Any Intelligent Fool Can Make Things Bigger, More Complex and More Violent.

Any intelligent fool can make things bigger, more complex, and more violent. It takes a touch of genius – and a lot of courage – to move in the opposite direction.

In Part 6 of the AHA 2020 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Resuscitation and Education Science was discussed. Of the top 10 take- home messages the first 2 will be reviewed here not only through the lens of resuscitation training but in the wider context of prehospital care education.

1) Effective education is an essential contributor to improved survival outcomes from cardiac arrest.

2) Use of deliberate practice and mastery learning model during resuscitation training improves skill acquisition and retention for many critical tasks.

These 2 points have implications that reach far beyond the realms of cardiac arrest resuscitation. These initial 2 of 10 points should be adopted into all EMS education programs.

The first point emphasises that in order to improve patient outcomes effective education is essential. To take one example every year millions of people around the world are trained in CPR with the aim of improving patient outcomes of cardiac arrest. Despite widespread CPR training survival rates from out-of-hospital cardiac arrest survival remain suboptimal. Educational activities are not reaching their intended outcomes. Significant skill decay within months of course completion has long been recognised, observed and documented yet the educational delivery models remain relatively unchanged. Design and delivery at all levels of EMS education as with resuscitation training must be optimised using proven educational methods that promote learning and retention to ensure that patients receive excellent care. Knowledge translation and implementation science is inadequately considered during prehospital education despite their critical impact on patient outcomes. In short not only should our course content be evidence based but the delivery should be as well.

Initial EMS educational offerings seem to have culturally shifted from sound clinical education and safety practices to balancing books, placing "bums on seats" and doing this as cheaply and quickly as possible. Rather than searching course content for relevance, rigorously ensuring it is delivered uniformly and ensuring that the implementation science is considered we continue down well travelled paths with poor track records. Culturally it appears that EMS educational offerings emphasise course breadth rather than depth. With course durations shortening this will inevitably lead to significant skill fade over shorter time periods. Fundamental basic elements are sacrificed at the alter of time constraints in order to meet the broader syllabus creating conditions for a perfect storm. Students find themselves in possession of large amounts of seemingly unconnected information which leaves them feeling confused and disenfranchised. Ultimately it is not only the learner but also the patient that suffers the consequences. Perhaps it is high time that we spent more time teaching less material more thoroughly. Greater emphasis on effective education will improve provider performance, enhance local implementation of guidelines and potentially decrease patient mortality and morbidity rates.

This brings me to the second point that addresses deliberate practice and mastery learning. Deliberate practice is a training approach where learners are given (1) a discrete goal to achieve, (2) immediate feedback on their performance and (3) ample time for repetition to improve performance. Mastery learning is defined as the use of deliberate practice training along with testing that uses a set of criteria to define a specific passing standard that implies mastery of the tasks being learned. Despite the phrase "practice makes perfect" not all practice is equal. It is possible for a learner to practice multiple times with no observable improvement in performance. Educators should deliver prehospital education that allow learners to practice key skills, receive direct feedback and improve until they attain mastery. Incorporation of these instructional design elements for key competencies has the potential to improve translation of skills acquired in the classroom to the real clinical environment. Mastery implies that the can consistently demonstrate a predefined level of competence for a specific skill or task. To optimise the likelihood that a learner will be able to master key skills the learner may be asked to repeat it multiple times to increase the probability of achieving the identified learning objectives. Mastery learning and deliberate practice have been identified as "features...of simulation-based medical education that teachers should know in order to...maximise educational benefit."

Mastery Learning should include the following 7 features;

1) Baseline testing

2) Clear learning objectives, sequenced as units of increasing difficulty

3) Engagement in educational activities focused on reaching the objectives

4) A set minimum passing standard for each educational unit

5) Formative testing to gauge unit completion at a preset minimum passing standard for mastery

6) Advancement to the next educational unit given measured achievement at or above the mastery standard

7) Continued practice or study on an educational unit until the mastery standard is reached.

We utilise mastery learning in all our courses. Course design includes frequent assessments of learning and an element of flexibility. We plan for learners to be given more time (or a new teaching method) if the standard approach is not working for them to attain minimum passing standard for a specific skill.

Deliberate practice includes activities that have been specially designed to improve the current level of performance in which weaknesses are systematically identified and addressed to move to the next level. It should be emphasised that repetition is not sufficient, rather, repetition should be paired with feedback directed at weakness and coupled with the assignment specific exercises for the individual to address between sessions with the instructor or coach. We apply the key principles from this framework to create the most effective and efficient training programs possible, given the limited time available and the high stakes of our curricula.

Standard setting in mastery learning is contrasted with the process of setting cutoffs for examination scores. Rather than predicting the behaviour of a minimally competent student who is just at the edge of acceptable performance, judges will be modeling the performance of a student who is well prepared to succeed at the next stage of instruction or practice. Overlearning and automaticity should be considered with the learner spending extra time practicing a skill even after performing it correctly once, with the goal of performing it correctly a specified number of times or more quickly within a timeframe to attenuate the natural decay of skill. Cognitive load is the amount of mental effort and memory used during an educational experience. Training to overlearning and automaticity is associated with increased ability to free up cognitive space (ie reduce cognitive load) to be able to attend to other clinical issues because not all mental energy is going into doing the basic procedure. Delineating key outcome measures in all our courses and setting minimum passing scores are important concepts for mastery learning and deliberate practice, particularly in our resuscitation courses where lives are at stake and failure is not an option.

If you as a student or as an organisation are seeking prehospital medical education are not receiving these evidence based effective strategies please contact us so that we can discuss your needs. We are passionate about prehospital education. Whether you are just starting your prehospital career or are already well established and are looking at a specific course such as PHTLS we will provide the finest education. We also are able to provide financing for any of our courses.

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