Once you understand the protocol / skill connection you might come to see a host of problems with the way we develop, use and teach our protocols. I’d like to tell you about two biggies.
As we explained in the protocol / skill connection, we are dependent on our protocols to different degrees at different levels of skill development. This is defined by the Dreyfus model of skill acquisition. Misunderstanding this concept leads to some predictable problems.
The problem with our protocols is that they were written with the expectation that everyone would use them the same way.
The problem with our field education is that proficient and expert field providers teach novice and advanced beginner students. These two groups think differently about their protocols.
Let’s look at both of these problems a little more closely.
1.) The problem with our protocols.
Your protocols were developed by a group of physicians who were trying to give direction to a competent EMT or Paramedic provider. Remember the competent caregiver? She’s the one who feels safe operating inside of her protocols and still depends primarily on rules, guidelines and routines.
This Goldilocks approach to protocols is neither too hot nor too cold but it leaves a large segment of caregivers wanting something more. Our novices want more detail. Our advanced beginners want more structure to the prioritized treatment lists. Our proficient caregivers want to be able to operate outside of the protocol with less formality and scrutiny and our experts want to work without the protocol book at all.
This can also create problems if your quality assurance manager has an idea that everyone should adhere to the protocols as if they were an advanced beginner. If the care provider is an advanced beginner, that level of compliance may be entirely appropriate. If the caregiver is proficient, there are going to be some problems.
With both of these situations, the clear answer is to build protocols with detailed direction meant to guide the caregiver through an example of what ideal care might look like with an emphasis on flexibility. Protocols should guide appropriate care; they should not dictate appropriate care.
The necessity of that guidance will change as a caregiver’s skill and knowledge advance. When we are reviewing field care, we should always focus on the appropriateness of the care given, not the strict adherence to protocol directed treatment. If our field personnel are giving appropriate care that falls outside of the protocol, the problem is with the protocol, not with our providers.
2) The problem with our field education.
In the documentary movie Hearts of Darkness, Francis Ford Coppola describes his frustration with actor Dennis Hopper’s improvisation from the script. Hopper would want to enter the scene and just begin filming and see how the scene flowed from there. For a brilliant (Read expert) actor like Hopper, this type of improvisation was appropriate.
There was just one problem. Hopper hadn’t read the script. Coppola and him would have yelling matches with each other where Coppola would lament, “You can’t improvise from the script if you don’t know the script!” Well said Francis.
As new providers enter the field we need to account for the fact that they will be highly dependent on their protocols. They need to learn the script. A certain level of protocol dependence needs to be OK…in fact, in needs to be emphasized.
The problem we can run into here is when we take on a new trainee and we have an expectation that they will act as a proficient provider immediately. The new provider needs to know the rule book before they can deviate from the rule book. As field instructors, we can’t rush into demanding improvisation from the script until we have emphasized the need to learn the script.
We need to teach the script. And we need to recognize that it can be hard to teach someone a script that we haven’t been using for years. It’s easier to just say, “Do it the way I do it.” But that is a recipe for disaster.
If we are the new trainee we can also get ourselves in trouble by wanting to eschew the formality of protocols when we haven’t yet developed the skills to do so. This isn’t a field known for attracting people who are willing to take the long slow approach. That just isn’t in our DNA. But skill development in something as dynamic as EMS is a long slow process. It flies in the face of our impatience.
When we put our protocols in the context of the Dreyfus skill acquisition model our view changes dramatically. We change our perspective and recognize that protocols are not a one-size-fits-all endeavor. We change the way we see this essential element of EMS care. Hopefully this model will eventually change the way we write protocols, the way we perform quality assurance, the way we educate our EMS novices and the way we use the protocol book during patient care.
All of these changes can start with you.
What do you think? Are these the two most significant challenges to our protocol use? What are the others? Does the Dreyfus model change the way you see your protocols? Leave us a comment and join the discussion.
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