Educator Update/Domain 3 - Spring 2014

EU UPDATE

Is the Paramedic Education Model Failing Its Students?

by Nicholas Miller, BS, NREMT-P

Also in this issue:

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INSIDE This photo courtesy of Brandon Ciampaglia Š 2014

IN THIS ISSUE

SPRING

National Association of EMS Educators 250 Mount Lebanon Boulevard Suite 209 Pittsburgh, PA 15234 Phone: 412-343-4775 Fax: 412-343-4770

2014

2013-2014 Board of Directors Scott Bourn, PhD, RN, NREMT-P President Michael Nemeth, AEMCS(f), EMT-P, ICP, MA(c) Vice President Connie Mattera, MS, RN, EMT-P Treasurer Richard Beebe, MS, RN, REMT-P Secretary John Creech, MEd, LP Kim McKenna, M.Ed, RN, CEN, EMT-P

WHAT’S INSIDE

Michael Miller, BS, MS, EMS, RN, NREMT-P Nerina Stepanovsky, PhD, MSN, RN, PM Donna Tidwell, MS, RN, EMT-P John Todaro, REMT-P, RN, TNS, NCEE

Page 3 NAEMSE NEWS/ MEMBER SPOTLIGHT Page 5

Rebecca Valentine, B.S., EMT-P, EMT I/C, NCEE Bill Young, M.S., NREMT-P

Ethics Education in the Health Professions

by Thomas R. Cole

Page 7

Domain3

Page 23

Tracking Patient Encounters

National Office Staff Joann Freel, BS, CMP Executive Director, Editor Stephen Perdziola, BS Business Manager Nora Davidson, BA Membership Coordinator Brandon Ciampaglia, AS Communications Coordinator Laurie Davin, AS Education Coordinator Larissa Kocelko, BA Administrative Assistant

by Patricia L. Tritt, RN, MA

William Raynovich, MPH, NREMT-P, Ed.D Editor, Domain3

Page 25

Ease Up on Social Science

Reprinting Information

by Michael Stratford

Interested in reprinting one of the articles you find in this publication? If so, please contact Brandon Ciampaglia via e-mail at brandon.ciampaglia@naemse.org or by phone at (412)343-4775 ext. 29

Submission Guidelines

Unsolicited submissions are welcomed. Members of the NAEMSE Publications Committee review Domain3 manuscripts. Acceptance of a manuscript for publication is contingent upon completion of the editing process.

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Manuscripts should be e-mailed to submissions@ naemse.org. Submit a cover letter with each manuscript indicating: Author name, credentials, title, and affiliation. A title letter should also be included disclosing any commercial associations that could post a conflict of interest. If you have an idea brewing that you’d like to submit, please contact us. We would be happy to discuss it. New authors are welcome and encouraged.

MEMBER SPOTLIGHT / NAEMSE NEWS

MEMBER SPOTLIGHT Name: Terri Bailey

Hometown: Munfordville, KY Current Employer/s: Hart County Ambulance Service State Fire Rescue Training Area 4 Job Title/s: EMT/Educational Instructor EMS Training Supervisor Job Scope: Educational Supervisor over EMT, EMR, CEU, CPR, First Aid, Blood Pathogen classes. Full time on a truck as an EMT. Evaluator for skills competency testing.

Hardest job aspect: Making sure that the lesson plans hold the student’s interest as well as making sure that they absorb the information.

Most rewarding job aspect: Hearing the excitement in a voice when they have passed the National Registry and now have a job doing what they love.

Why I joined NAEMSE: When I attended the training in Orlando, Florida, I realized how much of an asset the organization is to me. The organization is an endless resource for educators.

Activities: Serving on the Kentucky Board of EMS Educational Committee. Track official for a tractor/ truck pull organization called KTPA. Personal Hobbies: Participating in walk/run events, time with my grandchildren and outdoor activites.

Who would play me in a movie: Jennifer Aniston

“I can honestly say that I love

both of my jobs. The idea of helping people learn the field of EMS, or helping current workers further their quality improvement, is a rewarding feeling. ”

“ When I became a NAEMSE

member I was so elated to have this wonderful tool. This organization has greatly enhanced my ability to become a better educator. The tools that are at my disposal give me so many ideas and educate me, as well as continue to improve my skills as an educator. Thank you NAEMSE. ”

What my refrigerator is never without: Ketchup

Upcoming CoAEMSP/CAAHEP/NAEMSE Course Dates and Locations Register today for the upcoming CoAEMSP/CAAHEP/ NAEMSE Accreditation Update & Student Evaluations Workshops at the following locations:

NEW ORLEANS, LA - March 6-8, 2014 PITTSBURGH, PA - June 5-7, 2014 Don’t miss out on your chance to attend these highly informative workshops!

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INSTRUCTOR COURSE DATES NAEMSE continues to bring its heralded EMS instructor course to all corners of the country.

If you have never attended, you can reserve your spot online. If you’re an instructor, spread the good news to your colleagues in the EMS community.

The following are upcoming Winter courses: INSTRUCTOR COURSE I

Elizabeth City, NJ: March 14-16, 2014 Held in partnership with Union County College Cambridge, MA: March 21-23, 2014 Held in partnership with Pro EMS Center for Medics Champaign, IL: March 28-30, 2014 Held in partnership with Parkland Community College St. Louis, MO: April 4-6, 2014 Held in partnership with IHM Academy of EMS Greenville, SC: April 25-27, 2014 Held in partnership with Greenville Technical College

INSTRUCTOR COURSE II Orland Park, IL: March 7-8, 2014 Held in partnership with Orland Fire District

WEBINARS Accelerating Performance In Your Education Programs: Getting Ready for the Street Taught by Rommie Duckworth March 12, 2014 @ 3PM (EST)

For more information, please visit

NAEMSE.ORG

!

NAEMSE.org

- 11 Pre-Conference Sessions - 28 Breakout Sessions covering: Technology Classroom Management Hot Topics Simulation CoAEMSP Accreditation Administration

The mission of The National Association of EMS Educators is to inspire and promote excellence in EMS education and lifelong learning within the global community.

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250 MT. LEBANON BLVD. STE. 209, PITTSBURGH, PA 15234 / (P) 412.343.4775 / (F) 412.343.4770 www.naemse.org | Educator Update | A WWW.NAEMSE.ORG (E) naemse @naemse.org

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ETHICS EDUCATION IN THE HEALTH PROFESSIONS

Ethics Education in the Health Professions By: Thomas R. Cole

Students moving from undergraduate school to graduate training in the health professions do not automatically understand that they are stepping across a threshold in which service to others takes precedence over self interest.

They are beginning a journey of moral education, which requires a supportive environment, mentors, models of conduct, inspiring teachers and compelling materials.

Forming a professional identity means internalizing an ethos of altruism and service, developing a commitment to lifelong learning and expertise, and participating in the self-regulation which society grants to professional groups devoted to the welfare of their constituents.

In recent years, ethical misconduct in research, clinical care, education and between peers in the health professions has been a source of mounting concern.

Speculation about the reasons for these moral lapses center around an increasingly commercialized and competitive health care system, which results in pressure for cheaper and quicker student learning and for increasing clinical faculty productivity.

But regardless of the reasons, Deans and Associate Deans today are concerned.

To name just a few things, they worry about cheating on tests, scientific misconduct, sexual harassment, and failure to respect patients and other health professionals—problem behaviors which are exhibited by faculty as well as students.

As a result, education in ethics and professionalism has become a requirement for accreditation in all the major health professions.

Also, it has become clear that such education is ideally carried out using interprofessional materials and instructors, and in interprofessional settings, virtual or real. The obstacles, however, are forbidding.

Socializing students into the health professions is a daunting task. At bottom, it means helping them form a professional identity, acquire the tools of ethical analysis, and develop the skill and motivation to act according to the highest moral standards.

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There are many criticisms of traditional education in ethics and professionalism.

Some argue that basic morality is learned at home and that ethics education has no real effect on values, character, or behavior. It is not true, however, that students learn everything they need to know about being a good person at home or in church or in some religious community.

One’s original beliefs and values are important but they are not universally true, nor should they be the basis of every action.

Learning to respect the values and world views of others—and learning how to act when values and world views clash—requires knowledge of ethics, cultural humility, and conscious effort to apply both in professional life.

There are other, often apt, criticisms of education in ethics and professionalism: there is little evidence that knowledge of ethics translates into ethical behavior; ethics education is boring; it affects the intellect but not the emotions; it is logistically difficult to get students from different professional schools together; and there is a paucity of good teaching materials.

At the University of Texas- Houston, the McGovern Center for Humanities and Ethics, working with Archimage Design Studio, has developed an online and hard-copy fictional text which addresses several of these problems.

Modelled on the genre of the choose-your-own adventure novel, The Brewsters is a nonlinear story about three generations of a family involved in the health care system (www.meetthebrewsters.com).

ETHICS EDUCATION IN THE HEALTH PROFESSIONS Students readers decide to become a character in each of three Acts, and they play out the storyline from the point-of-view of that character. They take on the roles, for example, of medical student, patient, dental or nursing student or epidemiologist.

“It is one thing to read material and look and pictures, but it is a whole other to be immersed into something that actually feels real,” noted a nursing student. “. . . . [students] don’t even realize that they are learning about ethics and instead think that they are reading a very interesting story.”

They make choices from that point of view in ethically sensitive situations, and these choices have consequences for the fate of their character and the shape of the plot.

We have found that interaction and fictional immersion are significant factors in interprofessional learning about ethics in health care. Online activities can be followed up with small group discussions or even a theatrical appearance of the story’s characters performed live by professional actors. It is no secret that students like to be entertained in immersed.

The story is written in three Acts: Professionalism, Clinical Ethics, and Research Ethics. Each act is followed by a short section of didactic themes (e.g. codes of ethics, ethical principles, conflict-of-interest, accepting gifts from industry or patients, duty to report, etc.). The Brewsters is assessed by short pre- and post-tests.

Educational innovations should take this to heart: serious games, fiction and online interaction can yield humanistic forms of learning with strong potential to shape the hearts and minds of our future health care providers.

Our health science center in Houston has six professional schools—nursing, medicine, dentistry, public health, biomedical science, and bioinformatics.

Thomas R. Cole, Ph.D., is Director of the McGovern Center for Humanities and Ethics at the University of Texas-Houston Health Science Center.

The Brewsters is now a required exercise for all 1,000 students who enter these schools annually.

Assessments reveal significant knowledge gains, and student reaction has been very positive.

Reprinted from INSIDE HIGHER ED February 4, 2014 with the permission of Inside Higher Ed, copyright 2014.

Inside Higher Ed is the free daily news Website for people who work in higher education.

Breaking news, lively commentary and thousands of job postings bring more than 800,000 people to the site each month.

“This story tricks you into learning,” wrote a student in Public Health.

2014 Call for Abstracts Now Accepting Research Abstracts for Presentation.

Submit your abstract or learn more via online at: www.pcrf.mednet.ucla.edu Category: Deadline: Presented at:

Educational st March 31 , 2014 NAEMSE Conference 2014

Category:

Clinical, system, management, or personnel st October 31 , 2014 EMS Today Conference 2015

Deadline: Presented at:

For additional questions contact the Prehospital Care Research Forum at: Telephone: (310) 312-9315

Email: pcrf@mednet.ucIa.edu

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DOMAIN SPRING 2014

Providing a Voice for EMS Educators

3

Official Publication of the National Association of EMS Educators

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Death Notification in Emergency Medical Services: A North American Perspective (PART 2) pg

by Nicholas Miller, BS, NREMT-P

14 Teaching Intercultural

pg

Competence in Emergency Medical Services

by Kim McKenna, M.Ed, RN, EMT-P

pg

20 2014 Revision to

Education Agenda for the Future: Achieving Higher Education

by Walt Stoy, PhD, John Pierce, MBA, William Raynovich, NREMT-P, EdD, MPH, BS, and Thomas Platt, EdD

Editorial Review Board William Raynovich Les R.Becker Bruce Butterfras Todd Cage Lynne Dees Kim McKenna Mike G. Miller

Maddie O’Donnell Michael D. Pante Richard A. Walker David Blevins Greg LeMay Beth Ann McNeill Fred W. Wurster

NAEMSE MISSION: To inspire and promote excellence in EMS education and lifelong learning within the global community.

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|Educator EducatorUpdate Update| |www.naemse.org www.naemse.org

DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

Is the Paramedic Education Model Failing Its Students?

By: Nicholas Miller, BS, NREMT-P

For the past two summers, there has been an

outstanding young paramedic who has taught an EMT class for the EMS Education program where I am a faculty member. He is very intelligent, has high ethical and professional standards, and is well liked by his students. He was approached by some of the full time staff about coming and teaching full time. Without hesitation, his answer was no. He was in nursing school to obtain his Bachelor’s degree in Nursing. When he graduated, he left the EMS profession and now works full time as an RN. His story is not unique. All across the United States, the paramedic profession is losing its best and brightest. They leave for a multitude of reasons, many of which are well documented. They leave because of they need to support their families without working three jobs. They leave to escape the burnout of terrible hours and high stress. They leave to avoid years of disrespect and being known simply as an “ambulance driver” by other medical professionals. They leave for lack of career advancement and to escape the suffocation of ever increasing bureaucracy.

This exodus of paramedics is placing additional stress on an emergency medical system that is already strained with a nationwide shortage of paramedics. Communities, especially in rural areas, are struggling to replace them. The public expects that the ambulance that comes to their rescue will be staffed with seasoned veterans. Instead, they are often surprised to find that the paramedic that comes to their home is under 25 years of age and has less than two years of experience. The profound loss of these veteran paramedics leaves Paramedicine at a distinct disadvantage to tackle the multitude of problems that it faces.

As a paramedic educator, I have trained hundreds of paramedics. In that time, I have come to realize that EMS does not have a shortage of paramedics…it has an attrition problem. The program I currently work for graduates over 120 Paramedics annually and yet we struggle to meet the demands of our local community. How is this ever going to change?

This question reminded me of a conversation I had very early in my career as a rookie paramedic with my field training officer. I remembered asking him why we are not treated on the same level as the registered nurses in the hospital where I first worked. After all, our jobs are very similar. We both perform patient assessments, and both have to exercise critical thinking on a daily basis.

Both perform advanced life support skills. As paramedics we even perform advanced skills that most registered nurses do not perform such as 12 lead EKG interpretation, rapid sequence intubation, and surgical cricothyrotomy. Yet registered nurses are paid much better than paramedics and have better hours than paramedics. Registered nurses are considered medical professionals, while paramedics are often considered technicians. On a medical helicopter, the paramedic usually reports to the registered nurse. In the military, paramedics are enlisted personnel while registered nurses (BSN) are officers. Why are paramedics and registered nurses not considered equals in advanced medical care?

My FTO responded by saying the paramedic will never be on the same playing field as the registered nurse until we (Paramedicine) recognize as a profession that we need the same level of education as nurses.

Until we get the same degrees as registered nurses, we will never get the pay of registered nurses. My FTO was a rarity in the profession in the 1990’s. He was a paramedic with a Bachelor’s degree. He understood what a degree meant and its importance. He understood what academic rigor was and the difference between a technical certification, and a Bachelor’s degree.

As I remember that conversation, I realized just how insightful his perspective was 15 years later. I realized that most attempts to address the exodus of paramedics have been focused on the other end of the career path.

Those attempts were focused on the end point where paramedics leave, trying to plug holes with inadequate pay raises, and other stopgap measures. The focus really needs to be on the place where paramedics begin their journey…and the journey begins with the paramedic educational model.

I cannot help but wonder if the current model of paramedic education is failing both paramedics and the EMS profession. Now let me be clear on this…. I am not saying that the paramedic curriculum is inadequate or that we are not teaching our future paramedics well. I am saying the current model in which that education is delivered could be failing them. Allow me to illustrate.

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DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

A Tale of Two Students Kate and Mary are two recent high school graduates with an interest in the medical profession. They both enroll in the local community college. Kate enrolls in the paramedic program while Mary enrolls in the nursing program. In two years, both Kate and Mary graduate with associate’s degrees. Kate, will first obtain her Paramedic certificate, and then depending on the particular school, she may get an associate’s degree in Paramedicine, Emergency Medical Technology, Emergency Medical Care or Public Safety. Mary will simply get an Associate’s of Science Degree in Nursing. They will both start off in entry level positions at the local hospital.

Kate will work nights on the ambulance run by the hospital and Mary will work nights on the surgical floor of the hospital. After a few years both are making the median salary. Kate is making about $34,000 per year while Mary is making about $58,000. Mary makes $24,000 a year more than Kate even though both of them have an associate’s degree.

After getting their respective bachelor’s degrees, both decide to use them to try to advance their careers.

An opening comes up for manager of the emergency department. Kate, despite working in the department for years as paramedic and being ideally suited with a bachelor’s degree in Emergency Management, is ineligible to apply for the position because she is not a registered nurse and does not have a BSN. Mary, even though she has never worked in the ER, can apply for the job because she is an RN and now has her BSN. Because she is a hard worker and good at what she does, Mary gets the job. The only supervisory job Kate can apply for is the ambulance manager. Luckily, Kate gets the job and gets a raise to $52,000 per year. Mary got a raise also and is now making $80,000. Both started at the same time in college, both have bachelor’s degrees, both have advanced medical training; however, Mary makes $28,000 more a year than Kate and Mary is now Kate’s boss.

Kate is getting frustrated. She is now married with children and wants more for her family. She looks for other management opportunities in the hospital; but, she either has to be an RN or she needs a master’s degree in business or hospital administration. Kate Both women want to move up in their careers and eventually realizes that she wants to be a leader; but, decide to get their bachelor’s degree. Kate enrolls does not enjoy being a manager. Out of frustration, she in the local university; but, firsts she has to decide looks for a way to get back to her paramedic roots. She what to major in. Does she want a business decides that she will go back to school and become a degree for management, a biology degree for physician assistant and work in a clinic. Kate does some medical school, a degree in Emergency Health research and finds out that because her degree was in Services, a degree in Emergency Management, or Emergency Management and not Biology, she will have Unified Public Safety? This is an important to go back to school for another three to four semesters decision as it will lock her into one career track. and get the necessary science prerequisites. Frustrated at the idea of going to school for two more years and not After making her decision to get her degree in even getting a master’s degree, (7-8 years total Emergency Management, Kate meets with her undergraduate study) Kate decides to leave advisor. She is stunned to learn that only her one Paramedicine and uses her Emergency Management semester of general education credits will count degree to get a job in the business sector as a manager. towards her degree. If she is lucky, her three Kate works normal business hours and her stress is a semesters of paramedic training will partially count fraction of what it used to be. She now makes $65,000 as elective credit. She will still have to go to school a year and Paramedicine has lost yet another of its best and brightest. for three to four years (5-6 years total) to finish her bachelor’s degree. Mary, on the other hand, Mary, also married with children, realizes that can simply enroll to get her Bachelor’s Degree in management is not working for her. She too decides she Nursing. All of her credits will transfer towards her degree and she will finish her degree in just two wants to get back to her nursing roots, have better hours, and practice as a clinician in a clinic. Her transition is years (4 years total). much easier. She does not have to worry about prerequisites to apply to physician assistant School.

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DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

They were built into her BSN. But, because she does have the BSN, she can instead enroll in a master’s degree program to become a nurse practitioner. She goes to back to school and becomes a Family Nurse Practitioner (6 years total to MSN, RNP).

Academically and professionally, she has grown with her Master’s degree. She has been able to successfully transition to a part of Nursing she loves and after a few years, she now makes $92,000 a year.

She is happy and feels fulfilled in her career.

This illustration demonstrates how Kate’s paramedic education led to glass ceilings, dead ends, and additional years of study, while Mary’s nursing education enabled her to grow and advance at her pace. Why did Kate’s associate degree fail to open all the doors for her that Mary’s associate degree did?

The Limitations of the Current Paramedic Education Model I believe the answer to this question is that Kate’s education was designed for only one purpose; to train her to be an entry level paramedic. That is as far as her education could take her. It was not designed with the future in mind. It was not designed to be part of a comprehensive, lifelong professional educational path. Kate was growing as a person and she was growing in terms of what she wanted out of her career. Kate wanted to branch into management, but her paramedic education was not designed for that. Kate had to branch off to an ancillary discipline, Emergency Management, to find that growth. Later in life, Kate wanted to grow in her profession and become a clinician, but again, her education was not designed to grow with her. It was not designed to transfer to another institution; and it was not designed with a bachelor’s or master’s degree in mind. Kate wanted to go places in EMS, but her paramedic education gave her nowhere to go but stagnant. Because Kate’s education gave her nowhere else to go, Kate left Paramedicine for good.

I believe this is how the Paramedic education model fails paramedics and the EMS profession as a whole.

It fails to give them anywhere else to go in the EMS or medical profession other than a field or ED paramedic. The Paramedic education model does not allow for college credits to be transferred easily from one institution to another. It does not allow for an easy transition from an associate’s degree to a bachelors or graduate degree. All human beings grow and evolve throughout their lifespan.

If a person’s current profession no longer meets their needs, they will leave. This I believe, in addition to the poor pay and bad hours, tips the scale beyond the point of return.

We also lose all of the best and brightest students who might have gone into Paramedicine; but, instead choose to go into Nursing or pre-medicine because Paramedicine has no degree pathway. We, as a profession, are shutting ourselves off from an entire population of bright and educated people who would otherwise consider Paramedicine; but, because our profession makes them choose between a college degree or a certification, they never take the first step in Paramedicine. They know how important the degree is for their career success. Imagine how our profession would be advocated and advanced if many of the future physicians did their undergraduate studies in Paramedicine and became paramedics prior to becoming physicians.

The paramedic education model also hurts the profession as a whole in other ways. Currently the demand for physician assistants, certified nurse anesthetists, nurse practitioners, and physicians is growing like never before. There are shortages of these key practitioners across the United States. I believe that paramedics are ideally suited to transition to physician assistants, practitioners or anesthetists.

They are already experienced in performing a physical exam, interpreting 12 Lead EKG’s, and performing endotracheal intubation. They have proven clinical and critical thinking skills, and they have tremendous experience in providing critical treatments, independently, in life and death situations. Yet, there is not one paramedic practitioner or one certified paramedic anesthetist program. Instead, registered nurses, who may or may not have any experience working independently, are instead seen as the ideal choice to fill these voids.

There are literally thousands of paramedics who could potentially be educated and trained to fill these critical shortages. However, the medical profession as a whole will not even consider tapping into this huge resource because they do not have a bachelor’s degree. As a result of this, the medical profession usually sees paramedics as technicians and not as the professional clinicians they truly are. This lack of paramedic utilization is a terrible waste of resources, training, and talent. It is a true loss to the medical profession.

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DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

The Solution I believe that if Paramedicine is ever going to reach its true potential, and take its rightful place as an important member of the medical community; the paramedic educational model is going to have to be fundamentally changed at all levels. Fortunately, Paramedicine does not have to completely reinvent the wheel. There already exists a proven educational model that meets all the needs of the paramedic profession.

This model can address the broad and dynamic educational needs of paramedics from entry level to executive leadership. It can provide paramedics with the advanced education they need to succeed in leadership, management, and patient care. This proven model can help to fill the critical shortages of clinical practitioners. This model is the nursing educational model.

Historically, the nursing profession is not that much different than paramedics. Over the last 100 years, the nursing profession has evolved from primarily a medical assistant role, to their modern incarnation as professional patient care providers and clinical practitioners with education, training and expertise on par with physicians. The modern paramedic is a relatively new creation in the medical profession, and Paramedicine is currently experiencing its own set of difficult growing pains as it evolves from a blue-collar to a white-collar profession. It could greatly benefit from learning from its brothers and sisters in Nursing.

I propose that the paramedic profession, like nursing, must adopt a comprehensive education model to address those needs. The implementation of such a model will require very specific and essential paradigm shifts.

A Comprehensive Paramedic Education Model: Necessary Paradigm Shifts 1. Paramedicine must become a degreed profession.

2. Paramedicine must adopt one degree model for the paramedic.

3. The time for the BSP has come.

4. Paramedicine needs to create and develop graduate programs.

5. Paramedicine must have career pathways on par with Nursing.

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Educator Update | www.naemse.org

1. Paramedicine must become a degreed profession.

The first major milestone in the transition of the registered nurse from assistants to highly paid clinical practitioners was when the profession stopped issuing certifications for registered nurses and mandated that all registered nurses have a minimum of an associate’s degree. The education shifted from hospital training programs to community colleges and universities. Likewise, if paramedics are ever to get the compensation and respect they deserve, the EMS profession must make an associate’s degree the minimum standard for the paramedic. This will put paramedics on an equal educational footing as the registered nurse. The National Registry of Emergency Medical Technicians has already begun the difficult task of driving this paradigm shift forward by requiring in 2013 that all students taking the NREMT-Paramedic examination must be a graduate of an accredited paramedic program.

Without this degree minimum, the paramedic profession will never achieve its rightful place in medicine and will never receive pay on par with the demands of the profession.

2. Paramedicine must adopt one degree model for the paramedic.

EMS education grew up piece meal over the last 30 to 40 years. The names for associate’s degrees in Paramedicine vary from school to school, and include titles such as Paramedicine, Emergency Medical Care, Emergency Medical Technology, and Emergency Medical Services. The curriculum can often vary from school to school, with wide variations and emphases in the remaining general education credit. Some will lean towards business, other towards fire science, and others towards life sciences. When these paramedic graduates try to go to finish their bachelor degrees, they often encounter headache after headache as admission counselors try to determine what credit to award and where it counts in the overall degree program.

Nursing, in contrast, is very simple. Nursing students earn an Associates of Science in Nursing.

No matter what community college you go to in the United States, the name is the same… Nursing.

There is very little deviation in the required curriculum and general education credits. Nursing credits usually transfer to any other nursing program or advanced degree program.

DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

Paramedic education needs to adopt this model so its members are not encumbered in their educational progress. Just as Nursing is called Nursing, I believe that Paramedicine should be called just that‌ Paramedicine. I propose that all accredited paramedic education programs adopt the Associates of Science Degree in Paramedicine as the minimum standard for paramedic education.

3. The time for the BSP has come.

There are very few universities that offer a bachelor degree program for EMS. These schools have different names and focus for their degrees. The University of New Mexico has a BS in EMS. Creighton University is similar with a BSEMS degree. Eastern Kentucky University has a BS in Emergency Medical Care with a Paramedic/Science Option and the University of Pittsburgh has a BS in Emergency Medicine. These degrees titles are not uniform and do not clearly emphasize that they are BS degreed paramedics.

The nursing profession, in contrast, has one model for the bachelor degree, the Bachelor of Science in Nursing or BSN. Every medical professional knows exactly what those three letters stand for and the level of academic rigor the registered nurse underwent to achieve that distinction. The BSN serves as the foundation for every registered nurse who wants to further his or her education and become a leader, specialist, or practitioner in Nursing. The BSN prepares the registered nurse for a variety of graduate career paths from nurse practitioner to nurse manager.

Unfortunately, the Paramedic has no similar level of distinction. If a paramedic wants to further his or her education, he or she has to choose from a variety of ancillary degree programs that may or may not be related to Paramedicine.

4. Paramedicine needs to create and develop graduate programs.

Once we achieve the development and execution of the BSP model, Paramedicine will finally have sufficient quantities of paramedics who are academically prepared to attend graduate education programs. This is absolutely essential if we want to stop the brain drain of Paramedicine. Very few EMS services are willing to pay paramedics what they are truly worth. If we, as a profession, are to keep our paramedics, and not lose them to other professions, we must give them somewhere to go. The only way to do that is to create graduate programs that provide paramedics with the same opportunities for career advancement as other allied health professionals. Again, the solution can be found in Nursing.

Nursing education programs have a variety of Master of Science in Nursing programs (MSN) and even doctorate programs to meet the additional needs of the nursing profession and the community at large.

Nurses with BSN degrees can become clinicians on par with physicians, get specialized education in leadership and management, and are prepared to teach the next generation of nurses. They also get compensation, respect, and clout on par with physicians. The possibilities are endless for anyone with a BSN degree.

Paramedicine has none of this. We need graduate programs to keep our best and brightest. We need these programs to prepare our leaders to handle the tremendous challenges they face.

5. Paramedicine must have career pathways on par with Nursing.

Once graduate programs are in place, the final piece will to be to create Paramedic career pathways that are on par with the Nursing profession. There is no reason The paramedic profession needs to follow the nursing why Nursing has to be the only allied health profession lead and create one Bachelor of Science in that can transition to primary care practitioners or Paramedicine or BSP Degree. Ideally, the degree anesthetists. With a paramedic education model that would have similar prerequisite background courses in has true BSP and MSP programs, paramedics can math and science that is required of registered nurses finally evolve to be primary care practitioners and and other degreed allied health professionals. Elective anesthetists. The state of Minnesota has already credits could be used to create routes that prepare the approved the designation of Primary Care Paramedic student for a specific course of graduate study. Just and a new curriculum has been developed for it. Let like Nursing, Paramedicine needs a true BSP that us, as a profession, take this concept to its full provides the academic foundation for clinical practice potential. and leadership.

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To inspire and promote excellence in EMS education and lifelong learning within the global community

The only thing stopping paramedics from becoming advanced practitioners is the degree. We, as a profession, must lobby and advocate to be seen as equals with our other allied health professionals. We must lobby our universities to create bachelor and graduate programs for our profession. We must lobby our communities to see our tremendous potential to solve some of their most difficult challenges. We must solidify, once and for all, that Paramedicine is a true medical profession in its own right, and not simply a sub set of fire, public safety, or an advanced medical technician. We must demonstrate, with absolute certainty, that paramedics are no longer technicians but advanced medical clinicians, worthy of the respect due to such professionals.

Once we create these advanced career pathways for our profession, we will not only slow down the exodus from Paramedicine, we will begin to attract the future leaders who previously would not have considered Paramedicine as a career.

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We will attract these people because they will finally see Paramedicine as not only as financially viable, but as a career pathway that will always provide them with challenges, opportunities and a good quality of life.

In conclusion, the failure of the current paramedic education model is very real and very costly to our profession and to our nation. The solution is more complex than simply demanding better pay and better hours. I believe a big part of that solution requires a complete overhaul of the Paramedicine education model to provide paramedics with the necessary training, career growth and quality of life throughout their entire career. We must give our paramedics somewhere to go or they will go somewhere else. Look around you. They are leaving. I believe a huge part of the solution to this exodus is for Paramedicine to develop a comprehensive educational model on par with Nursing that gives paramedics the ability to grow and evolve throughout their entire career. The need is great. The time is now.

DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

Teaching Intercultural Competence in Emergency Medical Services By: Kim McKenna, M.Ed, RN, EMT-P

In a 2007 article in Texas EMS magazine, Lynne

Dees relates the story of paramedics in a fire-based EMS program who responded to a call for a two-year-old child who collapsed in the back of the family truck and subsequently died. The family sued the EMS agency, alleging that the crew delayed transport to question the family in an attempt to rule out child abuse because they were Hispanic. While the investigation determined no inappropriate care by the paramedics, the city paid an out-of-court settlement of $93,000 and all uniformed personnel in the department were required to take cultural sensitivity training.

This case illustrates the impact of real or perceived intercultural competency failure. This family’s belief that paramedics delayed care to their precious child because of cultural factors exacerbated an already tragic situation. Additionally, the paramedics and their department were subjected to the expense and emotional effects of the lawsuit and its subsequent settlement.

Considering culture, particularly in situations that require ethical decision-making is “relevant, even necessary” (Morgan, 2006, p.10). Yet, as Morgan points out, culture does not define everything about a person, but is rather “among the many identities that each person holds” (p. 12).

As the cultural diversity in our nation increases, so does the opportunity for cultural failures. These failures can result in patient dissatisfaction, or worse, decrease their likelihood of receiving appropriate, equitable healthcare.

What is Culture?

Culture is one of many features that distinguishes individuals. The enhanced National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (National CLAS Standards) define culture as:

The integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics (Office of Minority Health, 2013).

The breadth of that definition underscores the need for EMS personnel to understand this dimension of individuals so they can effectively meet their needs.

This is particularly true when on calls involving highly emotional issues such as fertility and child bearing, illness and end-of-life care.

Cultural Diversity in the United States The cultural landscape of America is broad and dynamic. In the 2010 United States Census data, of the 308.7 million people living in the United States (Humes, Jones, & Ramirez, 2011), 64 percent identified as non-Hispanic white while 16 percent were Hispanic.

The racial groups reported in this census were white alone (72 percent), black or African-American (13 percent), American Indian and Alaska Native alone (0.9 percent), Asian alone (five percent) and Native Hawaiian and Other Pacific Islander (0.5 percent).

Another six percent were classified only as some other race alone. About three percent of census respondents identified with more than one race.

The United States Censure Bureau (2012) projects these demographics will change. In a news release on December 12, 2012, they note that the American population will be significantly more diverse by 2060.

In these projections, they predict that although the non-Hispanic white population will be the largest single group – no one ethnic or minority group will constitute the majority. By 2060 one in three Americans will be Hispanic as compared to one in six today. The proportion of African Americans will also expand from 13.1 per cent to 14.7 percent. Likewise, the Asian population will grow to more than twice its present size to constitute almost eight percent of the Nation’s citizens. The number of American Indians and Alaska Natives, Native Hawaiian and Other Pacific Islanders is also expected to have substantial growth. In fact, “minorities are projected to comprise 57 percent of the population by 2060” (U.S. Census Bureau, 2012).

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To inspire and promote excellence in EMS education and lifelong learning within the global community

Health Disparities In their 2002 publication, titled Unequal Treatment: Confronting racial and ethnic disparities in health care, the Institute of Medicine (IOM) outlines the crisis of inequity in American health care. They explain that:

Brisbin, McKenna, Howey, Soucheray, and Hanson (2009) found non-Caucasian patients cared for by paramedics were less likely than Caucasian patients to receive advanced life support interventions.

Patient Safety

Cross-cultural issues can jeopardize patient safety and contribute to medical errors (Agency for Healthcare Research & Quality [AHRQ], 2012, Alpin, 2007, Walker, Pierre-Hansen, Cromarty, Kelly & Minty, 2010). Failure to understand or respect cultural traditions can lead to misunderstandings because This IOM report suggests a number of solutions to “culture embodies a separate set of risk factors that narrow this gap. They include reimbursement for threaten patient safety” (Walker et al, 2010, p.65). interpretation services, workforce, training, data Cultural bias can introduce “countertransference, a type collection for monitoring, and regulatory action. of affective” decision-making error based on a caregiver’s preconceived beliefs about patient The IOM report illustrated a stunning healthcare characteristics (Croskerry, 2008 p. 247). The goal of divide within this nation and yet, their research cultural competency training to reduce errors should found that many Americans believed that blacks focus on improving communication and should “receive the same quality of healthcare as whites” explicitly describe how the specific strategies are (2002, p.2). Their many examples found that ethnic important to improve patient safety. The AHRQ minorities were less likely to receive routine tests, recommends training that incorporates goals and that African American and in some cases principles of culturally competent care and teaches Hispanics were less likely to receive cardiac broad cross-cultural skills so health workers understand medications, coronary artery bypass surgery, how sociocultural factors influence health care and can peritoneal dialysis or kidney transplantation than manage them more effectively. The training should also whites. A lack of diversity in health care providers outline beliefs and traditions common to local cultural and leadership is cited as one factor that groups; present specific cases that demonstrate how influences these disparities (Betancourt, Green & cultural factors can hinder patient safety; and discuss Carrillo, 2002). These authors note that, despite the how staff diversity relates to issues of power that can fact that in 2000 minorities constituted 28 percent of interfere with communication and safe practice (2012). the American population, they only made up Croskerry (2008) suggests that teaching metacognitive “3 percent of medical school faculty, 16 percent of skills is critical to reducing medical errors. This should public health school faculty, and 17 percent of all city include activities such as simulation to teach cognitive and county health officers” (p.3). and affective de-biasing with cases known to contain common sources of bias. Walker et al (2010) developed a framework for safe cross-cultural care after This disparity appears to extend into prehospital emergency care. In a longitudinal study of emergency experiencing several sentinel patient events with unfavorable outcomes that were attributed, in part, to medical services (EMS) workers Brown, Dickison, a poor understanding of First Nations culture. Their Misselbeck, and Levine, (2002) found that 71.2% of program, based on a Zone of Cultural Safety (Figure 1) emergency medical technicians (EMTs) and 69% of strives to merge cultural beliefs so learners incorporate EMT-paramedics are male (p. 435). Further, an diverse viewpoints within their own value sets. This overwhelming majority of the EMS workforce (over enables them to avoid bias and provide equitable care.

90% of EMTs and paramedics) is white (p. 435).

The federal EMS Workforce report (2008) recommended that EMS “will need to likely focus on diversity, drawing from new pools of workers” (p. 88) to better reflect American population demographics.

This lack of workforce diversity may have implications on patient care.

Minorities may experience a range of other barriers to accessing care, even when insured at the same level as whites, including barriers of language, geography, and cultural familiarity (p.1).

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DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

FIGURE 1.

Caring for Patients with Limited English Proficiency

Limited English proficiency (LEP) affects health outcomes. Patients with LEP are “less prepared than English speakers to care for themselves or benefit from health promotion programs, resulting in poorer health” (Olivia, 2008, p. 73). Further, translation errors can cause “omission, substitution or editorialization,” leading to unsafe care (American Academy of Pediatrics, 2004, p. 1679). When healthcare workers cannot understand a patient, it can lead to “prescribing error, insufficient analgesia, and misdiagnosis” (Olivia, 2008, p. 73).

Olivia suggests that even when interpreter services are available, staff may not be trained to use the services appropriately.

The AHRQ (2012) details specific elements of interpreter training needed to promote safe healthcare.

They note that, “under no circumstances should minor children be used to interpret, although in 2013 this language was softened to reflect the reality that sometimes, in emergency situations, there is initially no other option than to use a child interpreter (Office of Minority Health, 2013). Information about the role of the interpreter, including that of patient advocate and cultural broker should also be included in training.

Federal Standards for Cultural Competency in Healthcare In 2001, the Office of Minority Health developed 14 standards recommended for voluntary adoption by health care organizations (Office of Minority Health, 2007). These recommendations were updated and released on April, 24, 2013 (Office of Minority Health, 2013). The Enhanced National Standards for Culturally and Linguistically Appropriate Services (CLAS) include recommendations relating to diversity in the healthcare workforce, training, translation services, communication and data collection (Office of Minority Health, 2013).

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The CLAS standards are mandated for all departments that receive federal funds.

Teaching Cultural Competence in Health Care The mismatch between patient culture and healthcare provider culture are seen as major barriers to patient satisfaction and health outcomes (IOM, 2002). If healthcare providers fail to consider the patient’s sociocultural needs, bias or discrimination based on their race, language, culture or social status can have a negative impact on care.

Yet, despite an acknowledged need for cross-cultural education in health curricula since the 1960s, there is no solid literature to demonstrate how well health programs that include nursing, graduate medical education or continuing medical education cover this material.

The IOM report (2002) proposed cross-cultural training that includes attitudes, knowledge and skills to integrate into the training of all health professionals. They recommend that this education incorporate information related to “racial and ethic disparities in healthcare, and the impact of social cognitive factors and stereotyping on clinical decision-making” (p. 214). Training should include a case-based curricula developed around core competencies that can be objectively assessed.

Several approaches can be used alone or in combination to deliver cultural competence education in healthcare. To develop the affective domain, educators can use a sensitivity/awareness approach that focuses upon the provider attitudes regarding patients’ health values, beliefs, and behaviors. Participants reflect on culture, racism, classism, and sexism when using this method.

The multicultural/categorical approach focuses upon cognitive aspects of cultural knowledge and provides “knowledge on the attitudes, values, beliefs, and behaviors of certain cultural groups” (Paniagua, 1994 in IOM, 2002, p. 204). This strategy focuses on information relevant to specific cultures such as Asian or Hispanic. Because of the myriad of influences on a person’s health behaviors, the multicultural/categorical method has been reported to oversimplify the issues and may cause stereotyping. Despite this limitation, it can be helpful when focusing on specific community ethnic behaviors and traditions within a specific geographic area where a group is delivering health care. The program described by Walker (2010) represents such a case.

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Their health system serves patients of First Nations.

Because of this, they seek consultation from tribal elders as part of their education plan to assure appropriate culture-specific content is incorporated.

However, this strategy would not be effective in a community such as Toronto, Ontario, which is a cultural melting pot. When using this approach, the instructional designer should determine whether it is applicable to the community of interest and assure that the material presented reflects current cultural behaviors, traditions and beliefs (IOM, 2002).

The cross-cultural approach to healthcare education focuses on skills that blend elements of therapeutic communication and interviewing with ethnographic approaches used in anthropology (IOM, 2002). With communication at its center, the cross-cultural approach teaches practitioners awareness of “cross-cutting cultural issues, social issues, and health beliefs, while providing methods to deal with information once it is obtained” (p. 206). Providers are taught to elicit the patient’s view on what is causing their illness and how they feel it should be handled.

Effective cross-cultural therapeutic communication is emphasized. Other features taught include how to assess “decision-making preferences, the role of family, determining the patient’s perception of biomedicine and complementary and alternative medicine, recognizing sexual and gender issues, and being aware of issues of mistrust, prejudice, and racism” (p. 206).

This is an inductive, rather than a deductive approach to cross-cultural care and focuses on the individual patient and his or her beliefs, instead of assigning them to a larger, generic cultural group.

Classroom strategies to teach cross-cultural education vary widely. It is felt that the most effective are “interactive, experiential, practical, case-based approaches that address” all of the learning domains (IOM, 2002, p. 207). Simulation using standardized patients would be an ideal method to accomplish this.

Programs to Teach Intercultural Competency in EMS Government agencies have developed many specific age and discipline specific courses and curricula to aid health programs to teach cultural competency. Many of them are available free of charge on the Internet. Two of these programs will be described.

Cultural Competency Curriculum for Disaster Preparedness and Crisis Response Cultural competency curriculum for disaster preparedness and crisis response is an online program for first responders.

DOMAIN3

To inspire and promote excellence in EMS education and lifelong learning within the global community

The Office of Minority Health, a division of HRSA developed the program in 2011. Their curriculum outlines strategies for culturally sensitive response to disaster and crisis including all phases of the disaster. Students learn the roles of the public health and emergency response communities and how culture impacts preparation, response and recovery from disaster. The program, offered as a narrated screencast, outlines specific strategies to address and overcome cultural challenges during crisis and disaster. Attendees are awarded nine continuing education credits for successful completion.

Curriculum in Ethnogeriatrics In 2001 HRSA released a detailed curriculum in ethnogeriatrics (Kyung, Choi, Enslein, Hendrix, Skemp, Ishler et al, 2001). The core curriculum, developed by members of the Collaborative of Ethnogeriatric Education, describes methods for culturally sensitive assessment and treatment of older adults and is designed for use in multiple health disciplines. Ethnogeriatrics is described as the intersection between health, aging and ethnicity.

Effects of ethnocentrism described by these authors include misinterpretation of cross-cultural situations leading to miscommunication and possibly resulting in culturally inappropriate care. This program emphasizes that ethnic groups are heterogeneous.

The Curriculum in Ethnogeriatrics lists four cultural factors that influence a patient’s health care experience including “culture of the health care organizations; diversity among providers and teams, diversity among organizations, and diversity among older patients.”

They define individual staff member ethnic competencies as including: • Self-awareness of personal biases and how they can influence care.

• Knowledge about specific cultures related to health risk factors, health beliefs, values and behaviors, and ethnic response to treatment.

• Culture-specific skills such as showing respect, assessing patients’ acculturation, recognizing specific health beliefs, assessment, family nteraction and patient values and needs related to end-of-life issues.

While the ethnogeriatrics program incorporates broad strategies to promote intercultural competency, it also includes modules related to health issues of specific ethnic populations.

For example, each module addresses specific cultural definitions and traditions and explains how those differences can influence a person’s approach to illness and to the healthcare system. Risk factors for specific diseases are identified by group. The authors point out significant disparities between some populations. For example, they note that non-Hispanic black and Mexican Americans over 70 years of age had significantly higher incidence of diabetes than non-Hispanic white persons of the same age. Another section covers culturally specific traditions related to folk medicine and herbal remedies.

The curriculum recommends specific instructional strategies to teach these concepts to health care workers.

Evaluating Cross-Cultural Learning Strategies The IOM report suggests assessment of three elements of cultural competency: “Do providers learn what is taught? Do they use what is taught? Does what is taught have an impact on care?” (IOM, 2002, p. 210) Solid measures to demonstrate positive cultural behavior change are difficult to develop. Measuring attitude change is frequently done using self-reported surveys or other instruments that are prone to bias (IOM, 2002, p. 210). Direct observation is rarely practical. Patient satisfaction surveys can be used and some research has shown improvement in satisfaction after cultural competency training. Knowledge related to specific cultural traits could be measured using cognitive instruments such as multiple-choice examinations or essays given before and after the educational intervention.

Despite these recommendations, there is little strong evidence to support efficacy of cultural competency educational interventions in healthcare (Lie, Lee-Re, Gomez, Bereknyei, & Braddock, 2011). Lie et al. conducted a systematic review of research in this area and found seventeen published studies. Of the research they identified, only seven studies demonstrated curricular interventions or health care outcomes. The quality of the research methodology was classified as low to moderate. The papers they reviewed found that cross-cultural education had either no effect (or unable to assess in two cases) or was moderately beneficial in three cases. Their conclusions propose an algorithm to guide future researchers evaluating this area.

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Despite this current lack of evidence that demonstrates the effectiveness of training to promote culturally competent care, there is a growing need to incorporate such education programs into healthcare. As this nation matures, its population is growing increasingly more diverse. Failure to acknowledge and adapt to this change will impact health outcomes and stand in the way of equitable treatment for all patients.

REFERENCES Agency for Healthcare Research and Quality. (2012). Appendix A: Recommendations for staff training. Improving patient safety systems for patents with limited English proficiency: a guide for hospitals. Retrieved 4/1/9, 2013, from http://www.ahrq.gov/professionals/systems/hospital/lepguide/lepguideapa.html Alpin, G. (2007). Once is sometimes too much: cultural competence can reduce medical errors, increase patient satisfaction. MGMA Connexion, January, 21-22.

Betancourt, J., Green, A., Carrillo, E. (2002). Cultural competence in health care: emerging frameworks and practical approaches. Field Report. The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/usr_doc/Betancourt_improvingqualityachievingequity_961.pdf Brisbin, T., McKenna, K.D., Kim, C.S., Howey, T., Crain, L.A. Soucheray, C., Hanson, E. (2009). Does paramedic student ethnicity impact the likelihood of providing ALS interventions to caucasian versus non-caucasian patients?

(Abstract) Prehospital Emergency Care, 13(1).

Brown, W. E., Dickison, P., Misselbeck, W. J., & Levine, R. (2002). Longitudinal Emergency Medical Technician Attribute and Demographic Study (LEADS): An interim report. Prehospital Emergency Care, 6(4), 433-439.

Croskerry, P. (2008). Diagnostic failure: A cognitive and affective approach. Advances in Patient Safety, 2, 241254.

Dees, Lynne (2007). Culturally competent care in the Emergency Medical Services. Texas EMS Magazine, July/August, 34-39.

Halm, M. A., & Evans, R., Wittenberg, Amie. (2012).

Broadening cultural sensitivity at the end of life. Holistic Nursing Practice, 26(6), 335-349.

Health and Human Services Resources Association.

(2013). Culture, language and health literacy. Retrieved from http://www.hrsa.gov/culturalcompetence/index. html

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Humes, K. R., Jones, N., A., & Ramirez, R. R. (2011). Overview of race and Hispanic origin. 2010 Census Briefs Retrieved from http://www.census.gov/prod/cen2010/briefs/ c2010br-02.pdf Institute of Medicine, & Board on Health Sciences Policy.

(2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, D.C.: The National Academies Press.

Kyung, Y., Choi, E., Enslein, J., Hendrix, L., Skemp, L., Ishler, K., et al. (2001). Curriculum in ethnogeriatrics. In G. Yeo (Ed.) (2nd ed.). Washington, DC: Bureau of Health Professions Health Resources and Services Administration, U.S. Department of Health and Human Services. Retrieved from http://www.stanford.edu/group/ethnoger/index.html Lie, D. A., Lee-Rey, E., Gomez, A., Bereknyei, S., & Braddock, C. H. (2011). Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research.

Journal of General Internal Medicine, 26(3), 317-325.

Morgan, L. M. (2006). “Life begins when they steal your bicycle�: Cross-cultural practices of personhood at the beginnings and ends of life. Journal of Law, Medicine and Ethics, Spring, 8-15.

National Highway Traffic Safety Administration. (2008).

EMS workforce for the 21st century: A national assessment.

Retrieved from mcs.nhtsa.gov/.../ems-workforce-for-the21st-century-a-national-asse...

Office of Minority Health & United States Department of Health and Human Services. (2013). CLAS & the CLAS Standards. Retrieved from https://www.thinkculturalhealth.hhs.gov/Content/clasvid.asp Office of Minority Health & United States Department of Health and Human Services. (2013). Cultural competency curriculum for disaster preparedness and crisis response.

Retrieved from http://minorityhealth.hhs.gov/templates/ browse.aspx?lvl=2&lvlID=15 Olivia, N. L. (2008). When language intervenes: Improving care for patients with limited English proficiency. American Journal of Nursing, 108(3), 73-75.

United States Census Bureau. (2012). U.S. Census Bureau projections show a slower growing, older, more diverse national a half century from now. Newsroom Retrieved from http://www.census.gov/newsroom/releases/archives/ population/cb12-243.html Walker, R. St. Pierre-Hansen, Cromarty, H. Kelly, L, Minty, B. (2010). Measuring cross-cultural patient safety: identifying barriers and developing performance indicators.

Healthcare Quarterly, 13(1), 64-71. ###

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To inspire and promote excellence in EMS education and lifelong learning within the global community

2014 Revision to Education Agenda for the Future: Achieving Higher Education By: Walt Stoy, PhD, John Pierce, MBA, William Raynovich, NREMT-P, EdD, MPH, BS and Thomas Platt, EdD Reviewed by John C. Cook, MS - Jefferson College of Health Sciences, Robert McDaniels, MS - University of New Mexico, Keith Monosky, PhD - Central Washington University & Bruce J. Walz, PhD - University of Maryland Baltimore

WHERE WE ARE

This coming year, the U.S. Department of

Education is undertaking a project to rate the nation’s 7,000 plus institutions of higher education.

The government does not have a method to measure if the $150 billion in college grants and loans spent annually is efficiently spent. The national trend is for tuition to rise faster than the rate of inflation and student loans to surpass $1.2 trillion. The administration will address the question: What is a college education worth (Weise, 2013/2014)?

The EMS community needs to be informed about EMS education programs that are offered by institutions of higher education. This edition of the Education Agenda for the Future: A System Approach seeks to identify and categorize current programs by academic degrees and professional certifications that they offer.

The total number and locations of programs offering EMS Associate Degrees is unknown.

We need to aggregate the data, determine the number of existing programs and as appropriate, seek to increase the number…

There are, at the time of printing, 15 known programs offering a Bachelor’s Degree in EMS. Of those 15, approximately nine of the programs offer paramedic education as a component of the curricula. Many other programs offer degrees that are closely related to EMS, such as degrees in emergency management, urban rescue and health administration, with a concentration in emergency services. The full scope and array of these types of program offerings is currently unknown.

We need to establish confirmation of this number and as appropriate, seek to increase those institutions able to offer EMS programming…

There are several, approximately three or four, programs offering a Master’s degree in emergency medical services, with additional MPH, MHA or related programs that offer an emphasis in EMS. The number and locations of programs offering graduate degrees in EMS and EMS-related fields needs to be determined and we must also assess if there is currently a need to support and advocate for more institutions to offer graduate degrees in EMS. There are no specific doctoral degree programs in the EMS domain – however, there are more and more individuals with doctoral degrees becoming known to the EMS profession.

We should determine the number of individuals in the EMS profession with terminal degrees… Assist in the continued growth and development of these individuals to enhance the overall development of the EMS profession and ascertain the appropriateness and feasibility of a future doctorate in EMS. WHERE WE WANT TO BE IN 2025 The original Education Agenda for the Future: A Systems Approach offered: Basic level EMS education is available in a variety of traditional and non-traditional settings. Advanced level EMS education is sponsored by institutions of higher education, and most are available for college credit. Multiple entry options exist for advanced level education, including bridging from other occupations and from basic EMS levels for individuals with no previous medical or EMS experience. All levels of EMS education are available through a variety of distance learning and creative, alternative delivery formats. (page 2) The EMS profession should be in the position to know whether this goal has been achieved. Perhaps we are at the cusp of this endeavor. Over the next decade, we must seek to determine how higher education is interacting in the development and growth of EMS. The following citation is from page 6 of the Education Agenda for the Future: A Systems Approach: Throughout the past three decades, allied health professions experienced a transition from on-the-job training to education in formal institutions of higher education.

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Initially, most allied health education programs were sponsored by health care institutions.

However, since the late 1960s there has been a rapid and steady trend toward collegiate and university settings. Most allied health fields instituted more and better training and have adopted educational requirements that include formal academic degrees (Farber and McTernan, 1989).

The following citation is from page 15 of the Education Agenda for the Future: A Systems Approach: Current limitation: The EMS educational process has developed separately from the formal post secondary education system. This has frequently precluded EMS personnel desiring to obtain academic credits from doing so. This impedes EMS personnel from pursuing higher education, which would ultimately further the EMS profession.

The Emergency Medical Services Agenda for the Future (1996) was the foundational model for all the other EMS agenda documents. It is noteworthy that “higher education” has had zero (0) online “hits” in this document. It does seek to have “relationships” (13 times) with academic institution(s). Pages 15, 16, 27, 28, 32, 34, 35, 67, 68, 71. We must be willing and able to move beyond the aspect of a relationship with institutions of higher education. We need to promulgate and facilitate EMS toward engaging, advancing and achieving in higher education. The goal should be to have comprehensive integrated engagements with these facilities.

In the section of the Education Agenda for the Future: A Systems Approach presenting information on Education Systems (starting on page 33) the following comments regarding EMS education are provided.

Page 33 … increasing number of colleges offer bachelor’s degrees in EMS. (101). However, overall there is inadequate availability of EMS education opportunities in management, public health, and research principles.

Unfortunately, we have documentation demonstrating there were institutions of higher education that did not succeed in maintaining their ability to provide higher education to EMS professionals. We need to understand those factors that determine sustainability in higher EMS education, such as leadership, economics, scholarship, political engagement, and marketing.

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This data then must be shared with others seeking to create this level of programming. The stronger programs should be willing to share their insights.

Page 34 Higher level EMS education programs are affiliated with academic institutions. EMS education that is academically-based facilitates further development of EMS as a professional discipline. It increases the availability of education opportunities that acknowledge previous EMS educational/academic achievements, provides more academic degree opportunities for EMS personnel, augments the management skills among EMS professionals, and protects the value of personal and societal resources invested in education.

Institutions of higher education should assist existing non-academic, unaccredited, and non-degree-conferring EMS programs with articulation and credit-transfer agreements in order to assist the current EMS community with a transition to higher education credentialing. The University of Pittsburgh, School of Health and Rehabilitation Sciences, Emergency Medicine Program provided leadership in this area by opening a dialogue with CoAEMSP that resulted in a model transfer agreement provision. This transfer agreement option permits a paramedic program to align with an institution of higher education and complete needed requirements of accreditation that would have otherwise been impossible. National availability of EMS educational programming must continue to be an element of the agenda.

Page 35 Providers of EMS education should seek to establish relationships with academic institutions (e.g., colleges, universities, academic medical centers). Such relationship should enhance the academic basis of EMS education and facilitate recognition of advanced level EMS education as an accomplishment worthy of academic credit.

EMS education providers and academic institutions should develop innovative solutions that address cultural variation, rural circumstances, and travel and time constraints.

HOW TO GET THERE It is of utmost importance that we seek to initially benchmark our data of EMS educational programming held in institutions of higher education.

We must support the growth and development of EMS programs in institutions of higher education.

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To inspire and promote excellence in EMS education and lifelong learning within the global community

In time, we should seek to provide a comparative analysis or report carding of these programs in order for students to be knowledgeable of the capabilities and success rates of these programs.

EMS educational programs must follow-through to formal scholarly inquiry, reporting and publication of outcomes data. All educational programs need to be encouraged to provide information regarding the outcomes of the students in the programs. Time to step up with the other areas of health care.

For this second edition of the Education Agenda for the Future: A Systems Approach - we need to strongly consider the addition of academic degrees for EMS personnel. These would include Associate, Bachelor, Master and Doctoral degrees. As EMS continues to mature professionally, it must do so in the same manner that yielded success for other disciplines in the health sciences. Therefore, it is of utmost importance that EMS seeks to advance in the academic arena as part of the development of the profession.

The first publication of the Agenda assisted in advancing EMS education and enhanced the profession to a “benchmarking” level. It is now time for the profession to grow even further by demonstrating to the greater healthcare professional community that we, in EMS, recognize the importance and the need for academic credentialing and scholarship.

Much like the study of medicine, nursing or any other aspects of the health domain, EMS must seek to fulfill the missing educational link by having the study of pre-hospital care (EMS) recognized as an academic specialty.

Curricula – commonality of educational format.

Building upon the structured EMS educational format and assure congruency with educational practices recognized by the other health related domains.

Environment – assuring that institutions with the highest reputations are those providing the education.

We must continue to facilitate the enhancement of EMS education by supporting and encouraging providers to seek and achieve college degrees within the following levels: Associate Degree – move to establish this credential as the minimum employment requirement for the entry-level practitioner Bachelor Degree – move to establish this credential as the minimum for emerging and current governmental regulatory officials, major agency executives and middle managers, EMS educators, and advanced clinical care providers in the profession. Need to encourage that those directing EMS educational programs and those providing instruction in EMS education have a degree at the same level, and preferably higher than the level that they are teaching.

Need to tie critical thinking with this level of education.

Master Degrees – for the education of the lower two tiers as well as for administrators; for those in post-secondary accredited institutions; for those seeking to advance to national leadership positions.

Doctoral Degrees – to denote those that seek to impact education, administration and clinical aspects of EMS care through research and the establishment of national evidence based standards.

We need to address the four areas of education that takes place in any domain of education:

MILESTONES

Students – those individuals that are willing and able to achieve it.

Instructors – those individuals with the knowledge, skills and attitude to acquire the intended information of the EMS domain. Then, be positioned to achieve measurable success in sharing their cognitive, psychomotor and affective information to those who seek it.

ORGANIZATIONS/ RESOURCES INVOLVED

Position institutions of higher education to share data

EMS Education Task Force, NAEMSE, FEHSE, CAPEMS (an informal group of the BS degree granting programs)

Fund EMS educational projects towards the evaluation of degree granting programs

Private, federal, state, and local governments

Identify all of the institutions of higher education offering EMS provider education

National Certification Agency

Development of a national EMS data base of NHTSA, EMS medical community, EMS regulators, institutions of higher education EMS educators, and EMS providers Have accreditation in place for undergraduate EMS degree granting programs

CoAEMSP, CAPEMS

* References: Weise, K. (2013/2014, December/January). The Government Wants To Grade Your College. Bloomberg Businessweek, 31-32.

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TRACKING PATIENT ENCOUNTERS

Tracking Patient Encounters by: Patricia L. Tritt, RN, MA One of the challenges for Paramedic programs, and students, continues to be the tracking/ documentation of patient encounters and skill events.

In the days of the DOT Curriculum, suggested numbers were provided. Were these scientifically determined and evidence based decisions? No, the numbers were averages from a sampling of program practices. Interestingly, many programs that adopted these recommendations found that, indeed, graduates were typically competent across the spectrum, and programs continue to use this framework.

With the implementation of the National Education Standards, recommendations for numbers of encounters are no longer provided. CoAEMSP allow programs to establish their own minimum requirements, but, achieving competency should always be the goal, not simply achieving the determined numbers. Some caveats:

The CAAHEP Standards and Guidelines for the Accreditation of Educational Programs in the Emergency Medical Services Professions requires that “The program must track the number of times each student successfully performs each of the competencies required for the appropriate exit point according to patient age, pathologies, complaint, gender, and interventions.” Unfortunately, adequate tracking, documentation, and the ability to produce summary reports are a common citation at the time of the site visit.

• The minimum requirement must be determined by the communities of interest based on the outcome (i.e. all graduates are competent entry level Paramedics in all domains).

But to start at the beginning, why is tracking and documentation required? Isn’t this supposed to be an outcome-based process? Can’t a program just intuitively decide a student is competent based solely on positive feedback from instructors and preceptors? The short answer is that good feedback only provides part of the evaluation. Obviously, Paramedics encounter every patient type, chief complaint, age, and gender so the skill set must be equally extensive to cover them all. In order to insure graduates are competent entry-level paramedics, it is the responsibility of the program to adequately prepare and evaluate the student over this spectrum. However, the clinical and field internship periods in Paramedic programs are relatively short.

Another area of confusion is the terminology of goal vs. requirement. Some tracking software use the word goal and Paramedic programs interpret this to mean that the number is just a target and not all students have to reach it to successfully complete the program. CoAEMSP requires that every graduating student has achieved the minimum number set in every category.

One method of adding to the competency evaluation process is to identify complaints, ages, and skills that are part of the Paramedic scope and quantify the number of times the student should successfully ‘perform’ the assessment, management, and use of appropriate skills in each category.

Then comes the hard part, what numbers are ‘enough’?

After how many (or what types) of encounters is a student competent in that area?

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• The minimum requirement is not determined by what is available: just because you don’t have a good pediatric rotation does not mean it is OK to set low requirements.

• And in that vein, one is never enough of anything.

This leads to the necessity for programs to have an efficient, user-friendly tracking system for all patient encounters. Comprehensive commercial products are available that have been designed to meet the program and student needs. Some education programs choose to develop an in-house database.

Some systems are entirely electronic, others entirely paper, and still others a combination. The technology is evolving to make these tasks less laborious but there is still a considerable amount of time and attention to detail required.

No matter which type of system you select, it is only a tool and instructional faculty and students must be thoroughly familiar with how to operate the tool.

TRACKING PATIENT ENCOUNTERS It is not an uncommon scenario for a program to find at the end of the internship that not all students were entering their data correctly or not entering all the data and that the next CoAEMSP site visit is scheduled in a month – and your records will be reviewed. Also, for programs that assign students to enter their own data, faculty must audit a percentage to verify accuracy.

Once all the data is gathered, how is it organized and presented? Program faculty must monitor student progress towards meeting requirements on a regular basis and may need to adjust clinical or field internship sites and shifts to assist the student in obtaining the necessary experiences. There should be an ongoing dialog between the clinical coordinator and student regarding progress. Documentation should clearly show the minimums and requirements for each student.

A summary report is also required that lists each student in the cohort, each required ‘event,’ the minimums in each category, and the total number achieved by each student in each category. This is required for the site visitors to be able to easily determine that all graduates met the requirement.

Remember to remove students from the summary report who dropped or did not complete the program for any reason, otherwise it will appear that students graduated that did not meet program requirements. Note that some programs also track when a student ‘observes’ an assessment or skill but this cannot count toward the required minimums.

Which brings us back to the question: “If the education process is outcome-based, why do we have to track numbers?” Good point and the process is definitely imperfect, but it is the best compromise we have available in the world of high-level of responsibility for managing a wide variety of emergent patient situations and a short clinical training period for students. In the medical model, internship and residency are long, offering extensive direct observation and evaluation of students by faculty over time and types of situations.

This process in not available in Paramedic education and we must continue to rely on numbers of encounters / experiences and skills. However, we must continue to study and answer the question of “How many is enough?” * Disclaimer: Ms. Tritt is a member of the Board for the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) and a long time accreditation site visitor. However, the views and advice expressed here are her own and should not be interpreted as CoAEMSP policy.

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EASE UP ON SOCIAL SCIENCE

Ease Up on Social Science By: Michael Stratford As the federal government considers an overhaul to rules governing scientific research involving human subjects, the National Research Council is urging officials to be more exacting in determining which types of social and behavioral science research should receive oversight.

A report released by the council on Thursday outlines a wide range of recommendations for how to protect human subjects while making social and behavioral research more effective. A committee of National Research Council-appointed researchers drafted the document -- described as “a consensus report” -after holding a workshop with researchers earlier this year and reviewing empirical literature on protecting human subjects.

The report is a response to the federal government’s proposal, released in 2011, to make sweeping changes to the regulations governing human subjects, known as the Common Rule, for the first time in more than two decades. The Department of Health and Human Services has proposed to, among other things, create a new category of “excused” research that would subject certain kinds of research posing minimal risks to lower levels of scrutiny from institutional review boards.

Some social science and humanities researchers have complained that the current review process is too burdensome, especially since their research typically possess minimal risk to participants.

In its report released Thursday, the National Research Council report endorses that approach, but also urges the government to refine its definition of what types of research ought to be overseen by an institutional review board in the first place.

The Department of Health and Human Services should clarify that only “human subjects research” is subject to the Common Rule and IRB procedures, the report says. Only research that involves direct interaction with a living individual or involves obtaining identifiable information about an individual should fall into that category, the committee wrote.

Research that relies on publicly available information or information that can be observed in public contexts should not be considered “human subjects research,” the report says.

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Neither should studies that collect or rely on some personally identifiable information so long as there is no reasonable expectation of privacy, the report adds.

“If you’re analyzing the phone book -- or the 21st century version thereof -- you shouldn’t have to consider it to be human subjects research,” said Susan Fiske, a professor of psychology and public affairs at Princeton University, who led the committee.

“So much of what people are doing now with Big Data includes observation of people in public places like the Internet,” Fiske said. “If you’re tweeting, the pattern of your tweets is certainly not expected to be private.”

The report also makes recommendations about which types of human subjects research should enjoy the lesser scrutiny of being deemed “excused research.”

Excused research should include projects that involve human subjects in benign or familiar activities, such as educational tests, surveys and focus groups.

As part of the new “excused” research category, the government had proposed that researchers should have to develop a data protection plan that adhered to standards similar to those required for health care providers handle patient data under the federal Health Insurance Portability and Accountability Act. The committee also rejected that approach, arguing that the standard would, in the research context, overprotect some types of data and not provide subjects with sufficient protection in other areas. The report calls for data protection approaches to be dynamic and adapt to the specific needs of an investigator.

Zachary M. Schrag, a professor of history at George Mason University, who has been critical of the IRB system, praised the report’s thoroughness and call for empirical research, but said it not address some underlying problems with how social and behavior science is overseen by review boards.

“The only time the word freedom appears in the report is freedom for IRBs,” he said, adding that the current federal rules can be an impediment to social scientists who want to explore controversial topics.

Reprinted from INSIDE HIGHER ED January 10, 2014 with the permission of Inside Higher Ed, copyright 2014.

Inside Higher Ed is the free daily news Web site for people who work in higher education.

Breaking news, lively commentary and thousands of job postings bring more than 800,000 people to the site each month.

Read more: http://www.insidehighered.com

T H E IN D U ST RY LE AD E R IN S IM U NEERI NG.

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