Educator Update Spring 2020

EUPDATE

DUCATOR Spring 2020

Simulation at a Distance: Going Virtual Adapting Simulation during the COVID-19 Pandemic Andrew Spain

Higher - Order Thinking Implementing Higher-Order Thinking in the EMS Classroom Paul Rosenberger

Diversity in the EMS Classroom Joseph Grafft

EUPDATE

DUCATOR

Contents 1-2

COVID-19 Resources / 2020 NAEMSE Symposium Announcement NAEMSE’s response to the pandemic.

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Simulation at a Distance: Going Virtual Andrew Spain

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NAEMSE Member Benefits Join a network of over 3,000 high-level educators!

10-18

Higher - Order Thinking in EMS Education Paul Rosenberger

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Online Education Resource Repository Learn from NAEMSE members and partners.

20-22

Diversity in the EMS Classroom Joseph Grafft

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References Higher-Order Thinking in EMS Education

Resources &

COVID-19 Responses

NAEMSE’s Response to COVID-19 NAEMSE Online Education Resource Repository During the unprecedented COVID-19 pandemic, EMS educators have been faced with the task of providing quality online education on short notice. NAEMSE started discussion forums on social media and naemse.org to aggregate resources and possible solutions for educators to offer lessons and testing remotely. Connect and share links, tutorials, guides, advice and ask questions to a nationwide network of experienced EMS educators!

Please join In! Log on to naemse.org and share what has worked for you or ask some questions to the EMS Educator community!

NAEMSE YouTube Page Subscribe for archived webinars, video tutorials, NAEMSE media and convenient access to content from our partners and faculty!

Statement Regarding the 2020 NAEMSE Symposium The COVID-19 pandemic is rapidly evolving. Our members are part of the medical community confronted with fighting this virus. As such, we hope that members of our NAEMSE community, together with their families and our corporate partners are all safe and healthy.

In an ideal world we could wait and see what happens in the months to come. Not knowing what will be or not be complicates this difficult decision and in all good conscience, we cannot ask our attendees and our exhibitors to invest into a symposium that potentially ends up being cancelled, is poorly attended, and ultimately not providing a positive return on their investment.

There is a great deal of uncertainty in how long the pandemic will last and/or the financial impact. Considering the same, the NAEMSE Board of Directors, to protect the health, welfare and safety of our members, our attendees, our exhibitors and our corporate partners, has made the difficult decision to cancel NAEMSE’s August 2020 Symposium in Pittsburgh, PA. In the interim, NAEMSE wants to thank you for all you do to provide EMS education and care for your communities. The NAEMSE Board of Directors looks forward to working with our membership as we move forward. We look forward to seeing everyone healthy next year for Symposium in Orlando, Florida (August 3-8, 2021).

Bryan F. Ericson President, NAEMSE Board of Directors Stephen Perdziola NAEMSE Executive Director

Simulation at a Distance: Going Virtual Andrew Spain, MA, EMT-P Introduction If you are part of a Paramedic or EMT Education program, you probably are having quite a bit of “fun” currently. For many, campuses are closed, access to clinicals is restricted, student engagement is only through some kind of technology, and staffing needs in some places are so great that education has been put to the side. Simultaneously, there is an ongoing drumbeat to open the pipeline to get new healthcare professionals licensed to support the demand of more patients and to help fill the gaps of many staff being out sick or caring for family. A demand that normally would be met by increasing our in-classroom and other time.

This likely feels like a “caught between a rock and a hard place” type moment for many of you. While there is no one single magical solution that balances all the needs, in this article we will look at where you can continue to utilize simulation as an educational methodology—even without having students in the classroom. The intent of this article is to support education programs in continuing to move students forward in the curriculum and subsequent licensure. This should support any other efforts in online education, for instance virtual lectures or other means of educating that utilizes various technologies.

Terminology This list consists of selected terms relating to this article, there are many other simulation terms that can be found in the Healthcare Simulation Dictionary, 2nd ed, located at www.ssih.org/Dictionary.

Distance Simulation: Implementing a simulation or training at a physical distance from the participant(s).

(LeFlore et al., 2014; von Lubitz et al., 2003)

Mental Simulation: Cognitive rehearsal of a task in the absence of overt physical movement that can be used to learn cognitive, kinesthetic, psychomotor, or technical skills. (Healthcare Simulation Dictionary 2nd ed, 2020)

Remote Simulation: Simulation performed with either the facilitator, learners or both in an offsite location separate from other members to complete educational or assessment activities. (Shao et al., 2018)

Telesimulation: “Telesimulation (TS) is a novel concept that uses the internet to link simulators between an instructor and a trainee in different locations.” (Okrainec et al., 2010, p. 417)

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Applicable Simulation Concepts What does not change are the underlying educational constructs as applied to simulation. The need for identifying goals and creating objectives does not disappear. The need to assess performance of the learners does not change.

But of course, things quickly diverge as the simulation activity design components come into place. Many of the current simulation activities are predicated on the ability to have a hands-on approach where tactile assessment or performance of skills are actually performed. One does not simply convert all task trainer (e.g. IV arm) or manikin-based simulations into the virtual world. Each modality in simulation has strengths and weaknesses that meant the choice of modality was driven accordingly. Further, many programs do not have access to many of the technologies that could be used in distance, remote, or telesimulation settings, such as virtual reality headsets.

Another consideration for simulation activity design variations is what can actually be achieved in either teaching or demonstrating knowledge, skills, or attitudes in a simulation activity. While knowledge may seem the easiest to convert between in-person and simulation by other means, this is not always the case. Working to have the simulation activities engage the learners in each domain of learning is never easy. But it is not unreasonable to see that they can be converted with a little bit of work and that many of the benefits of in-person simulation activities can be maintained, and in some ways, this could actually be beneficial. For instance, consider that the learners may need to verbalize more about what they are doing when demonstrating a skill in a remote simulation activity. This could actually support them passing the National Registry exams in the future.

Debriefing and feedback—key components of simulation. The good news is that the ability to perform either is not particularly changed, merely the setting through which they are performed. There may be some challenges related to the setting of psychologically safe environments and ensuring that the psychological safety is maintained. Many of us depend on factors such as how someone looks, or how they appear emotionally when performing debriefing.

This is more challenging when performed through computers or phones. It may be much more difficult to ascertain when someone is having either a positive or negative response to what is being discussed.

Video recordings might be especially challenging, notably due to the issues of student privacy to which we must adhere. There are wonderful video capture technologies that are present in the classroom or simulation lab but are not present and available for simulation at a distance. While it seems easy just to convert and do recordings while using video conferencing software, or even using mobile phones, the security is not present to ensure privacy.

There are solutions to ensure privacy, but this can be costly. Begin with the first consideration of how video recordings will be used, and thus whether they are necessary. If not needed, and video only serves to see what is occurring, do not record. If needed, then explore the rules and options for your institution.

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Technology We turn our focus towards how to achieve what is desired. A quick discussion on the role of technology helps us set the platform. In short, there are numerous options that are available. We must consider the use of technology for communication as a priority. And the addition of the visual component is critical when considering continuing simulation activities at a distance. Mobile phones and tablets have this functionality, and of course computers do as well through various means, including virtual meeting programs such as Zoom or GoToMeeting.

The simulators themselves also fall in this category. Many of the common simulator technologies used such as programmable manikins may not be an option. The programs used to run those same simulators might be an option.

This may take some conversion and require some permissions to use outside of their intended purpose. Of course, there are simulation programs that are designed for use on computers or mobile devices that can be used—and perhaps these are already used in your program and it is merely expanding their use.

Non-technology (assuming technology means that a computer chip is involved in some way) are options as well.

Perhaps you remember learning how to start IVs on an orange? Many other options exist that do not have any sort of technology involved. The challenges here become whether there is access for the learners, including how to distribute these safely if they are located at your physical educational facility. This applies also to any supplies that would be needed to accomplish the activity. How do the learners obtain the IV catheters and other supplies such as sharps boxes to practice on oranges at home?

Continuing the Simulation Activities The shift of simulation activities to support the ongoing education of your learners should be driven by the following concepts: 1. Be creative in finding solutions that take advantage of technology and your own imagination.

2. Focus on the activities that will best support your learners in moving forward.

3. Do not focus on the activities that would be best left to in-person activities in the classroom or clinical activities.

Given these guidelines, these are examples of the types of simulation activities that you can work to implement:

Mental simulation While this option is focused on the cognitive aspects of learning, there is significant value in this type of activity. In many ways, you probably already use this in your classrooms, perhaps in a problem-based learning approach for example. An easy way to implement this is to present problems, and then have the learners walk through the steps of how to assess, decide, and treat the patients, how to manage the scene and the teams, and how to then make transport decisions. These can by synchronous or asynchronous activities, and individual or group activities, perhaps even using virtual break out rooms with facilitators for example.

Take home simulation If resources, processes, and logistical concerns allow, there are a number of activities that can be taken home. One of the obvious groupings for simulations are the simple tasks such as the IVs mentioned before. And even with the limitations of numbers—just how many airway heads do you have—there could be a rotation of simulators over time for learners to practice and demonstrate their competency to instructors by video. While the learners may not be able to practice on each other, many have family who would willing help. How about practicing bandaging and splinting at home?

Small group activities Many of the conference software platforms can be used for this option as can simply using mobile phones and tablets. The facilitator can get the various participants online, present scenarios, and have questions, injects, triggers, and all the components of an in-classroom simulation activity ready to go. This in many ways is similar in construct to a table-top simulation, so if you’re familiar with these or already designed them, these would likely convert easily.

Virtual standardized patients Many of you use standardized patients in your activities. There is no reason not to continue to do so through remote simulation and telesimulation. This is a great option when considering the need to improve history taking for all of our EMS learners. The scripts used in the classroom will still apply, and with a little work the affective domain for meeting the patient where they are emotionally is still achieved even by video.

Virtual simulations The framing of this option is oriented more towards the use of virtual or augmented reality platforms. This may be very limited for many reading this article, but as long as the equipment is available, there are many options here.

One can orient these activities to include heavier components of scene awareness, engaging with virtual patients and other virtual representations of individuals, and even global scene management concepts as designed in the virtual world.

Computer-based simulations (conversion of software, etc) There are a wide range of options here, beginning with the programs that were designed and built for this to begin.

Many options exist for computer-based simulations. Perhaps you have seen the programs to manage disaster responses for example. But there are others that focus on responding to EMS patients that you may have used in the classroom and may be provided by textbook publishers. Slightly more complicated options include converting software used for programming and running manikins. This may be more work, but your vendor may have some options that display a virtual patient using the manikin software in which you already have many patients programmed.

Limitations The above options should not be considered all-inclusive as to what you might be able to do. Be creative and think how many things might be converted. There are even some ways to take the flipped classroom style and engage your learners in creating simulation at a distance—and give them credit as well. But there are limitations that must be considered.

As mentioned previously, student privacy must be considered. There is even a new term, “zoom-bombing” which refers to the hijacking of virtual settings (FBI, 2020). There are additional considerations and rules that must be in place to ensure that students can continue learning with fear of their privacy being violated.

Closely linked to the privacy notion is the likely need for enhanced need for paperwork. This includes not only more detailed simulation activity paperwork to ensure that the simulation is of appropriate quality, but there are also modifications and additional paperwork to consider. For instance, assessment tools may need to be edited. Students may need to complete more items for tracking purposes—items that do not currently exist but need to be created and disseminated. Instructions to support understanding and performance by all may need to be added as well. We cannot simply send a National Registry checklist home with our learners and expect that they can perform at a level sufficient to demonstrate competency.

Alas, there are always rules to consider. If distribution equipment or supplies, such as task trainers, IV catheters, or other items mentioned in this article, there are rules. Rules for pickup, disinfecting, safety, accountability, maintenance, and so many other pieces to ensure that we all are safe, and that all equipment is accounted. Sadly, there must also be rules for those who do not appreciate the privileges that are being extended, and how they must be held accountable.

Of course, we must also realize that we cannot just give everything to simulation—it cannot do everything. While it might be a great thought to provide some kind of simulation activities to make up for missed clinical time, the reality is that for most, this is not even allowed by the governing bodies. We also know that simulation is not able to fully replicate every situation, setting, issue, and construct we face in EMS, so we have to consider that limitation and what we may or may not be able to do in simulation at a distance.

FBI. (2020). FBI Warns of Teleconferencing and Online Classroom Hijacking During COVID-19 Pandemic. Retrieved from https://www.fbi. gov/contact-us/field-offices/boston/news/press-releases/fbi-warns-of-teleconferencing-and-online-classroom-hijacking-during-covid19-pandemic Lioce, L. (Ed.), Lopreiato, J. (Founding Ed.), Downing, D., Chang, T.P., Robertson, J.M., Anderson, M., Diaz, D.A., Spain, A.E. (Assoc. Eds.), and the Terminology and Concepts Working Group. (2020). Healthcare Simulation Dictionary (2nd ed.). Rockville, MD: Agency for Healthcare Research and Quality; January 2020. AHRQ Publication No. 20-0019. DOI: https://doi.org/10.23970/simulationv2.

LeFlore, J. L., Sansousie, D. A., Cason, C. L., Aaron, A., Thomas, P. E., & Anderson, M. (2014). Remote-controlled distance simulation assessing neonatal provider competence: A feasibility testing. Clinical Simulation in Nursing, 10(8), 419-424. https://doi.org/10.1016/j. ecns.2014.04.004 Okrainec, A., Henao, O., & Azzie, G. (2010). Telesimulation: An effective method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surgical Endoscopy, 24, 417–422.

Shao, M., Kashyap, R., Niven, A., Barwise, A., Garcia-Arguello, L., Suzuki, R., ... & Dong, Y. (2018). Feasibility of an international remote simulation training program in critical care delivery: a pilot study. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2(3), 229-233.

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Final Words We do know that simulation can still do a great deal. There has been a great deal of literature published on remote and virtual simulation, a short listing of which can be found on the Society for Simulation in Healthcare (SSH) webpages (https://www.ssih.org/SSH-Resources/Remote-Simulation). There are many standards out there such as published by SSH, the International Nursing Association for Clinical Simulation and Learning (INACSL), and the Association for Standardized Patient Educators (ASPE) that can guide your simulation designs and ensure quality. Use these and the resources found on the National Association for EMS Educator Trading Post—share with your colleagues and help cut the amount of work down. And don’t forget the simple activities to be easily accomplished. How easy would it be to create a quick scene safety activity to be delivered virtually by flashing pictures for 10-15 seconds, and having your learners write down the threats? It is an extremely simple simulation activity but trains the brains of the learners. Be creative, do what

The tools you need to prepare The Coronavirus disease (COVID-19) has created a healthcare crisis that has put a major training burden on hospitals and emergency medical services.

Yet training continues to play an important role in the fight to stop the spread of the COVID-19 pandemic and is essential in responding to critically ill patients.

During this crisis, we have developed free resources to help you prepare, plan, and act during the outbreak of COVID-19.

Visit our Resource Center for more information.

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Higher - Order Thinking in EMS Education Paul Rosenberger, EdD, NRP, RN

Introduction There are demands for higher-order thinking from government, educators, and employers.

Higher-order thinking has been determined to be a necessary skill for adults in the classroom and workforce. Employers have helped identify a need for (a) creative thinking, decision-making, and problem-solving; (b) logical thinking; and (c) visualizing pictures, symbols, objects, or other information in the mind; thus, thinking skills have been classified as among the most important worker competencies (U.S. Department of Labor, 2000). Each of these government-identified aptitudes relate to higher-order thinking. In education, many organizations have demanded more relevant and practical applications of knowledge (Buck Institute for Education, 2012; Samford University, 2012). Based on federal and state mandates and first-hand experience, higher-order thinking has been identified as a necessity in science classrooms (Barak & Dori, 2009). The demands of the 21st century require more than contextual knowledge; students need to know how to learn most effectively (Wilson & Bai, 2010). In health care, clinical educators have called for different instructional methods that go beyond rote recall and that require higher-order thinking skills (Chikotas, 2008; Cooper, 2009; Larkin & Burton, 2008; Lunney, 2010; Varkey Hernadez, & Schwenk, 2009; Vogel, Geelhoed, Grice, & Murphy, 2009). In fact, critical thinking is a foundational clinical skill that is needed when taking care of patients (Lunney, 2010). When critical thinking is absent, diagnostic errors often occur, and patient care can be compromised.

Government-identified aptitudes related to higher-order thinking: Creative thinking, decision-making and problem solving.

Logical thinking.

Visualizing pictures, symbols, objects or other information in the mind.

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Higher-order thinking is cognition that requires learners to analyze, synthesize and evaluate information to develop informed conclusions regarding data, procedures, or feelings (Cason, 2013).

Article Learning is an active process that requires deep thinking (Wilson & Bai, 2010) and deep learning based on direct and meaningful connections between students and course material (DeLotell, Millam, & Reindardt, 2010). Learning requires subject involvement and higher-order thinking activities, such as integration, synthesis, reflection, and a personal commitment to learning.

Deep learning strategies encourage students to think, to question, to solve problems, to make decisions, to explore, to reflect, to apply, and to integrate. Deep learning occurs when learners connect course topics, find value in the topics, and apply topics to real-world situations (DeLotell et al., 2010). Specific instructional methods that achieve deep learning are identified as PBL, case-based learning, and student research. Surface learning is the opposite of deep learning and simply requires that students accumulate and retain facts through rote memorization and shallow knowledge that solely focuses on mastering terminology (DeLotell et al., 2010).

Bloom’s Taxonomy of Cognitive Classifications. Higher-order thinking is cognition that requires learners to analyze, synthesize, and evaluate information to develop informed conclusions regarding data, procedures, or feelings (Cason, 2013). Higher-order thinking is a non-algorithmic and complex method of thinking that generates numerous solutions and that corresponds with levels above comprehension in Bloom’s Taxonomy of Cognitive Classifications (Barak & Dori, 2009). This taxonomy was devised as a classification system for cognition and includes six levels of cognitive domains (Bloom, 1956). The major purpose of this classification system was to facilitate precise communication among test constructors, curriculum workers, and teachers (Bloom, 1956). Today, Bloom’s Taxonomy has been utilized in many aspects of education. The cognitive levels of this taxonomy are knowledge, comprehension, application, analysis, synthesis, and evaluation (Bloom, 1956). The taxonomy is organized from simple to complex behaviors. Knowledge is the considered the simplest behavior, and evaluation is considered the most complex behavior (Bloom, 1956). Another key principle of this classification system is that simple behaviors are built upon and are included in complex behaviors.

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The lowest cognitive level is knowledge and focuses on memorization and recall of information and mastery of subject matter. Understanding specifics, terminologies, facts, methods, processes, patterns, structures, and settings is involved in this level of cognitive learning (Bloom, 1956). Some learning examples at this level of cognition include knowledge of dates, events, persons, and places or ability to define technical terms. In essence, learners must be able to retrieve stored and filed information to progress to the next level of cognition, which is comprehension. Comprehension focuses on interpreting and understanding the meaning of information. Translation and extrapolation are also involved in comprehension. At the comprehension level, learners can use material or ideas but may not be able to relate concepts to other ideas or to perceive all implications of concepts or ideas (Bloom, 1956). Comprehension represents the most basic level of understanding (Bloom, 1956). An example of comprehension includes learners’ abilities to grasp the main ideas of lessons.

Higher-order thinking involves the remaining four cognitive levels of Bloom’s Taxonomy (Barak & Dori, 2009). Application is the third level and focuses on knowledge or abstractions being applied to new concrete situations and experiences (Bloom, 1956). Abstractions may include technical principles, general ideas, rules of procedures, or theories (Bloom, 1956).

Stated differently, application is the practical use of knowledge. At this level, learners can apply phenomena, predict probable effects, and solve problems and are prepared to move to the fourth level of cognition, analysis. Analysis involves the separation of whole concepts into smaller parts; meaning and importance of concepts can be perceived by comparing the smaller parts to the whole (Bloom, 1956). At this cognitive level, the general message of a given lesson is clarified and organized. Ideas become clear, and relationships among smaller parts are understood in a larger hierarchical order. At the analysis level of cognition, learners can understand connections and interactions among elements of communications.

Synthesis is the fifth level of Bloom’s Taxonomy and involves combining pieces, parts, or elements of knowledge into new and different ideas (Bloom, 1956). The result of this combination is a new pattern or structure of knowledge that did not previously exist. At the synthesis level of cognition, learners can develop communications, plans, or sets of operations and can logically combine seemingly unrelated ideas together to predict, define, and defend

Knowledge

Comprehension

Application

Memorization and recall of

Focuses on interpreting and

Knowledge or abstractions

information and mastery of

understanding the meaning

being applied to new concrete

subject matter.

of information.

situations and experiences.

(Bloom, 1956)

(Bloom, 1956)

(Bloom, 1956)

ideas and choices. A specific example of analysis is learners’ abilities to develop a plan of work based on previous knowledge. After the analysis level, the final and highest level of cognition is evaluation. At this level, learners have mastered concepts (Cason, 2013). Learners at this level retain understanding from the five aforementioned levels. These learners are able to make judgments of value and decisions about information and can utilize metacognition (i.e., thinking about thinking; Cason, 2013; Barak & Dori, 2009). Objective quantitative and qualitative judgments are used to compare, discriminate, and make decisions about knowledge based on criteria and reasoned judgment (Bloom, 1956). Logic, consistency, and reference are used to make judgments about the worth of elements of knowledge. An example of evaluation is learners’ comparing works against high standards in their related fields. Learners who have achieved this cognitive level are able to take responsibility for and control of their minds (Barak & Dori, 2009). Application, analysis, synthesis, and evaluation clearly are cognitive levels that reflect complex and higher-order thinking (Barak & Dori, 2009).

Bloom’s Taxonomy has been extensively used in health care to structure educational offerings, outcome testing, and workshop objectives for professional development in nursing, all of which improve and measure critical thinking in clinical settings (Larkin & Burton, 2008). To prevent complications associated with disease processes, nurses whose training had been based on Bloom’s Taxonomy were able to understand patient situations more clearly when they presented patient data to other nurses, which resulted in better patient care. Thus, Bloom’s Taxonomy proved to be beneficial, logical, and easy to understand and can have long-lasting effects to improve clinical practice (Larkin & Burton, 2008).

Higher-order thinking allows learners to deal with uncertainty, to apply multiple criteria to given situations, to reflect on learning, and to self-reflect (Barak & Dori, 2009). Higher-order thinking enables students to think critically by asking significant questions, analyzing, reasoning, arguing, and solving problems in complex situations (Barak & Dori, 2009). Higher-order thinking contributes to long-term knowledge retention, personal growth, and understanding (DeLotell et al., 2010). Additionally, higher-order thinking equips students to participate in and contribute to society and to succeed in their lives.

Analysis

Synthesis

Evaluation

Separation of whole concepts

Combining pieces, parts, or

Objective quantitative and qualitative

into smaller parts; meaning and

elements of knowledge into

importance of concepts can be perceived by comparing the

new and different ideas.

smaller parts to the whole.

(Bloom, 1956)

judgments are used to compare, discriminate, and make decisions about knowledge based on criteria and reasoned judgment.

(Bloom, 1956)

(Bloom, 1956)

Higher-order thinking is taught through deep learning strategies that are connected to constructivist learning theory (DeLotell et al., 2010). These strategies include active, learnercentered, socially constructed, holistic, and context-based educational encounters (HmeloSilver & Barrows, 2008; Hmelo-Silver, Chernobilsky, & Jordan, 2008; Seimears, Graves, Schroyer, & Stayer, 2012). Learner-centered approaches promote significant levels of understanding through facilitative instruction, relevant and real-world experiences, and social interactions, which expand learners’ knowledge. Specific examples include verbal and written educational discourses, narrations, expositions, persuasions, logical arguments, questions, and open-ended problems (Barak & Dori, 2009). These learner-centered lessons require students to participate actively in learning, and challenging problems are presented that are based in examples.

Additionally, learner-centered lessons require students to solve problems together, to accept instructor feedback, and to improve student self-efficacy (DeLotell et al., 2010). Learnercentered lessons also enhance problem-solving skills (Barak & Dori, 2009; Brookfield, 2012).

Critical thinking. Critical thinking is a component of higher-order thinking and is a complex process (Brookfield, 2012). Critical thinking is a multifaceted activity that has been debated often and that is defined differently by various authors (Scheffer & Rubenfeld, 2000). Critical thinking may be the most abused vocabulary term about thinking (Scheffer & Rubenfeld, 2000). Critical thinking is manifested in unlimited ways across different disciplines, students, and teachers (Brookfield, 2012). Some scholars believe that critical thinking is a universal phenomenon that is common across all disciplines, but others believe that some aspects of critical thinking are discipline specific (Scheffer & Rubenfeld, 2000). The definition of critical thinking is based on its users and is subject to multiple interpretations. However, scholars have formally acknowledged the importance of critical thinking (Scheffer & Rubenfeld, 2000), which is necessary for survival (Brookfield, 2012).

Five traditions of critical thinking have been identified and may help explain the vagueness of the concept (Brookfield, 2012). These traditions are analytic philosophy and logic, natural science, pragmatism, psychoanalysis, and critical theory. The tradition of analytic philosophy and logic is argued to be the most influential in North America (Brookfield, 2012). In this tradition, students learn to construct and deconstruct arguments through reasons, conclusions, or statements.

The tradition of natural science is based on careful observation and experimentation to promote sound thinking. The scientific method, which includes forming and testing hypotheses, is used to make evidence-based informed decisions. The tradition of pragmatism is the

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third identified tradition of critical thinking. In the tradition of pragmatism, continuously experimenting, learning from mistakes, and seeking new information and possibilities are implemented to reinterpret the past and to make incremental changes to the future. The tradition of psychoanalysis is the process whereby people have core personalities that wait to be released and realized so that people can become fully developed. The tradition of psychoanalysis is emancipatory in the way that people see relationships and themselves.

In this tradition, critical thinking is used to restore inner potentials and views to fulfill outer commitments. The fifth and final tradition of critical theory can be considered from a critical theory perspective. The tradition of critical theory is overtly political. In this tradition, critical thinking is used to advance social justice and to address power inequities. These five different traditions with their unique perspectives help explain the differing views and definitions regarding what compromises critical thinking.

In a general sense, critical thinking is the process of (a) identifying the assumptions that frame our thinking and that determine our actions, (b) checking the accuracy and validity of these assumptions, (c) evaluating our ideas and actions from different perspectives, and (d) taking informed action (Brookfield, 2012). Critical thinking is argued to be contextual, and decisions that are made using this form of thinking are not always right or wrong; rather, the context of decisions can change the acceptability of the decisions due to incremental growths in knowledge (Brookfield, 2012). In educational contexts, critical thinking is a process through which students investigate assumptions held by scholars regarding how legitimate knowledge is created and advanced in particular fields of study. Additionally, students investigate their assumptions and the ways in which these assumptions frame their thinking and understanding (Brookfield, 2012).

Each discipline has determined what constitutes legitimate knowledge. For example, subject-content grammar and epistemological grammar are used to determine valid knowledge (Brookfield, 2012). Content grammar is considered the building block of knowledge within a subject. To be considered well versed in their subjects, learners must be able to use the language of their subjects and to know the laws or theories of their disciplines. Epistemological grammar refers to the processes by which disciplinary content is determined to be true, which is based on the five traditions of critical thinking that were previously identified. Together, these traditions and expectations help determine processes for identifying and accepting legitimate knowledge.

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Students learn to think critically with small-group discussions, examples of teacher modeling, concrete experiences, transformative encounters, and developmental steps (Brookfield, 2012). In fact, critical thinking is argued to occur best in small groups because accuracy and validity of assumptions can be checked by group members’ different perspectives (Brookfield, 2012). Critical thinkers apply appropriate skills and strategies to obtain desired outcomes (Ku & Ho, 2010). Critical thinkers select and utilize higher-order thinking skills that work best in given situations and actively control thinking processes to develop justified conclusions (metacognition). Specific examples include project type assignments, based in research, that emphasize thinking things through, exploration, raising additional questions, and connecting learning to real world experiences (Cason, 2013). These skills in higher-order thinking are framed in assumptions and are checked against established legitimate knowledge through social participation and exhibited informed actions (Brookfield, 2012).

Need for and development of critical thinking in clinical environments have been identified because of the complexity of these work atmospheres (Larkin & Burton, 2008; Lunney, 2010). Specifically, deliberate and intentional educational foci are required to develop critical thinking so that critical thinking is available when needed in clinical environments and can be used in conjunction with domain knowledge (Lunney, 2010). In summary, critical thinking is a component of higher-order thinking that is needed in clinical settings.

Metacognition. Metacognition is another core component of higher-order thinking (Ku & Ho, 2010; Wilson & Bai, 2010). Good critical thinkers engage in metacognitive activities (Ku & Ho, 2010). Metacognition is important because students who use metacognition are successful in school (Wilson & Bai, 2010). Metacognitive students can comprehend material better, and higher-order thinking skills are valued in learning. In health care, repeated practice of critical thinking and metacognition has helped nurses to develop a broad spectrum of thinking (Lunney, 2010). The most simplistic definition of metacognition is thinking about thinking (Brookfield, 2012; Ku & Ho, 2010; Rahman & Masrur, 2011). Despite this simple explanation and its similarities to critical thinking, the definition of metacognition is not clearly established; metacognition is a fuzzy concept, has been defined in many ways, and encompasses various dimensions (Rahman & Masrur, 2011). This is the result of various viewpoints, purposes, standpoints, and influences of differing disciplines, such as cognitive psychology, developmental psychology, and philosophy of the mind. Another explanation offered for the fuzzy definition

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of metacognition is related to the complexity of the human-thinking process (Ku & Ho, 2010).

Metacognition is a complex form of higher-order thinking and involves the ability to think and regulate cognitions by analyzing, drawing conclusions, learning from conclusions, and putting into practice what has been learned (Rahman & Masrur, 2011).

Metacognition is important because of its usefulness, and developing metacognition is an integral part of learning (Rahman & Masrur, 2011). Metacognition allows comprehension, argumentation, reasoning, and various other forms of higher-order thinking (Ku & Ho, 2010).

In sum, metacognition is a complex strategy of higher-order thinking that is as complicated as is the human mind. A simple definition of metacognition can be used, yet the concept of metacognition is multifaceted.

Metacognition is comprised of two components or constructs: (a) knowledge and (b) regulation or supervision of knowledge, thoughts, and actions (Ku & Ho, 2010; Rahman & Masrur, 2011).

The knowledge component of metacognition involves cognitive processes that are needed for understanding and learning (Wilson & Bai, 2010). Regulation and supervision of knowledge, thought, and actions involve understanding and utilizing strategies that assist in learning, utilizing components needed to learn, and controlling understanding and proper use of learning knowledge (Wilson & Bai, 2010). When metacognitive strategies are implemented successfully, thought processes are scrutinized as closely as is the product of the thought processes (Cason, 2013). Additionally, effective learners must be willing to revise metacognitive approaches when desired outcomes are not realized (Ku & Ho, 2010).

The method to implement metacognition includes practicing thinking strategies, participating in active discussions, using the language of thinking, reflecting, solving problems, using debriefing techniques, and using explicit strategy instruction (Wilson & Bai, 2010). In health care, educators have recommended that students write journal articles to describe thinking processes (Lunney, 2010). This process worked for graduate and undergraduate students by helping them to reflect on clinical practices. Additionally, the journal-writing activity helped educators to develop a pattern of continuous professional growth in students (Lunney, 2010). Testing hypotheses, reasoning verbally, arguing constructively, analyzing, understanding the likelihood of results, and making decisions are ways in which students demonstrate metacognition (Ku & Ho, 2010).

Research was conducted to determine what teachers know about metacognition and what they need to teach metacognition (Wilson & Bai, 2010). The sample for the metacognition

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research was 105 graduate students who taught in different subject areas in K-12 schools. A mixed-method approach was used. Two open-ended questions and 20 Likert-scale questions were used. It was concluded that metacognition is an active process of thinking to solve problems or to learn something, and teaching conditional knowledge is the key to helping students be metacognitive. Put into simpler terms, activities such as student discussion, discussion facilitation, and teacher guidance helped students to develop metacognition (Wilson & Bai, 2010). Additionally, teaching metacognitive strategies increased student awareness, and teaching how to use metacognitive strategies worked best when students completed assignments that required metacognition. However, simple awareness of metacognition did not translate into effective use of metacognitive strategies. In order to teach metacognitive strategies, students needed to use and experience metacognitive strategies; therefore, courses should be organized so that students have time to engage actively in metacognition and are required to demonstrate and select higher-order thinking strategies (Wilson & Bai, 2010). It was determined that instructors should teach and scaffold lessons in metacognition.

References on next pages

Paul Rosenberger Ed.D., RN, NRP

Paul Rosenberger has over thirty years of EMS experience with over twenty years of adult education instruction. He has performed ground and flight paramedic duties and leadership in town administration during his service.

During his career as a practicing paramedic he flew for an aeromedical provider, worked in Emergency Room and Intensive Care Units, and provided 911 ground paramedic duties for several Texas cities (Arlington, Fort Worth, and Austin).

He has served as a faculty member and Assistant Program Director for University of Texas - Southwestern, which included initial education and continuing education platforms. During his tenure as an Educator he has coordinated initial EMT and EMT-Paramedic courses in preparation for NREMT certification examinations. He was responsible for and maintained program accreditation with the Committee on Accreditation of Education Programs for the Emergency Medical Services Professions. He is also an instructor for the NAEMSE Evaluating Student Competencies seminars. In 2017 and 2018, Paul Rosenberger was a senior facilitator for the NREMT’s scenario workshops. Currently, Paul is the Associate Director of the EMS Continuing Education program at UT Southwestern and an Adjunct Faculty member for the Emergency Services Administration BAAS program at the University North Texas - Dallas. He is also a Co-Chair for the National EMS Education Standards Developmental/Revision Team.

Paul Rosenberger graduated from Auburn University at Montgomery with a Bachelor of Science in Political Science. He then earned a Master’s Degree in Public Administration from the University of North Texas. He graduated from Northcentral University with a Doctorate of Education in 2013.

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Higher-Order Thinking in EMS Education: References Barak, M., & Dori, Y. (2009). Enhancing higher-order thinking skills among in-service teachers via embedded assessment. Journal of Science Teacher Education, 20, 459–474. doi:10.1007/s10972-009-9141-z Bloom, B. (Ed.). (1956). Taxonomy of educational objectives. White Plains, NY: Longman.

Brookfield, S. (2012). Teaching for critical thinking: Tools and techniques to help students question their assumptions. San Francisco, CA: JosseyBass.

Buck Institute for Education. (2012). Project-based learning for the 21st century. Retrieved from http://www.bie.org/index.php/site/PBL/ overview_pbl/ Cason, D. (Ed.). (2013). Foundations of education: An EMS approach (2nd ed.). St. Louis, MO: Mosby JEMS Elsevier.

Chikotas, N. (2008). Theoretical links supporting the use of problem-based learning in the education of the nurse practitioner. Nursing Education Perspectives, 29(6), 359–62. Retrieved from http://search.proquest.com/docview/236656088?accountid=28180 Cooper, E. (2009). Creating a culture of professional development: A milestone pathway tool for registered nurses. The Journal of Continuing Education in Nursing, 40(11), 501–508. Retrieved from http://search.proquest.com/docview/223310880?accountid=2818 DeLotell, P., Millam, L., & Reinhardt, M. (2010). The use of deep learning strategies in online business courses to impact student retention.

American Journal of Business, 3(12), 49–55. Retrieved from http://search.proquest.com/docview/846791553?accountid=28180 Hmelo-Silver, C., & Barrows, H. (2008). Facilitating collaborative knowledge building. Cognition and Instruction, 26, 48–94. doi:10.1080/07370000701798495 Hmelo-Silver, C., Chernobilsky, E., & Jordan, R. (2008). Understanding collaborative learning processes in new learning environments.

Instructional Science, 36, 409–430. doi:10.1007/s11251-008-9063-8 Ku, K., & Ho, I. (2010). Metacognitive strategies that enhance critical thinking. Metacognition and Learning, 5(3), 251–267. doi:10.1007/s11409-0109060-6 Larkin, B., & Burton, K. (2008). Evaluating a case study using Bloom’s taxonomy of education. AORN Journal, 88(3), 390–402. Retrieved from http://proquest.umi.com.proxy1.ncu.edu/pqdweb?did=1557092171&sid=6&Fmt=6&clientId=52110&RQT=309&VName=PQD Lunney, M. (2010). Use of critical thinking in the diagnostic process. International Journal of Nursing Terminologies and Classifications, 21(2), 82–88. doi:10.1111/j.1744-618X.2010.01150.x Rahman, F., & Masrur, R. (2011). Is metacognition a single variable? International Journal of Business and Social Science, 2(5), 135–141. Retrieved from http://search.proquest.com/docview/904525300?accountid=28180 Samford University. (2012). Samford University: Teacher education. Retrieved from http://www.samford.edu/ctls/archives.aspx?id=2147484112 Scheffer, B., & Rubenfeld, G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39(8), 353–359.

Retrieved from http://proquest.umi.com.proxy1.ncu.edu/pqdweb?did=63580112&sid=1&Fmt=6&clientId=52110&RQT=309&VName=PQD U.S. Department of Labor, Employment and Training Administration. (2000). Workplace essential skills: Resources related to the SCANs competencies and foundation skills. Retrieved from http://wdr.doleta.gov/OPR/FULLTEXT/00-wes.pdf Varkey, P., Hernandez, J., & Schwenk, N. (2009). 6 Techniques for creative problem-solving. Physician Executive, 35(3), 50–53. Retrieved from http://search.proquest.com/docview/200072456?accountid=28180 Vogel, K., Geelhoed, M., Grice, K., & Murphy, D. (2009). Do occupational therapy and physical therapy curricula teach critical thinking skills? Journal of Allied Health, 38(3), 152–157. Retrieved from http://proquest.umi.com.proxy1.ncu.edu/ pqdweb?did=1878252461&sid=4&Fmt=3&clientId=52110&RQT=309&VName=PQD Wilson, N. & Bai, H. (2010). The relationships and impact of teachers’ metacognitive knowledge and pedagogical understanding of metacognition.

Metacognition and Learning, 5(3), 269–288. doi:10.1007/s11409-010-9062-4

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Diversity in the EMS Classroom Joe Grafft, MS, NREMT For several years NAEMSE has attempted to increase diversity within the EMS, Public Safety and Instructor ranks! However, as I attend Symposiums and other EMS Conferences throughout the United States, minorities are still underrepresented. Even in our IC1 and IC2 classes, there are very limited number of minorities in classes. What are we to do?

I have an idea that will work: we need to work on diversity issues within the high school! If we can train these students while they are still in high school, they will join our ranks! However, if we wait until after high school graduation, we do not witness minorities moving into EMS or other public safety sectors.

Presently there are five (5) EMR to EMT Programs offered in Minnesota, that I work with; at the following High Schools: Forest Lake Senior High, Forest Lake, MN; Simley Senior High School, Inver Grove Heights, MN; Fridley High School, Fridley, MN; and since 1976 – Spring Lake Park Senior High, Spring Lake Park, MN and Since 1987, Osseo Senior High, Osseo, MN. Many of these high schools have a high proportion of minority students. Once you put together the right team of EMS and Health Care Professionals you would be amazed how these students respond. These high school EMR/EMT students are outstanding and are seeking a way to enter into the Medical Field, Law Enforcement and Firefighting. The Medical Director, John W. McBride, MD, Cardiologist and Tony Orecchia, MD are very active in the classroom with both didactic and practical portions of studies.

Three of these High School EMS classes are enrolled through Current Enrollment with Pine Community Technical College and I serve as the Adjunct Faculty & Mentor for these schools.

For example, at Forest Lake, 17 students have taken the National Registry Practical and Written Examinations, with 16 passing on the first try. The remainder will be taking the NREMT exam when they turn 18 years of age.

The clinical parts of the required training are being completed by those who are 18 years of age at North Memorial located in Forest Lake. As of February 2020, Lakes EMS is now providing the clinical experiences. Those under the age of 18 go through Simulation Training sponsored by Lakes EMS. The remainder of the high schools are working with their own Public Safety Agencies.

When the students reach the age of 17 ( NREMT lowered the age where you can apply to take the NREMT Practical and Written Examinations) they register with the NREMT and Minnesota Emergency Medical Services Regulatory Board and complete the didactic and practical portions of the class.

Now, I can imagine a collective sigh – we have tried this in our areas and it simply does not work!

How can this be successful?

• Put together the right team of Health Care Professionals including an active Medical Director.

These Health Care Professionals must complete the State required DOT Instructor Training.

They must also have an ability to relate to high school students.

• Work with the school administration to seek their support through the Principal, Superintendent and School Board. There must also be a high school teacher who is interested in being the classroom educator. This individual must be or work at becoming and EMR and an EMT under the supervision of a State Training Center approved program.

• Support must be sought from the local or County Fire/EMS/ Law Enforcement Agencies who share the vision and provide guidance and instruction of the students.

• Liability insurance comes from two sources: Forming an EMS Explorer Post which provides up to $500,000.00 in liability coverage; the school district additionally has liability insurance.

• All practical skills instructors must teach every required skill the same way. If necessary test each practical skills instructor in the way you as the coordinator want the skills to be covered.

• Involve the students in the community and the school activities. For instance: Our state requires each student before they graduate from high school to have CPR training. At Forest Lake the student EMT’s actually teach the other high school students the required CPR training. Other schools get involved in their communities by volunteering at local food shelters, Ronald McDonald house, athletic events, assist in teaching EMR in the community.

• The high school students want direction, discipline, are very anxious to learn and want an opportunity to demonstrate they can do what is necessary to be caring Health Care Professionals.

• By the way the tools taught in the IC1 class work very well with the high school EMS students; White Boards, Eyes Forward, Stand and Deliver, make tough tests and other activities.

• NAEMSE and the EMS instructor cadre needs to get involved with their local high schools.

These wonderful young people are ready, anxious and need your guidance, care, mentorship and patience to be the next generation of health care providers.

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Who would you want to take care of you? Can you provide this type of EMS education and training at the high school level? Or are you too “busy” to groom the next generation of health care providers?

Feel free to contact me for more information and the “how to” get started!

Joseph A. Grafft, MS, NREMT

NAEMSE, Board of Directors Contact Joe via naemse.org!

NAEMSE Board Announcements: The National Association of EMS Educators is proud to announce that Ron Lawler has been assigned as the NAEMSE representative to work with The American College of Surgeons (ACS) on a cooperative agreement. This agreement with the National Highway Traffic Safety Administration (NHTSA) updates Field Triage Guidelines.

Featured Member Spotlight NAEMSE members represent the best and brightest in the EMS Educator community. We are proud to shine the spotlight on one of our members in each Educator Update to recognize the outstanding achievements of our members.

Scott Lancaster, PhD, MHA, NRP Scott recently finished his PhD in Health Professions Education from Simmons University in Boston, MA. Scott lives in Goffstown, NH and works at Northern Essex Community College in Haverhill, MA.

CONGRATULATIONS! 21

NAEMSE Online Education Resource Repository Explore NAEMSE.org for the resources you need!

Click ‘Member Benefits’ to find the NAEMSE Resource Repository.

Resources for Video Sharing Platforms Find helpful resources for commonly used video sharing platforms such as Zoom, Teams and GoToMeeting. Members have shared their favorite Zoom hacks, tips for teaching and conducting exercises virtually, and using virtual simulation software online.

Learn more about your LMS Many educators are currently utilizing the capabilities for integrating video sharing and effectively executing lesson plans remotely using: D2L, Blackboard, Engage and others. The NAEMSE Resource Respository has links to articles and personal accounts of ways to maximize the potential of these LMS’s.

Access to Resources from Partners in EMS The EMS community has stepped up in unprecedented ways to accommodate the needs of the educator community during this pandemic. NAEMSE has been hosting webinars, as well as reposting resources from organizations such as: iSimulate, Public Safety Group, Society for Simulation in Healthcare, and NHTSA.

Save the Date The unprecedented circumstances presented by the COVID-19 pandemic forced NAEMSE to make the difficult decision to cancel our 2020 EMS Educators Symposium & Trade Show. We can’t wait for next year to bring this unique, week-long educational experience to Orlando, Florida.

26th Annual NAEMSE Educators Symposium & Trade Show

July 30 - August 8, 2021

OMNI HOTEL - CHAMPIONSGATE

ORLANDO, FLORIDA

EUPDATE

DUCATOR

Spring 2020