SPEC SOCIETY FOR PREHOSPITAL
Society r., Prehospital
Educators in Canada

EDUCATORS IN CANADA

Excellence in Paramedic Education
Ron Bowles
President, Society for Prehospital Educators in Canada
Exploring the idea of competence and
excellence in paramedic education is timely
as stakeholders in Canadian EMS work with
the Paramedic Association of Canada (PAC)
to redevelop the National Occupational
Competency Profile for Paramedics in Canada
(NOCP). Education programs can serve
many goals: fostering consistent performance,
contributing to efficient and effective patient
care, laying a foundation for future growth
in the discipline, and encouraging personal
growth in paramedic learners. Each of these
goals implies a different view of competence
and excellence. The concept of competence in
health education is often studied as the development of expertise.
Donald Schon is an educational theorist
who is best known for promoting reflective
practice and professional expertise. Schon
(1983) contrasts two views of excellence and
competence. The first is based on what Schon
calls Technical Rationality and involves the
use of analytic strategies and algorithms to
solve known types of problems. But, he claims,
professional practitioners work in a dynamic
environment that is far less predictable than
Technical Rationality assumes and where
discernment and adaptability are as important
as consistent performance.
In the context of paramedicine these two
approaches are often framed as technical
competence and clinical competence. Technical competence can be defined as consistent,
independent (un-coached), timely, accurate,
and appropriate performance as outlined by
an external authority and assessed through
observable behaviours. This view is embedded
in the current NOCP and PAC definition of
competence. Clinical competence, by contrast,
can be thought of as the ability of paramedics to apply, adapt, and integrate procedures
appropriate view of excellence. Competencies that require discernment and the ability
to distinguish and choose between a variety
of acceptable options (e.g., interpersonal and
interprofessional communications or applying guidelines to unique situations) are more
indicative of developing clinical competence.
Excellence at the level of expert performance
involves the paramedic's ability to become
aware of and make use of increasingly nuanced
contextual clues from the environment.
A paramedic's journey from novice to expert
stretches over his or her career and encompasses both formal education and personal
reflection. Writers such as Schon and Dreyfus
give us ideas and language that help us better
understand the implications of differing defini-

and strategies within the dynamic, unpredictable environment of field practice. Clinical
competence emerges over time as paramedics
encounter and reflect on their experiences and
build a foundation of professional expertise.
Excellence for the technically competent
practitioner involves the acquisition of a large,
unique body of specialized knowledge and
the application of standardized principles and
guidelines (Schon, 1983). Excellence in clinical
expertise, however, is indicated by an increasing awareness of the context of practice and the
ability to choose between a number of potentially acceptable options for problems that are
difficult to categorize. Schon poses these views
as opposing conceptions and the difference
between them as a gap that should be better
addressed by professional education programs.
Other theorists, however, see these differing
views of competence as simply different ways
of knowing in different situations. Hubert
and Stuart Dreyfus (1986) developed a model
of skill acquisition that is commonly cited in
nursing and medical education. The model
outlines five stages: novice, advanced beginner,
competent performer, proficient performer,
and finally, expertise. Novices learn context-independent rules (e.g. indications and contraindications) for performing specific procedures.
Advanced beginners recognize situational
aspects of calls and develop principles for
dealing with them. With experience, competent performers recognize salient features
of different types of common situations and
develop customised management plans from
various potential options. Over time, proficient performers intuitively recognize situations as similar to various prior examples. They
discriminate between potentially conflicting
interpretations of the situation (e.g. develop a
differential diagnosis) and develop _plans that
tions of concepts like competence. Documents
such as the NOCP that attempt to describe
that journey are complex. The varied competencies in the NOCP foster differing types of
learning goals, which in turn call upon varying
forms of competence and measures of excellence. In this sense, we must acknowledge that
no single definition of competence is adequate
to describe paramedic practice.
NOTE: This year's SPEC AGM and
Educator's Symposium is being held concurrently with the Alberta College of Paramedic's
Con-Ed Summit on May 14 - 15, 2014 in
Calgary. Information, registration, and the Call
for Presenters can be found on the SPEC
website: www.my-spec.org. cP

Excellence
for the technically
competent
practitioner involves
the acquisition of
a large, unique
body of specialized
knowledge.
will work in "this" situation. Finally, expertise
develops as the experienced paramedic acquires
and employs a vast repertoire of these situations and plans.
In contrast to the pursuit of consistency
which characterizes technical competence,
clinical expertise is situational, adaptive, and
intuitive. Indeed, a technically competent
practitioner would be considered an advanced
beginner in the Dreyfus (2001) scheme, while
clinical competence develops with time and
experience.
From the perspective of the Dreyfus model,
technical competence and clinical competence
are not opposing views of excellence. Rather,
they merely focus on different types of learning and different stages in the development
of expertise. When learners are mastering
rule-based competencies (e.g., procedural
skills such fracture management, initiating
intravenous lines or implementing protocols),
then technical competence, with its focus on
consistency an~ observable behaviours is an

References
Dreyfus, H. L., & Dreyfus, S. E. (1986). Mind
over machine: 7he power of human intuition and
expertise in the era of the computer. New York,
NY: Free Press.
Schon, D . A. (1983). 7he reflective practitioner.
New York, NY: Basic Books.