State the affirmative

You have just entered a training scenario with your students, and the stakes are high. You are hoping that your months of work leading up to this moment will ensure that the student walks away with value after completion. You have created a great scenario, demanding training that ensures the provider is challenged but not defeated. You are hoping that the time that you spent preparing allows the student opportunities to make healthy mistakes in a controlled environment and that they can then take those lessons and apply them in real life to produce real-worldd, positive impact.

The student enters the scenario and begins to ask questions working to identify the problem they need to solve. However, the student is smart, and the first question they ask is, “what is the problem?” Your answer will determine the learning opportunities and outcome of your scenario training. Do you tell them? Do you simply say, “I can’t answer that question”? Do you ignore them? How do you navigate this benevolent question asked to speed the scenario along?

This situation occurs more often in our training more than we care to admit. In emergency medical services, it proliferates the ranks of educators and instructors, and unfortunately, the way we have addressed it in the past has created a crutch for the student, prevented some great lessons from being learned, and hindered that providers ability to perform independently. In EMS it usually goes like this:

STUDENT: “BSI! SCENE SAFE! DO I SEE ANY MAJOR HEMMORAGE!?”

INSTRUCTOR: “You see massive hemorrhage from the left lower extremity.”

It is easy to rationalize that the instructor's response in the scenario was appropriate. The student asked an assessment question, and the instructor responded with only an assessment finding and nothing more. However, what is often overlooked is that the response to the question leads the student to the problem. The instructor has found the wound and is Inadvertently taking away the opportunity to allow the student to perform a thorough and complete rapid trauma assessment in which they would find the wound. Failing to ensure that they are building the physical and mental skills necessary to accomplish a high-quality trauma assessment in the field.

So, what is the issue, and how do we mitigate it in our training? The issue is “feedback.” Think about any time you do something, you apply an action, and you wait to see the reaction. You then analyze and synthesize the reaction to determine your next action. In an EMS environment, this is when you see bleeding, so you apply pressure. You then look to see if the bleeding has stopped. If it has, you know that you can move on; if not, then you apply more pressure until it does. Your decision was based on the feedback from the patient’s wound after your intervention.

If you are a leader, this may look different, but the theory is the same. Say you have an issue with an employee, so you meet with them and ask for their side of the story. After gathering all the useful information, you decide you do not want to counsel (discipline) them and instead want to coach their improvement. At which time, you give them some goals and send them on their way, hoping they improve. You then watch them to see if they improve or if the problem persists. If the situation gets better, you can move on, if it persists, you must intervene again and, most likely, get progressively more disciplinary with your actions. The feedback here is the behavior of the individual after your intervention.

The theory can be identified and applied to any environment or training. The instructor must simply identify what feedback the student is looking for to make their decision. The instructor/educator must then ask themselves, “How does the student get this information in a real-life situation?” The instructor’s goal then becomes to create a scenario that requires the student to get that information in a way that is as realistic as possible.

In our training, we are mitigating this issue by having the student always gather the information themselves and then do what we call “state the affirmative.” That is, they are to state what is real, what they found in their real assessment. An example of this would be If they are assessing a manikin with 0 moulage they must perform a complete head-to-toe assessment, looking, listening, and feeling as they go along before they are told of any illness/injury. As they move through their assessment, they state to the instructor what they are finding. In the case of the manikin with no moulage this means when they look at the head, they would say, “I see no bleeding, and there are no obvious signs of trauma to the head,” and they would proceed with their assessment.

The student would continue this process as they complete their entire assessment, simply stating what they are finding. In our EMS scenario from above with the left lower extremity hemorrhage, the student would get to the left lower extremity and state, “I see no major hemorrhage, no DCAP-BTLS present.” Obviously, this would not align with the scenario and would not work, right? This is where the instructor finally gets involved to ensure the case progresses correctly by saying, “negative operator, you find massive hemorrhage from the left lower extremity.” The student can then begin treating the wound as THEY found it.

Feedback is an interesting thing, and I think that we could spend quite some time learning and discussing its many nuances. Feedback affects us every day in everything we do. Our annual evaluations from our superiors on our performance are sources of feedback on the work we’ve done. Feedback that we use to course-correct our behaviors or stomp on the throttle. towards achievement. When we type our emails to our coworkers, we read the screen and ensure the feedback matches the intended message. If not, we adjust. When we drive our vehicles, we look down at the speedometer, looking for feedback that says we are going the speed we want to be, and so on.

This theory can be applied in so many ways as well. When it comes to us as EMS clinicians, when we drop a patient off at the hospital and fail to follow up with definitive care to identify what the patient’s outcome was, we miss the feedback needed to validate or disprove our thought processes and treatment algorithms. We often walk away thinking that we did everything we thought we needed to do, but, in fact, we may have missed some things or, worse caused harm. In this scenario, we are taking the lack of negative feedback and inferring that we did good, positive work. Unfortunately, the absence of negative feedback does not equal positive feedback and failing to understand this may mean that we are doubling down on skillsets, habits, or behaviors that are not helping us, our students, or anyone. These are just some small, simple examples of how feedback is at play. Hopefully, it will help you better understand what feedback is present in your lives as you begin to identify what feedback your students are using to make decisions. The question then becomes, “How do we use that information to create better training?” Well, surprisingly, as you work through those issues, many of the solutions will become evident to you in your various disciplines. Remember, the goal is to create as realistic of a training environment as possible and having your students do as close to what they would be doing in real life as possible. This ensures that they are building the knowledge, skills, and abilities necessary to complete the mission.

Once you have identified the feedback the student needs, it is often clear how they obtain it. For example, in a trauma injury, the student would have to look, listen, and feel the patient to find the injury and then begin applying their medical knowledge and experience to mitigate the issue. So your scenario would then be built to require them to look, listen and feel. Other examples include the “buffeting” a pilot might feel before a stall. In this case, the pilot has a physical sensation, as well as a decrease in performance from the aircraft that precedes the stall and creates a predictable moment of occurrence that can be mitigated through the proper application of knowledge and skill.

Another example would be the color of smoke a firefighter sees, and the behavior of that smoke that would suggest what the fire is about to do. In this case, the firefighter would need a training environment that simulates that color and behavior, if you can make a real fire and instead need to create an oral scenario when the student says, “what is the fire doing? Or “Is it about to flash?” do tell them instead ask them what they specifically want to know and look for questions that would show they understand what they are looking for and applying their skillset such as “what does the smoke look like, how is it behaving?” etc. For meteorologists, it is the current state of the weather that they measure and then use those measurements to predict outcomes. Ideally, you want to give them those devices and have them use them to gather the data they will then use to make their predictions.

All this to say, if you cannot make the scenario real, make the process real! Do not allow students to use the virtual, oral, or scenario-style training environment as a crutch to lead the instructor into giving the answer to the problem. By doing this, you will prevent training scars that will cause problems in the field. You will mitigate issues and improve the quality of the education you are delivering, and you can become much more proficient in what you do daily. You will find that the simple awareness of feedback will have you analyzing what it is that you are doing and why you are doing it. As you gather that information, you will find ways that will speed up your efficiency and effectiveness in all you do and, in turn, give you more lessons to teach others to make them better as well!

In closing, I challenge you to get out of your comfort zone and give this theory a try. I honestly believe that you will find so much value in it. Especially if you work in fast-paced, dynamic environments where decisions are based so largely on the feedback that you gather in the moment. Also, something else I hope you can take away from this is that “The enemy of performance is variation”. As educators and instructors, it is our duty to create demanding training for our staff that challenges them to be better and do better. We must take these lessons and work to create reproducible habits that ensure high-quality outcomes in all areas. Unfortunately, we do not always have the time or funding for high-quality training so remember this: Every stable patient, normal incident, and minor problem we deal with on a regular basis is practice/training for our unstable patients, major incidents, and severe problems. If we are lackadaisical in our management of minor issues, we will not perform where we want to perform when things hit the fan.

Real life is training too, making sure we are learning the right lessons from life.