NREMT now requires each paramedic student to complete a portfolio during their program which documents competency in skill and scenario performance, clinical experience in hospitals and team leadership during their field internship.
Within each phase, paramedic students should learn and be assessed in skills, then apply those skills in new and more complex situations. Here is what paramedic students and educators need to know about each phase in the NREMT Paramedic Psychomotor Competency Portfolio.
1. Students must demonstrate competency in skills before performing them in scenarios.
The National Registry Paramedic Psychomotor Exam previously emphasized testing isolated skills based skill sheets before an examiner, which assessed candidates on only one occasion and out of context with what they will perform in the field. In fact, pilot projects testing the portfolio showed that many paramedic students struggled when asked to perform skills in a scenario [1].
The NREMT portfolio requires paramedic students to practice skills and demonstrate competency earlier in programs, to apply those skills in lab scenarios and be tested on a simulated patient care scenario on exam day. Students in the portfolio pilot projects also did better in their field internship and on the cognitive exam using this approach [1].
The NREMT has skill sheets for 33 skills covering areas of history taking and physical exam, airway, oxygenation, and ventilation, trauma, medical, cardiac and obstetrics. After being introduced to a skill and guided practice, students may use these sheets to grade each other under supervision by an instructor [2].
Competency is achieved after repeated practice when students can deliver the skill automatically without the need to think through all of the steps [2]. NREMT has recommendations for number of successful peer and instructor evaluations that should be met for each skill and students should pass a summative skill assessment before performing that skill in a scenario.
2. Paramedic students learn how to walk with formative scenarios, and are assessed on how well they can run with summative scenarios.
Soon after skill competence has been assessed, students should perform skills in the context of a simulation scenario with a human patient actor, task trainer or mannequin. In addition to performing the skill, students must also assess simulated patients and justify why the skill is necessary. Programs do not have to wait until students are competent at all of the skills before doing formative scenarios; students may participate in a scenario requiring airway management or intravenous fluid soon after demonstrating competence in the airway and intravenous therapy, and before learning other skills.
Students should get experience as both team leaders and team members in scenarios. Team leaders are expected to manage the scene, perform the patient assessment, make clinical decisions and direct team members. Team members are expected to confirm and carry out orders correctly and speak up if there is a safety threat to the patient or provider.
Scenarios should cover airway, medical, cardiac, obstetric and trauma conditions, and be distributed among adult, geriatric and pediatric patients. Scenarios should increase in complexity as students progress through the program. Early formative scenarios cover isolated learning objectives and involve more teaching. Summative scenarios are longer; they include more complicated patient presentations and scene dynamics, and involve more assessment from instructors. Students should only lead summative scenarios after they have successfully lead formative ones.
For example, a formative scenario may be for an uncomplicated COPD exacerbation during the respiratory module. A summative scenario may assess students toward the end of their program on how well they manage a respiratory patient with a history of COPD, heart failure and a fever, along with an upset family member. Instructors may intervene and guide students through formative scenarios, and should only intervene if a mistake would harm the simulated patient in a summative assessment. NREMT has skill sheets to grade team leaders and team members, and a bank of piloted formative and summative scenarios is available on their website.
3. Lab skill and scenario practice is applied to human patients in the Clinical Phase.
During the Clinical Phase, paramedic students are expected to assess patients, interact with their family members, observe and participate in patient care as team members, develop treatment plans with a preceptor and perform psychomotor skills. Students must be signed off on skill competency in a lab scenario before applying those skills on live patients. The portfolio should include documentation of student clinical experience — not just hours — and evaluations by preceptors. This phase may also include time on a paramedic unit where students participate as a team member.
4. Capstone Field Internship completes the portfolio.
During the Capstone Field Internship, paramedic students are expected to function as a team leader on a paramedic unit under the supervision of a preceptor. This assesses paramedic students for entry-level competence before graduation and is the final opportunity to identify areas where remediation is needed. Paramedic students pass or fail calls based on how often the preceptor has to intervene or prompt the student on a call. NREMT’s minimum competency criteria for the field internship is passing 18 of a student’s last 20 team leads.
5. There are a variety of ways to complete the portfolio.
NREMT sets minimum requirements and sample assessment tools, but programs may add more skills, require more successful demonstrations of competency in topic areas and develop their own skill sheets. Paramedic students may also go into clinical and field sites earlier in the program, but should only perform skills on live patients until after they are signed off in lab.
It is also up to programs to determine the number of hours, patient contacts and successful team lead requirements in the Clinical and Capstone Field Internship Phases. Program advisory boards, medical directors and communities of interest should be involved in program-specific portfolio requirements, and the rationale should be documented.
Programs also have flexibility about how to meet portfolio objectives. One program may require students to successfully demonstrate skills in front of an instructor before they can be evaluated by peers; another may require a number of successful peer evaluations before an instructor evaluation. In order to maintain reliability among peer assessments, students or their peer evaluator may have a consequence if the student fails an instructor skill evaluation. Students may also participate in scenario development and grading. One model has student graders stop scenarios if they observe a safety threat.
6. Portfolio records are best kept electronically.
Electronic storage of portfolio documents is strongly encouraged. Schools may do this on their own, or use one of a number of commercial EMS skill tracking and scheduling programs. These programs allow students to be graded on skills with fillable forms using a tablet, laptop or smartphone, and portfolio data is updated in real time. Skill tracking programs also display when skill competence has been achieved and what topic areas and ages have been covered in scenarios. Some of these programs are included in textbook packages and include reviewed scenario banks.
The NREMT Psychomotor Competency Portfolio tracks paramedic student progress across program, from learning isolated psychomotor skills in lab to leading real scenes during internship. For more information, NREMT has documents about portfolio requirements, skill sheets and scenario templates on their website. The National Association of EMS Educators has archived webinars about the portfolio available to members, and NREMT and NAEMSE offer regional scenario development workshops.
References
1. National Registry of Emergency Medical Technicians. The NREMT Out of Hospital Scenario Update (2016 September 22). Retrieved from: https://www.nremt.org/rwd/public/document/paramedic-portfolio
2. National Registry of Emergency Medical Technicians. 2015 Paramedic Psychomotor Competency Portfolio Manual. Retrieved from: https://www.nremt.org/rwd/public/document/paramedic-portfolio
