The Protocol / Skill Connection

Part one of a two part series. (Part two is here.)

If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow.

Such is the nature of growing things.

It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-ha moments. Here’s how it works.

Stuart and Hubert Dreyfus developed the Dreyfus model of skill acquisition in 1980 at U.C. Berkley. They were working for the U.S. Air Force at the time, an organization who, I imagine, is keenly interested in how people develop advanced skill sets like aerial dog-fighting.

As you develop complex skills, you go through five phases. During these phases you are reliant on rules and guidelines to differing degrees. If I know where you are on the Dreyfus skill acquisition model, I can tell you exactly how dependant you are on your written protocols. I can also tell you whether or not you feel supported or confined by them.

Here are the five phases of skill acquisition.

1) Novice

As novice learners, we demonstrates strict adherence to the rules and the plans that we have been taught. We devote most of our mental energy to recognizing which rule best applies to the current situation and enacting that rule or plan.

When we are novices, we do not exercise discretionary judgment. We don’t like either-or situations and we don’t want systems built with too many user directed preferences. We want to be told what to do.

As you might imagine, in our novice phase, we are dependant on rigid, well defined protocols. We are afraid of the possibility of running into situations that are not addressed by our protocols. At this phase, more rules are better than less.

2) Advanced Beginner

This is the phase when we begin to develop some situational perception. We can recognize that some rules only apply to certain situations and not others. We start factoring in more if-this / then-this types of decisions, but we still follow the prescribed actions religiously.

We also still struggle to prioritize our actions. We know the right things to do, but ordering them appropriately is still something that needs to be emphasized by our rule book.

During our advanced stage we will remain extremely dependant on our protocols and may even wish that they were broader in their scope or more detailed in their descriptions of which treatment options should come first or second.

3) Competent

As we achieve competence, we experience a rush of new skills and abilities.This is when we often feel that we have come into our own with our medicine. In our competent phase we learn to cope with “crowdedness” or what we often call multitasking. We can now remember a list of medications, evaluate lung sounds and keep a watchful eye on the scene at the same time.

We also begin to plan ahead and see several steps into the future, directing our current activities towards future goals. We might set up our intubation equipment at the same time that we prepare a nebulized medication, seeing the two possible futures that lie ahead. Another hallmark of competence is the development of routines. We become particular about how we set up our rigs and our equipment with strong preferences about what goes where.

In our competent phase we begin to first see the inherent weaknesses of our protocol system. We may seek to operate outside of the rule book in some situations. (Hopefully with guidance.) When we are competent, we feel safe within the protocols but we also begin to feel confined, perhaps wanting for more treatments, more options and more protocols to regulate their use.

4) Proficient

As we transition from our competent phase to our expert phase we need to go through a prolonged period of proficiency. As proficient caregivers we are able to sense a holistic view of the situation. Our brains conceptualize how all the parts have come together to create the scene before us. We master prioritization of actions and we see when and how deviation from the prescribed course is desired.

It’s important to note that we don’t desire to deviate from the rules because of a sense of rebellion or a desire to break the rules. We want to deviate because we can see that there is another, better path for the patient. We recognize that placing this particular patient on a c-spine board is simply the wrong course of action. We know that nitroglycerin isn’t going to help this particular patient; in fact, it may hurt them. We know that the book says it’s time to give Lasix, but that course of action is useless. (Not contraindicated…that’s a rule. Useless as a concept.)

As proficient caregivers, we often process much of our decision making on an unconscious level so we may not be able to describe why we wanted to do what we wanted to do. We may fall back on axioms like “Skin doesn’t lie” or “When the Glasgow is less than eight, intubate.” to explain what was actually a very complex mental assessment.

This is the phase when we truly want less protocol driven treatment. We want to take the tools we are given and use them as we see fit. When the patient fits the protocol, we treat them by protocol, not because of the protocol, but because the protocol is correct. At this phase, protocols can only serve to confine us and we see less and less importance in their existence.

5) Expert

When we become experts we transcend the rules and the guidelines and the axioms and we act out of our intuitive understanding of the situation. Very few of us will ever fully move from competence, through proficiency to expert. When we do, our protocols are no longer necessary. Not only do we treat from our tacit understanding of the patient’s condition, we have learned the mechanisms to safely provide the treatments required within our scope of practice.

When we achieve the expert level of skill we can see what’s possible and analyze new treatments and approaches, applying all that we know to unknown situations and developing the best course of action. When we are experts we can write the next protocol. We create the rules for others to follow. We see the importance of our protocols from a different light. We see why they are necessary for the next provider that comes along.

And now you see too.

Next time, I’ll tell you why all this can be such a problem for EMS educators and EMS bloggers in particular. But first, I’d like to know what you think about all that. Where are you on the skill continuum? Does the Dreyfus model apply to EMS? Leave a comment and let us know.

Read More Stuff:

Too Much Information

Where Do You Put The Fear?

6 Reasons Why You Should Be A Better EMT

The Ultimate EMS Protocol

What Makes a Good EMT?


  1. “Not contraindicated…that’s a rule. Useless as a concept.”

    That’s not completely true, and the entire concept of deviating from protocol is a perfect example. Yes, -absolute- contraindications are simple “Don’t do this if ____ condition exists.” On the other hand -relative- contraindications are more of a “Be very, very careful, have a backup plan, and think twice before proceeding. The patient’s condition may become worse or may become better depending on the situation.”

  2. Steve Whitehead says:

    @ Joe P, I agree that Lasix is not completely useless. I happen to still like Lasix. I’ll leave the Lasix argument up to Rogue Medic. He does that stuff better than I do. My point with my parenthetical statement was to illustrate why we might choose not to administer a drug at different phases in our skill development.

    In our novice to competent phases we tend to decide not to administer a drug because there is a contraindication. (Perhaps relative…perhaps absolute, but a contraindication none-the-less) In other words, there is rule telling us to not give this drug or not do this intervention. Something in black and white to fall back on.

    By contrast, our proficient or expert caregiver may decide not to give a drug even though it is indicated. Not because of a contraindication, but because they don’t think it is going to be helpful in this particular patient, in this particular circumstance. Lasix is a good example because there are varying views on its effectiveness and there are some circumstances where the protocol may say it’s indicated and, in reality, it may not be very helpful. In some cases it may be indicated and it may also be harmful.

    That was the distinction that I was trying to make. Thanks for your input and your comment.

  3. Major bump, but still being a fresh EMT and currently in Medic school, I find myself in a conflict, thinking I’m going to be better than what I am, when in fact, I just need to admit I’m a novice on the road, and be comfortable and confident in being a novice. That’s where learning happens right?


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