The Preceptor’s Tool Belt: Creating Meaningful Field Training for Students and New Hires
On June 30, 2024, the National Registry of EMTs (NREMT) discontinued the psychomotor examination for paramedics entering the profession. The exams from NREMT are excellent tools for determining if individuals are prepared to enter the profession. They have served as a benchmark since the 1970s, and all 50 states recognize the NREMT certification. Forty-six states use it as the basis for licensure.1
The psychomotor exam, in addition to whatever final exam and practical exam offered by an EMT school, coupled with the onboarding process required by an employer, function as a gatekeeper to ensure the profession is fielding safe providers. A school wouldn’t send a student to the NREMT if they failed the final. An employer wouldn’t hire a job candidate unless they passed the NREMT exam and obtained a license. The ending of the psychomotor exam by the NREMT means there is a greater emphasis on what schools and employers do to ensure they are rostering safe EMS clinicians.
Internships and field evaluations provide an opportunity for clinical encounters, where EMTs simultaneously build the skills required to work independently in the field and schoold or employers can evaluate a student or a new hire. This is the toughest part of the developmental process for new EMTs.
Why Bloom’s Taxonomy Isn’t Enough
Tools like Bloom’s Taxonomy fail educators for developing a clinical encounter in the field.2 Bloom’s works perfectly for the development of lesson and activity plans in school. In the field, Bloom’s is severely lacking. Bloom’s is built on the idea of scaffolding or building upon prior levels of learning.
Why doesn’t Bloom’s work for EMS? Here is an example: As an EMS educator, when you’re speaking about your lesson or activity plan that you are using in school, the treatment and resuscitation of a patient with congestive heart failure (CHF), may be stellar.
In the field EMS providers aren’t afforded the luxury of a structured learning environment. Sometimes we arrive on scene and the patient is so far along into the clinical progression of the event that we don’t get to ramp up (scaffold) to build knowledge and experience. For example, a patient in a skilled nursing facility, with early onset Alzheimer’s, who is a diabetic, with mild CHF, who has fallen out of bed, fractured their pelvis, and is now hypotensive. Or what about a pediatric patient with osteogenesis imperfecta who tripped on the people mover at the airport and now has bilateral femur fractures? In any one of these patients, we are going from zero to 100 miles per hour in two seconds.
We may arrive on the location of an incident and the patient will need to be intubated; they may require transvenous external pacing; they may need needle decompression. These are few and far between skills and when they present themselves, we may not be offered the chance to build up to this event. As the preceptor you may take over the basic life support (BLS) parts of airway, preoxygenation with a bag-valve mask (BVA) and an oropharyngeal airway (OPA) while your intern or new hire gets ready to perform the intubation. You may focus on obtaining IV access, making sure the patient is well oxygenated, while your intern places pads for pacing and they run down the checklist. If you are the lone medic with your student on the scene of a mass casualty incident, you may divide and conquer. These are not every day incidents, but when we have them laid bare at our feet we cannot pass up on the opportunity for the student.
You can’t scaffold these events, and to try and use tools like Bloom’s to scaffold an educational encounter in the field is impossible. The patient in the field doesn’t know Bloom’s Taxonomy. The field environment is much more freeform. The five-step microskills model helps us structure the encounter between preceptor and student, and this is crucial to our interaction with the patient.
Microskills Model
There are tools available to improve training interactions. The five-step “microskills” model of clinical teaching is one that is essential for structuring the clinical encounter, and it should be a fundamental part of a preceptor’s toolkit.3,4 Preceptors need a framework to shape the clinical encounter, provide the direction and instruction a student needs, and the five-step microskills is a good option.
Webb’s Depth of Knowledge
Preceptors and students also need something that allows for patients that do not present uniformly. Webb’s Depth of Knowledge, which includes the concepts of recall and reproduction, skills and concepts, strategic thinking, and extended thinking, lends itself to the dynamic clinical encounter.5,6,7 Webb’s does not need to progress in a linear fashion; instead as we experience a patient who is crashing or improving, it allows for us to transition and adapt to the moment. Webb’s focuses on the complexity of thought needed for different tasks, rather than strictly sequential steps.5,6,7
In EMS, we need to apply knowledge quickly and in unexpected ways, this model’s focus on depth rather than scaffolding levels fits that need well. Webb’s is particularly well suited for real-time clinical decision-making in dynamic situations. During a student’s internship, it is especially useful for managing emergencies, formulating quick decisions, and problem-solving in the moment.
Marzano’s New Taxonomy
There are some things that need to occur before your first day with a student or a new hire. Do you meet with the student’s professor ahead of time? If you do, do you try and gain an understanding of what challenges they had in the classroom and the lab, so you are aware of them when they are in the field?
Do you meet with the student or the new hire before they show up, before you go on your first assignment? What questions do you ask?
We have all been exposed to Marzano’s New Taxonomy, except we didn’t know that is what it was called. It focuses on how learners process information. Marzano proposed a model with three systems—self, metacognitive, and cognitive.5
If you ever had a preceptor ask you, “Why are you here?” or “Do you believe you can succeed?” he was asking questions right out of the self-system of motivation and goals for Marzano.
Marzano’s metacongnitive system is demonstrated when on the way to a call the field training officer asks, “When we get on scene for this chest pain, how are you going to approach this patient?” or “What are the initial five steps for the assessment?” Also part of the system is the validation trainees receive when they look to the preceptor and have been given the knowing glance that all is well.
If after you were done with your assessment your preceptor asked, “Based on your exam, what do you know?” or “What do the chief complaint, assessment, and EKG tell you about what could be going on with this patient?” and “Based on this information, what are you going to do to treat this patient?” they have applied Marzano’s cognitive system. We have all experienced these types of questions or something similar, except we didn’t know it was part of a comprehensive system of assessment and education.
Putting it Together
If preceptors use Webb’s Depth of Knowledge and Marzano’s Taxonomy within the structured framework of the five-step microskills model of clinical teaching, this becomes an extremely powerful set of tools for the development of a meaningful clinical encounter. These frameworks provide flexibility, support for rapid decision-making, and the development of critical thinking, which are all essential in the dynamic and often chaotic world of EMS.
In this evolving landscape, Aristotle’s words, “Knowing yourself is the beginning of all wisdom, but virtue lies in action,” remind EMS professionals that competence is measured not by theoretical knowledge alone but by how effectively we act in real-world situations. Students and new hires require robust field evaluations to develop the clinical intuition and decision-making needed to thrive under pressure. The unpredictable nature of EMS means that clinicians must transition seamlessly between routine and high-stakes scenarios, often without warning. To meet these demands, preceptors must move beyond linear frameworks like Bloom’s Taxonomy and embrace models such as Webb’s Depth of Knowledge, which prioritize adaptability and complex thinking. Integrating Webb’s approach with Marzano’s systems and the five-step microskills model creates a dynamic structure for clinical teaching, ensuring that students not only learn but also embody the virtues of EMS: decisiveness, compassion, and professionalism. As the gatekeepers of clinical competence, we must ensure that every encounter becomes an opportunity for students to practice these virtues through deliberate and thoughtful action.
References
1. NREMT – About Us. https://www.nremt.org/about/about-us. Accessed Oct. 25, 2024.
2. Bloom, B. S. (Ed.). (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. David McKay Company.
3. Gerard, D. R. (2020, March 1). The one-minute preceptor: A framework for clinical education in the field. EMSWorld. HMP Global Learning Network. https://www.hmpgloballearningnetwork.com/node/157367.
4. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Amer Board Fam Practice, 1992; 5(4): 419–24.
5. Ormrod, J. E. (2016). Human learning (8th ed.). Pearson.
6. Price, K. M., & Nelson, K. L. (2018). Planning effective instruction: Diversity responsive methods and management. Cengage Learning.
7. Noddings, N. (2018). Philosophy of Education (4th ed.). Taylor & Francis.
