been utilised for the provision of feedback by myself. The protection of the professional standards, the rights and safety of patients as well as the self-conceit of the paramedic student must be safeguarded. Added to this is the acknowledgement of the psychosocial inevitably of the paramedic students as well as ensuring that the feedback is accurate and honest (Molloy , 2009 Higgs, Richardson Abrandt Dahlgren, 2004). These challenges are an ongoing bring out within paramedic education but despite this feedback has been described as the cornerstone of effective clinical teaching (Cantillon Sargeant, 2008).An important factor necessary for progress is the provision of feedback. Parsloe and Wray (2000) suggested that feedback is the fuel of remedyd performance, that it can provide motivation. However, they do warn that motivation can be reversed if you ache the feedback wrong. Feedback should be viewed as a positive tool as even negative aspects of feedback actively encourage learners to improve practice Bennett (2003) affirms that it can also highlight strengths and weaknesses which in turn can lead to enhanced practice. on that point are many types of feedback used to support learners and these can have either a directing or helpful function. Directive feedback can inform a learner of what requires some type of corrective measure whereas fa cilitative feedback can involve the provision of suggestions to facilitate learners in their own adjustment (Archer, 2010). Feedback specificity may also be variable. Specific feedback can sometimes be beneficial for an initial change in performance but it may have a negative effect on the learners ability to just explore their performance which can lead to an undermining of subsequent performance and learning in the long term (Goodman, Wood Hendrix, 2004). Less specific feedback can lead to uncertainty for the learner that may subsequently lead to a reduction in learning (Kluger DeNisi, 1996). Verification and elaborative feedback are structural variances of directive and facilitative types of feedback. Feedback can simply indicate that an answer is correct (verification) or it may facilitate the learner to arrive at the correct answer (elaboration). According to Bangert-Drowns, Kulik, Kulik and Morgan (1991) the guiding principles of feedback are that it should be specific, wi th verifying and elaborative feedback enhancing persuasiveness.I have attempted to utilise a number of types of feedback for my learners since the start of my current studies on the Post Graduate Certificate in Education (PGCE). I will now go on to discuss some of the methods of feedback utilised for the different learners I am currently supporting. I have utilised many of the types of feedback interchangeably and have slowly gained a conscious knowledge of their appropriateness. end-to-end their locatings paramedic students have regularly received constructive feedback which is usually delivered contemporaneously which is something that Price (2005) recommends. A large proportion of the feedback has been delivered informally and is often carried out in between emergency calls and has often been given as a running commentary during student/patient interaction.Non-verbal communication is seen as a strong method of conveying meaning and is often utilised in providing feedback (Stua rt, 2007). Non-verbal communication serves several functions which can be summarised as giving and receiving information, expressing emotions, communicating interpersonal attitudes (e.g. warmth, dominance and liking) and establishing relationships (Williams, 1997). Non-verbal communication requires acute observation by the murderer for accurate interpretation of the message (Golub, 1994). Non-verbal communication includes specific behaviours that include proximity, touch, core-contact and eye gaze, facial expression, body posture and head movements. I have used this form of communication as a method of feedback during bedside teaching sessions and when the student is involved within patient care episodes. A nod and a look of approval are seen as positive feedback which all ads to the feedback process. much formal feedback is given at the end of each shift. The timing and format of these feedback sessions are of great significance. For feedback to have maximal motivational impact o n learning, it should take place while it is still relevant and points raised are therefore more meaningful and alive (Hays, 2006). During these feedback sessions the format is a belong of oral and written. A copy of the written element is given to the student to place in their portfolio. Fish and Twain (1997) believe written notes are essential in providing continuity in the monitoring of progress.Initially, the students were asked to provide a self-assessment of how they felt the shift had gone. This was an addition to the feedback cycle and encouraged learners to be more self-aware and more self-critical but gives an insight into how the student feels about their progress (Mohanna, Wall Chambers, 2004). Rather than a one-way process the feedback becomes collaborative. On further exploration of the literature I became aware that involving the learner in comparative degree self-assessment that places them at the centre of the feedback process will not always improve competence. P aramedic students are frequently required to self-assess their performance in an attempt to identify their own strengths and weaknesses in relation to other peoples views.Written feedback is important for learners as well as teachers. As an on-line tutor for a local HEI I provide support and feedback to paramedic science students via email. These students throw me there work in progress and constructive feedback is given (see appendix X). Any negative comments made are supported to produce positive outcomes which is something that Webb (1955) advocates. According to Archer (2010), lengthy and complex feedback maybe ignored with its briny messages lost. In effort to counteract this problem some of my written feedback has been purposely left concise.In conjunction with verbal feedback students on clinical placement are provided with daily written feedback on patient encounters (see appendix X) which are supported by further written feedback monthly, quarterly and at the end of the cl inical placement (see appendix X).I consider the use of feedback on student progress generated from other sources such as other paramedics and assesors as highly important as part of a systematic approach. Feedback from a variety of sources is described as multi-source feedback (Archer, 2007). Paramedic students on clinical placement are sometimes rostered to work with other Clinical Supervisors or paramedics. beforehand(predicate) in a paramedic students placement a critical development issue was identified by one of my colleagues who had completed a set of shifts with the student. The unacceptably slow pace of the students clinical practice including patient assessment, patient management and long turnaround times at hospital following incidents had been fedback to me. As a students practice placement progresses, evidence of care activities should be gathered showing increasing speed and dexterity with increasing clinical experience (Stuart, 2007). Early support is decisive in pr eventing the student with a learning issue from experiencing the cycle of failure (Cleland, Arnold Chesser, 2005). Other key staff office who had observed the student in practice were consulted to ensure that the issue was as prevalent and problematic as had initially been assessed. Eliciting the opinions of other assessors also helps provide a more fair and unbiased assessment of a students abilities (Gomez, Lobodzinski Hartwell West, 1998). The issue was then raised with the student whilst they were performing a task too slowly. Stuart (2007) highlighted the critical importance of the critical role of providing feedback in learning and support. Furthermore, providing feedback of a development issue whilst it is relevant and alive is important for memory renounce (Bailley, 1998 Gipps, 1994).The key to support struggling students however is to identify specific reasons for worthless performance (Cleland, Arnold Chesser, 2005). Furthermore, major feedback which corrects a parti cular performance deficit should end with a plan of action (Branch Paranjape, 2002). During a feedback session with the student, input regarding specific areas where time could be saved was requested by the student but a specific action plan had not been prepared. Providing poor pure tone feedback may make the student feel they are being in person judged and can lead to defensiveness or reactivity (Katz, 2006). In order to rejuvenate this, the student was closely observed in practice for a set of four shifts in order to identify specific areas of slow practice (see appendix X). A tierce month plan was negotiated with the student to mitigate the problem and a ten point action plan developed which identified ten areas where the student could save time on each call attended (see appendix X). Data was collected over a three month distributor point of the students on scene times and hospital turnaround times. The student was not informed of this in order to avoid the Hawthorne effe ct when working with other members of staff where a subjects normal behaviour and/or study outcomes are altered as a resolvent of the subjects awareness of being under observation (Mangione-Smith. Elliott, McDonald McGlynn, 2002). Branch and Paranjape (2002) state that evaluation should follow efforts at remedying the learners problem. The results of the data after the three month period were therefore presented in chart format to the student (see appendix X) which provided material proof that the student had demonstrated real evidence of progress.Just as paramedic students are interested in their progress, so too should the paramedic educators be interested in the property of their teaching. The measurement of teaching quality can be a very complex, multi-perspective task that may include many different approaches (Hays, 2006). One form of teaching quality assessment is student feedback. Collecting student feedback also sends messages to students that their views are welcome (H ays, 2006). With this is in mind teaching assessment tools were designed to set up the students opinions on the teaching provided (see appendix X). Other feedback has been provided from peer observations (see appendix X).Prehospital education is changing rapidly, and as demonstrated the way paramedic education is delivered at clinical practicum level is also evolving. In order to establish quality and stability in this rapidly changing delivery of education, eliciting feedback from students is critical (Jones, Higgs, de Angelis Prideaux, 2001). A feedback questionnaire was designed to elicit the students opinions on the quality of the learning timetable and reference handbook after three months of the placement period. The students indicated a very high satisfaction rating for the timetable and especially the reference handbook (see appendix X).Feedback was also gained via a questionnaire regarding general teaching effectiveness in areas such as quality of feedback, supervisor/stu dent relationship, goal management and mentoring activities (see appendix X). Whilst overall the feedback obtained regarding general teaching and mentoring effectiveness was very positive, one of the students indicated some dissatisfaction with the prioritisation of goals. This was discussed further with this student who expressed concerns that it was undecipherable in reference to the learning timetable which goals were of a higher priority than others as the learning objectives were set out in chronological order.Patients have also been able to add to the feedback process as they can provide evidence to the students performance. This type of feedback is unique to healthcare professionals and is deemed influential in changing performance (Fidler, Lockyer, Toews, Violato, 1999). However, Archer (2010) warns that feedback elicited from patients may lack validity with Crossley et al. (2008) suggesting that there is expressage correlation with other sources of feedback. This form of feedback is often utilised when a student has been driving the ambulance and the patient is asked about the comfort of the journey to hospital, which is naturally carried out in earshot of the student.Giving feedbackIn the clinical environment it is vital to provide feedback to trainees as without feedback their strengths cannot be reinforced nor can their errors be turn (Ende 1983). It isa crucial step in the acquisition of clinical skills, but clinical teachers either omit to give feedback altogether or the quality of their feedback does not enlighten the trainees of theirstrengths and weaknesses. Omission of feedback can result in adverse consequences, some of which can be long term especially relating to patient care. For effective feedback, teachers need to observe their trainees during their patient interactions and not base their nomenclature on hearsay. Feedback can be formal or informal, brief and warm or long andscheduled, formative during the course of the rotation o r summative at the end of a rotation (Branch Paranjape 2002).Reflection on feedback role ModellingAmbulance services in the UK are slowly becoming reliant on undergraduate paramedic education programs to meet their employment needs (JRCALC, 2000). The HEIs and ambulance services have now forged strong links and work closely with one another in the education of student paramedics with the ambulance services providing the clinical practice placements. The clinical practicum is an important component of a student paramedics development. This practicum seeks to integrate theory and practice as well as enable the development and assessment of professional competencies. During this time in practice the student will have many opportunities to develop skills and to refine these skills based on performance feedback by clinical su