Future Plans

Contributing to the Profession

I am interested in understanding the current state of Continuing Medical Education in the Paramedical profession. Furthermore, I’d like to explore ways to standardize the approval proccess to ensure high quality CME in all Canadian jurisdictions.

Ongoing Projects

I plan to experiment with engagement in some of the online courses that I have created by changing the format of the formative quizzes to leverage instant feedback.

I was recently asked if I had a learning goal in mind for students when I teach.

“Is there a growth-oriented learning goal that you would like to see occur in students as a result of your teaching?”

When considering this question, I can’t help but think of my own career as a paramedic. When I recall the early educational phase of my career, I can look back with the perspective of experience and see that there were facets of my education that were insufficient. In paramedical education the cognitive domain is well addressed. There are almost 4 years of classroom learning about medicine, physiology, pathophysiology, anatomy, and myriad other topics. Similarly, in the psychomotor domain, there is plenty of practice with respect to the basic psychomotor skills. Many of these will continue to develop later with years of practice. Many need to be mastered in the acutely stressful settings of practice because they are entirely different skills in this setting than they appear to be in the relatively low-stakes classroom setting. Nonetheless, the cognitive and psychomotor domains are well covered, and it is the affective domain of the paramedical curriculum that I believe is most in need of improvement. For many years I have watched the evolution and growth of the paramedic profession from a simple emergency response model to one involving more holistic care. But there seem to be outstanding deficits in the areas of addictions treatment, mental health treatment and domestic violence.

My Goal

My goal then, is to enhance teaching and learning in the affective domain with respect to addictions, mental health, and domestic violence because I believe that these are insufficiently treated in the curriculum. Most of learning around these subjects occurs after graduation. The trouble with this approach is that the social learning is delivered by people who also lacked any significant treatment of the affective domain in their curriculum. As such, the attitudes and values learned regarding addictions, mental health, and domestic violence are not learned from any unified, approved, nor peer-reviewed paramedic curriculum. Rather, what is learned about these topics is derived from whatever ideas or social norm the senior or precepting paramedic subscribes to. These ambient social norms may or may not be aligned with goals of care, acceptable practice, medical science nor generally with attitudes and values that make paramedics effective in performing their duties.

The 2022 BC Coroner Service Death Review Panel found that “illicit drug toxicity is the leading cause of unnatural death in the province, accounting for more deaths than homicide, suicide, motor vehicle incidents (MVIs), drownings, and fire-related deaths combined” (BCCS, 2022). (Bolster et al., 2023) found the paramedics have a special role to play here. They state that the interface between paramedics and drug users “may be a highly influential a countering a patient’s journey through the healthcare system” and may represent a “unique opportunity for paramedics to intervene in meaningful ways that extend past traditional drug poisoning response”.

However, there is evidence that paramedics and other first responders still hold “negative attitudes” and stigmatize both illicit drug users themselves, and some of the very interventions (such as medication-assisted treatment) that are recommended by experts including the BC Coroner Service (Kruis et al., 2021).

Nonetheless, (Bolster & Batt, 2023) were able to show that the paramedic curriculum, at least in the province of BC, teaches paramedics to deal with acute drug poisoning responses with “Little consideration of holistic care, and no meaningful mention of harm reduction”. In other words, they perform the cognitive skills required to diagnose the patient and determine treatment and they perform the psychomotor skills involved in resuscitation without ever considering the holistic care nor the long-term treatment.

Perhaps the lack of curriculum around the subject can help explain the maladaptive and unhelpful attitudes that many paramedics carry about addiction. Williams et al. (2015) used a Medical Condition Regard Scale to investigate the attitudes of undergraduate paramedics in Australia toward various medical conditions and found that, of those investigated, “substance abuse ranked the most poorly in terms of MCRS scores”.

Similar arguments can be made about the importance of the subjects of mental health and domestic violence and about the relative silence in the curriculum on these matters.

(Bommersbach et al., 2023) found that emergency department visits in the United States for mental health reasons had “approximately doubled, including a fivefold increase in the proportion of visits for suicide related symptoms” between 2011 and 2020. Paramedics are increasingly called upon to take on additional roles and fill the gaps between other health and social services. They are “increasingly called to attend to individuals with more chronic conditions… including calls for mental health and psychosocial care needs (Ford-Jones & Daly, 2022).

(Mason et al., 2010) showed that in their sample population of Canadian paramedics 90% attended at least one domestic violence call in the preceding year and 65% had attended between 10 and 20 such calls. Of the paramedics studied in the by Mason et al. (2010), 84.5% wished for more education and training regarding domestic violence.

Theoretical Framework

First of all, it should be acknowledged that Benjamin Bloom’s taxonomy of learning domains is integral to any discussion of my aim to emphasize the affective domain. The goal itself is stated in terms of Bloom’s taxonomy. Bloom’s taxonomy, of course, divides learning into the three domains: cognitive, affective, and psychomotor. As I stated in the introduction, I believe that the cognitive and psychomotor domains of learning are well contemplated in the paramedic curriculum.

Obviously, there is some affective component to any teaching because students need to be willing to receive and interact with the content in order for learning to occur. What I am referring to though, is teaching aimed at securing affective outcomes – for specific attitudes on the three topics mentioned above.

In any case, Bloom’s taxonomy breaks the affective domain into the following tiers beginning with the least complex on the base of the triangle and progressing to more complex activities at the apex:

The bottom tier in this structure is “receiving”. This is simply an awareness or willingness to hear new information. The second tier, “responding”, means that the student is actively participating and reacting to the new information – either through class discussions, presentations, questions, or some similar activity. At the third tier, we encounter “valuing”. The value that students place on particular ideas or phenomena range from simply accepting them to completely committing to them. In the cases of addictions, mental health and domestic abuse, a student at this tier may demonstrate internalization of specific values by showing empathy, for example, or by creating a plan to address these issues.

Valuing is important but I would argue that the organizing tier appears to be the minimum goal in educating and producing safe and functional paramedics. At the organizing tier, the paramedic must be able to organize values into priorities by contrasting them and resolving conflicts between them. As a concrete example of this, a paramedic may be contrasting the value of providing effective and compassionate treatment to the mental health patient with preserving the safety of the public, colleagues, and himself. Both are important values that I would like to see internalized by practicing paramedics but when the patient themselves, as a result of their mental health challenge, creates the dangerous environment, the paramedic is forced to contrast and resolve the conflict between these two values. I believe that in order to train effective paramedics, we must help them to attain, at a minimum, the skills to think and practice in alignment with characteristics of the “organizing” tier of Bloom’s Taxonomy with respect to addiction, mental health and domestic violence.

The characterization tier is evident when a professional shows commitment to the ideal through pervasive, consistent, and predictable behaviour that is aligned with the ideal. In other words, the ideal has become part of the person’s character. Attainment of this tier may not be required to function as a paramedic but would be a benefit to those involved in the instruction and research of capacities within paramedicine.

In most of my teaching I draw heavily on Dewey’s ideas about experience, reflection, generalization, and application. Dewey, of course, suggested that learning is best done by experience, by trying the activity. The experience must be followed by reflection where in the student reacts or shares the experience with the learning community which intern allows the student to process and analyze the experience. After the reflection phase the student is meant to generalize and apply what was learned. I often tell my students that making mistakes is the best way to learn and I think this is in keeping with Dewey’s theories.  As I said, I rely heavily on this approach in much of my teaching, especially with the psychomotor skills. Learning what can go wrong by making mistakes is arguably more important than knowing how to perform a skill when everything goes right. However, in the context of teaching about addictions, mental health and domestic violence it can be difficult to create high-fidelity experiences in the classroom where students can safely make mistakes and have the opportunity to reflect and apply their learning. Fortunately, Dewey and Vygotski have considerable areas of agreement and overlap in their thinking.

Vygotsky’s ideas and “sociocultural theory” also inform the way that I think about teaching this material. I can neither know nor control the values that people enter a paramedic program with. I am wary of the pitfalls with respect to trying to persuade students to assimilate values and beliefs. But, I am reasonably comfortable with a collaborative and cooperative educational model in this context and, this is what Vygotsky’s work brings to the table. Vygotsky deals with ideas about how our education is influenced and facilitated by the people around us and he tells us that a student learns by being guided through their “zone of proximal development” by a “more knowledgeable other” (MKO). If I can act as the MKO and help “scaffold” learning through the student’s zone of proximal development, I can bring them, without coercion, to a place where they internalize an attitude that I think is safe and productive.  One of the techniques that I use to facilitate this is “reciprocal teaching”.  While this technique is usually celebrated for its role in teaching cognitive skills (Rosenshine & Meister, 1994), I believe that it has an equally effective role to play in helping students develop understanding and internal consistency in their affective learning. I take turns with my students leading conversations about the three topics and use questions and statements that summarize and clarify to help lead them to reach their conclusions. In this way the reciprocal teaching method derived from Vygotsky’s theories acts as a suitable proxy for the experience required in Dewey’s model.

Evaluation and Assessment

Assessing the efficacy of teaching to achieve an affective outcome can be challenging. As (Pierre & Oughton, 2007) state, “tests of cognitive knowledge can be marked right or wrong, but emotions exist on a continuum.” I can certainly teach people the science behind addictions treatment and mental health treatment; I can create cognitive objectives and teach students about the value of empathy in the context of domestic violence, but it is difficult or impossible to directly observe the resultant attitudes about these ideas. It is, in fact, difficult to settle on a definition of the term “attitude”. For the purposes of assessing the teaching outcomes with respect to these three topics it may be sensible to “equate attitude with behaviour” and use the term attitude “simply as a descriptive term summarizing observed consistencies and behaviour” (Cook, Stuart W. & Selltiz, Claire, 1964). With this in mind, the efficacy of teaching cannot be measured directly but may be inferred from subsequent behavior. This too has its challenges, as the instructor will rarely, if ever, have the opportunity to observe behaviours that students display once they are practising professionally. This may be an opportunity for further study. It may be possible to employ quantitative surveys to study the population of paramedics following graduation. Such a survey could be used to ask about stated attitudes and values with respect to addiction, mental health and domestic violence. The value of the survey would lie in a second group of questions that ask the practitioner to self-reflect on behaviours displayed while engaged with these cases. The study could use these data to contrast the statements with self-reporting of behaviours to discern whether the stated attitude is consistent with the behaviour. In this way, the instructor can learn whether or not they have achieved their goal of enhancing teaching and learning in the affective domain with respect to addictions, mental health, and domestic violence.

Bibliography:

BC Coroner Service. (2022, March). BC Coroner’s Service Death Review Panel: A Review of Illicit Drug Toxicity Deaths.

https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/death-review-panel/review_of_illicit_drug_toxicity_deaths_2022.pdf

Bolster, J., Armour, R., O’Toole, M., Lysko, M., & Batt, A. M. (2023). The paramedic role in caring for people who use illicit and controlled drugs: A scoping review. Paramedicine, 20(4), 117–127. https://doi.org/10.1177/27536386231171813

Bolster, J., & Batt, A. (2023). Substance Use-Related Curriculum for Paramedic Students in British Columbia: A Document Analysis (2023100284). Preprints. https://doi.org/10.20944/preprints202310.0284.v1

Bommersbach, T. J., McKean, A. J., Olfson, M., & Rhee, T. G. (2023). National Trends in Mental Health–Related Emergency Department Visits Among Youth, 2011-2020. JAMA, 329(17), 1469–1477. https://doi.org/10.1001/jama.2023.4809

Cook, Stuart W. & Selltiz, Claire. (1964). A multiple-indicator approach to attitude measurement. Psychological Bulletin, 62(1), 36–55.

Ford-Jones, P. C., & Daly, T. (2022). Filling the gap: Mental health and psychosocial paramedicine programming in Ontario, Canada. Health & Social Care in the Community, 30(2), 744–752. https://doi.org/10.1111/hsc.13189

Kruis, N. E., McLean, K., & Perry, P. (2021). Exploring first responders’ perceptions of medication for addiction treatment: Does stigma influence attitudes? Journal of Substance Abuse Treatment, 131, 108485. https://doi.org/10.1016/j.jsat.2021.108485

Mason, R., Schwartz, B., Burgess, R., & Irwin, E. (2010). Emergency Medical Services: A resource for victims of domestic violence? Emergency Medicine Journal, 27(7), 561–564. https://doi.org/10.1136/emj.2009.084129

Rosenshine, B., & Meister, C. (1994). Reciprocal Teaching: A Review of the Research. Review of Educational Research, 64(4), 479–530. https://doi.org/10.3102/00346543064004479