Will Cheating Kill EMS Online Education?

Isn’t it sad that one of the questions typically asked of online education vendors by EMS managers goes something like: “Is it possible for anyone who uses your system to print out the test? I’m concerned that people will pass it around.”

It’s been our experience that almost any discussion about EMS online ed turns sooner or later to the problem of cheating. Cheating occurs in EMS education as it does in any educational venue, and as we continue to embrace the use of the Internet to train and assess the knowledge of EMS personnel, EMS learners will have more freedom to take classes and assessments without direct supervision. Given this freedom, common sense suggests that the cheating issue is going to loom larger.

This article explores why it happens and, more important, how we can prevent it with good old-fashioned leadership and hard work.

One thing is sure: Field personnel, administrators and educators all have a role to play in solving the problem.

The Cheating Problem

Examples of cheating we’ve witnessed or heard about include: letting a rookie paramedic or EMT take a test for more seasoned personnel, passing around the answers to a quiz, several people working on a test together and—here’s one for you computer geeks—hitting the back button at just the right moment after submitting an online quiz, allowing the cheater to change an answer just marked wrong.

The National Association of EMS Educators (NAEMSE) recently ran a survey on its website that asked about cheating, to which 375 people from 46 states responded. Ninety percent of the respondents were either EMS educators or education administrators. While this was not a scientific study, the results of the survey help to define the problem. There was near unanimity among the respondents that cheating does occur in EMS education and more than a quarter of them (27%) said it occurs often. When asked what the leading causes of cheating were, failure to study, laziness and a desire to “just get their ticket punched” were the most common replies. Time pressure and poor test supervision were also cited frequently. Only a handful thought that cheating occurred because the tests were too hard—which may not be too surprising given that teachers, rather than students, were answering these questions.

Almost 60% of the respondents reported actual cheating incidents or strong suspicion of such incidents in their own organizations over the last year. When questioned about the cheating incidents known to them personally and the consequences that occurred, respondents working in government-based EMS agencies were more likely to describe less severe consequences, such as requiring that a test be retaken, verbal or written reprimands or no action at all. Instructors working in private companies, vo-techs, academies and colleges were more likely to report course failures, firings and suspensions as consequences.

The NAEMSE survey did not look into what we might call the “short-cut” cases. These cases are not clear-cut incidents of cheating in the traditional sense, but they are giving EMS online education a bad reputation. Online learners who are taking short cuts are the people who brag about how they “beat the system,” as if that were the challenge.

These are people who spend little or no time with the educational content of an online lesson. As soon as they figure out how to click through the content, they go right to the test and within a matter of minutes may have completed several hours of continuing education. This problem has generated concern among leaders at the Continuing Education Coordinating Board for EMS (CECBEMS), the National Registry of EMTs (NREMT), and state and local EMS agencies across the nation who are responsible for certifying the quality of EMS care provided.

CECBEMS responded to this situation by creating a rigorous set of content and testing standards for CE vendors and educators who want to earn approval for online courses. Tests, for example, must assess more than the ability of the learner to memorize a protocol; they must also measure higher levels of learning such as the ability to apply the correct treatment in a patient-care scenario. Vendors are also trying different methods to discourage short cuts and cheating with techniques such as reporting how much time was spent on a lesson, preventing the ability to retake a failed exam immediately, not revealing correct answers when a question is missed, and randomizing exam questions and answer blocks. CE certificates may carry traceable serial numbers linked back to the learner’s name and state certification number.

But are people who take short cuts really cheating? Assuming they didn’t have someone feeding them the answers, they took the test and they knew the answers. Even if they flunked the test, they were eventually allowed to take it until they passed. Practice makes perfect—right? Does it really matter if they didn’t pay much attention to the online readings or lectures? What’s the difference between this and going to a live CE class at work or at a conference, sitting there for an hour, paying little or no attention and easily passing the short test at the end because the questions are so basic that you would have to be in a near-vegetative state to get them wrong? While beating the system may not fully qualify as cheating, no one can deny that it displays a disdain for fully participating in continuing education.

The attitudes of many EMS learners and administrators are troubling and point to some underlying causes of cheating. We’ve heard people make comments such as: “Nobody really cares about this stuff—we just need to keep the regulators off our back,” or “Everyone does it, even the officers look the other way,” or “What does it matter? I’m a good medic on the street.”

We’ve heard medics argue that some con- ed training is such a waste of time they don’t feel it is cheating when they help each other get through a test. We’ve heard EMS managers say that there is little they can do to prevent cheating—as soon as the quiz is released, the answers are passed around. For most operations managers, what is essential is keeping units on the street. Since they must have a certified person aboard every unit, some managers will argue that how a CE test gets passed is not their primary concern.

These EMS attitudes seem to reflect a larger problem of cheating across our nation. A book published earlier this year, titled The Cheating Culture: Why More Americans Are Doing Wrong to Get Ahead, by David Callahan, paints an unsettling picture of the cheating that goes on every day in American business, government, sports, education, and the legal and medical professions.1 Using interviews and study results, Callahan suggests that our competitive nature and a cultural emphasis on getting results at all costs contribute to the cheating problem. He also points out that cheaters are winning. They are getting harder to catch, and in many cases when they do get caught, the punishments aren’t that severe. Sadly, he says the benefits of cheating seem to outweigh the risks.

Cheating in American education was also the topic of a six-month ABC News investigation completed last spring. ABC went into American high schools and colleges and reported finding both a high prevalence of cheating and a mind-set that cheating is becoming necessary to achieve success.2 They reported that a recent survey of 12,000 high school students found 74% admitted to cheating on an examination in the previous year. College students who were interviewed made comments like “The world is terrible; people will take other people’s materials and pass it on as theirs. I’m numb to it already. I’ll cheat to get by.” Another student said, “There are other people getting better grades than me and they’re cheating. Why am I not going to cheat? It’s kind of almost stupid if you don’t.” And another responded, “Everything is about the grade that you got in the class. Nobody looks at how you got it.” An engineering student who admitted cheating said, “What do I need to know about English literature? I shouldn’t have to take this course.” Equally troubling were findings that educators were sometimes passive on cheating. They quoted a survey of more than 4,000 U.S. and Canadian schools that revealed half of all instructors admitted ignoring cheating at least once.

Solutions

Given the evidence of a growing cultural problem in our nation, dealing with cheating in EMS online education is not going to be easy. New recruits bring their experience and values with them, so it’s less likely that the cheating they encounter in EMS will be all that shocking. In The Cheating Culture, Callahan proposes that solutions must begin by getting better at demonstrating to young people the value of personal integrity. Similarly, in the workplace, EMS organizational leaders and managers must actively promote and demonstrate in their own behavior the importance of professional integrity. Professional integrity should be a key component in every EMS organization’s code of conduct.

Managers must be directly involved in discussions with personnel regarding the organization’s code of conduct and why it’s important. Violations of the code that involve cheating on quizzes and tests should have agreed-upon consequences among all personnel, and when they occur, should be enforced. Soft sanctions such as requiring a test to be retaken will not achieve much. Collective bargaining units play an equally important role in promoting a culture of professional integrity, and should either take the lead or be directly involved in any efforts organized by management to address issues of cheating.

While these suggested changes in the cultural environment can help, there is much more that must be done structurally to discourage cheating in EMS education. We’ll focus on technology, educational policies and teaching methods.

Technology

Online education is growing in EMS. The regulatory agencies are developing rules about it. EMS organizations across the country are purchasing online classes for their personnel and setting up their own online education programs. The major EMS publishers are offering online courses such as ACLS, as well as website enhancements to their primary and refresher textbooks. The freedom of online EMS training provides ample opportunity for cheating.

Technological impediments to cheating, at this point, come primarily from software. Online EMS learning typically happens inside a software package called a learning management system, or LMS. These systems provide computer-based testing that generates a quiz by randomly selecting questions from one or more pools of questions each time a new person takes the test.

The LMS may also allow the educator to set a number of limits for the learner: The test can be made available only during a certain timeframe; a password for an individual test can be set so that a supervisor can release and proctor the test; a time limit can be set in taking the test; the number of attempts to pass a test can be restricted; a learner can be prevented from retaking a test he has passed; the display of corrected answers can be suppressed on test results; and it can be made difficult to print out a copy of the test.

Also available, but rarely implemented in the EMS educational environment, is security hardware used to limit cheating, including retinal and fingerprint scanners and facial recognition cameras. These are primarily intended to replace user passwords with biometric data, preventing unauthorized access to a computer or program. Additionally, random requests to authenticate the learner’s identity at any point during a training session are possible.

Though these enhancements do not add much to the price of the computers, their utility is nevertheless questionable. First, they force test-takers to use the computers on which the devices are installed, which is at odds with the anytime, anywhere cost-saving feature of online learning. Second, it’s impractical to think that home computer users would either purchase or install these controls. Besides, what would be the point—without supervision, who’s to say that the person touching the fingerprint pad does not have an open book or a “coach” standing by?

The best use of these technologies is for high-stakes testing events, such as initial competency testing or recertification, which should always occur in a supervised environment due to their public safety implications.

The National Registry of EMTs (NREMT) is currently investigating an innovative approach to computerized testing that will provide both accurate results and a high degree of security against cheating called Computer Adaptive Testing.3 This method provides the learner with a series of problems where each successive question is selected based on how the learner did on the previous one. The testing session continues only as long as is necessary to define the learner’s knowledge level on a set of topics. Computer Adaptive Testing makes sense for high-stakes tests and could be incorporated into online learning as well.

Education Policy

As promising as these technological strategies sound, the most important changes might need to be made in education policy and teaching practice. A useful step in curbing cheating can come from listening to what field providers tell us, and shaping our education policies to meet their needs.

In a recent conversation about cheating in EMS education, Chief Will Chapleau of the Chicago Heights (IL) Fire Department commented that cheating is not a significant problem in his department’s refresher and continuing education program. Chapleau says that every effort is made to triage knowledge deficiencies and match the refresher training to those deficits. Many departments make no attempt to customize learning, instead sending personnel to outside refresher courses that strictly follow the U.S. Department of Transportation (DOT) National Standard Curriculum from start to finish, ignoring what people may or may not need to be taught.

Online learning has the potential to offer a highly customized refresher education program to individual EMS providers. An adaptive pretest could result in the automatic selection of a curriculum that best meets the learner’s needs. This level of adaptation and customization is most practical in a computer-based learning environment.

As more organizations turn to online education solutions, the marketplace will demand—and vendors will provide—content that can diagnose and meet the individual needs of EMS providers. Online training vendors already specialize in producing cost-effective custom training solutions. In the future, EMS providers will be able to select pre-recorded classes they will see and hear online, delivered by nationally recognized experts and augmented by the necessary local information. Such customization will maintain field providers’ interest in refresher and continuing education and eliminate the justification for short cuts and cheating.

NAEMSE recognizes the potential for online education and has called for the use of online education for all levels of training when it can be of benefit to learners. The association cautions, however, that such education must be properly constructed and delivered by competent online educators, and is not recommended for skills training, except when classroom-based training is impossible.4

A major factor that contributes to the redundancy of training and the complaints about wasting time is lack of agreement in the regulatory environment about the difference between refresher training and continuing education. Some states define refresher training as a subset of an overall continuing education program. Depending on the jurisdiction, providers who want to recertify are required to take a refresher course, CE classes, or a combination of both.

The NREMT, however, clearly delineates a difference between a refresher course requirement and the completion of additional con-ed classes. The Registry’s philosophy is that refresher training should focus on refreshing knowledge and skills that are infrequently encountered in the field yet have high-risk consequences for the patient. Continuing education, on the other hand, should be directed toward professional development.

The lack of clarity about the definitions of continuing and refresher education has caused vendors to create online CE that looks much like the DOT National Standard Curriculum. The result is an online class with a topic that a learner may have just covered in a recently completed refresher course. The temptation for many will be to skip over what is obviously redundant content and go right to the test.

Teaching Practice and Curriculum Design

Curriculum designs for the classroom and for the online environment are different. In addition, not all EMS instructors are experienced educators—many are part-time or adjunct instructors without proper training in basic classroom curriculum design, something all instructors need to understand prior to being expected to develop an online program. College-based educators can usually obtain training on distance education from their college faculty developmental centers.

NAEMSE is committed to providing training for online education programs and has offered online and preconference sessions on the topic for several years. It has a distributed learning committee that provides an excellent networking resource for anyone interested in online learning methods. Collaboration with other online educators is an effective way to learn about online teaching methods that can help you get an online education program off the ground.

An example of a grass-roots collaborative effort is taking place in Wisconsin, where a pilot EMT-Paramedic refresher project is being tested. A district-wide curriculum committee was developed utilizing content experts. These experts, consisting of physicians, paramedics, nurses and educators, developed didactic and skill lab content based upon the National Highway Traffic Safety Administration’s EMT-Paramedic refresher curriculum. One goal of the project is to develop a statewide curriculum development committee using content experts throughout the state of Wisconsin. This would not only promote organization-sharing of content and content experts, it would reduce the development workload for individual organizations, which is significantly more demanding than classroom-only models of teaching.

On another front, EMS publishers have been working hard to provide Internet education for the EMS market. Online versions of ACLS, EMT-Basic and refresher courses are already available or under development by several publishers. These online classes, developed by highly qualified content experts, experienced distance educators and Internet technologists, provide learning that is both educationally sound and has enough high-tech glitz to engage users. In many cases, knowledge assessment occurs throughout the lesson and is used to determine if content has been mastered to the point where the learner can move on to the next segment of training.

The resources it takes to produce this type of learning are currently beyond the limits of most EMS organizations, but high-tech classes are not the only effective way to teach people online while limiting the likelihood of cheating. Low-tech, low-cost content—using simple online voice/slide-show technology and scenario-based learning methods—is also an effective way to engage learners and limit the urge to take short cuts and cheat, provided the content meets learners’ self-perceived needs.

Professional groups such as the American Ambulance Association and the Florida Fire Chiefs Association have responded to the needs and interest of their constituents by setting up online learning management systems that offer their members low-cost or free online CE and specialty topics classes. Members can also sign up their organizations for customized online learning support services.

Conclusion

The problem of cheating in EMS online will probably get worse if the underlying causes are left untreated. But we are making a great mistake if we brand Internet learning as too vulnerable to cheating, and thereby discount its utility in EMS education. We must also avoid the temptation to simplistically invoke stricter disciplinary sanctions—that will only make those who currently feel their refresher and con-ed classes are a waste of time more determined to cheat.

EMS education needs to be better aligned with the needs of each individual provider. We can succeed in that effort by adjusting our educational regulatory environment, our curricula and our teaching methods to embrace technologies not available when most EMS education policy and practice methods were developed.

In addition, we need to develop a cadre of properly trained EMS educators and give them access to these new technologies and curriculum design growth opportunities. Fortunately, training resources are emerging.

There is plenty of hard work ahead, but the rewards for EMS personnel and education programs will be worth it.

References

1. Callahan D. The Cheating Culture: Why More Americans Are Doing Wrong to Get Ahead. Orlando, FL: Harcourt Inc., 2004.
2. ABC News. Cheaters amok: A crisis in America’s schools—how it’s done and why it’s happening. Prime Time. Thursday, April 29, 2004; https://more.abcnews.go.com/sections/primetime/us/cheating_040429.html.
3. Personal correspondence via telephone with Gregg Margolis, associate director of research, National Registry of EMTs. June, 2004.
4. National Association of EMS Educators. The use of Internet based distributed learning in EMS education. Pittsburgh, PA, 2003; www.naemse.org/positionpapers/DLPositionPaper111003.pdf.