The importance of report writing in paramedic practice in the United States (US) is well-known (Munger, 2000; Ho et al, 2017; Konya, 2017). Providers write reports daily to document medical decision-making and support the continuum of patient care, making writing a vital paramedic skill (AlShammari et al, 2018). Despite its importance in the emergency medical services (EMS) workplace, limited research into EMS writing practices, processes, and pedagogy exist. Current pieces about report writing focus on the end product, the patient care report (PCR), which details expectations associated with well-written reports: they are correct, concise, clear, complete, concrete, courteous, effective, and professional (Cebollero, 2013; Eaton, 2014). Teaching practices that support providers' report writing processes and disciplinary learning are less well understood. This piece uses the framework of threshold concepts to help EMS educators understand how writing can help develop providers' practice. It ends with suggestions for integrating writing opportunities into paramedic training.
Review of relevant literature
The present study is grounded in the fields of writing studies and technical communication, two related fields where researchers study writers' practices and processes, and academic and workplace writing pedagogy. Technical communication researchers study the healthcare workplace, and research sites range from the neonatal intensive care unit (Bivens, 2018), organ donation (Harrison et al, 2008), simulation labs (Campbell, 2017), and medical translation (Bloom-Pojar, 2018). With a broad base of research into the writing process and pedagogy, these fields provide insights into writing that are unexplored in an EMS context (Munger, 2000; Angeli, 2015; 2019; Campbell and Angeli, 2019).
Seen from a writing perspective, some EMS training programmes follow ‘the inoculation method’ of writing instruction (Paine, 1999; Rutz and Lauer-Glebov, 2005; Condon and Rutz, 2012). In this method, students are introduced to writing in a ‘one-dose’ intervention, either in a few hours of training or college-level English courses. These methods often expect writers to be ‘vaccinated against’ writing challenges, like grammar errors, and to be prepared for all writing situations. In turn, these methods tend to reduce writing to a product to be learned (such as the PCR or a research paper) or introduce writers only to general writing principles, including analysis, research-driven arguments, and paragraph organisation. However, both of these approaches hold merit; students must understand the principles and process of writing to compose an effective product.
The inoculation method shortchanges the rich, complex EMS writing process that providers engage in to compose effective reports (Angeli, 2015; 2019; Campbell and Angeli, 2019). To write well, providers must develop foundational, disciplinary writing skills, such as reflection and genre awareness, to create effective workplace documents (Dayton and Bernhardt, 2004; Rainey et al, 2005; Henschel and Meloncon, 2014). In EMS, these skills also include audience awareness, scene dynamics and situational awareness, and collaboration. Disciplinary writing skills take years to develop, even when writers are immersed in the discipline, and the more writing opportunities students have, the more they are able to develop these foundational skills (for a review of longitudital writing research in this area, see Rogers, 2009).
Recently, scholars have used ‘threshold concepts’ to better understand how writers develop and demonstrate these skills (Pope-Ruark, 2011; Mercer-Mapstone and Kuchel, 2017). Rooted in educational theory (Meyer and Land, 2003), threshold concepts refer to ideas, knowledge, and skills writers gain that transform their thinking, process, and practice. Once writers pass through a ‘threshold,’ their writing changes, and writers often cannot go back to understanding writing as they did before (Adler-Kassner and Wardle, 2015).
Threshold concepts are particularly useful for this study because they focus on what writing can do and what it involves instead of only what writing is (Adler-Kassner and Wardle, 2015). For example, an effective, accurate report (what writing is) can support the patient's continuum of care (what writing can do) if a provider uses their situational awareness, critical thinking, and memory to present effective evidence of decision-making during a response (what writing involves). Although this study's data suggest that participants address numerous, interrelated threshold concepts, this article discusses the following concepts that highlight what writing can do and involves: ‘writing is a knowledge-making activity’ (Estrem, 2015), ‘writing addresses, invokes, and/or creates audiences’ (Lunsford, 2015), ‘writing is a way of enacting disciplinarity’ (Lerner, 2015), and ‘reflection is critical for writers' development’ (Taczak, 2015).
Methods
Study population
This study's research site is the Milwaukee Fire Department's (MFD) 3-year training programme located in the Midwest region of the US, which trains recent high school graduates to earn their paramedic and firefighter licenses. Although a fire service, the MFD's primary role is to provide emergency medical care to citizens (2017 annual report (Milwaukee Fire Department, 2018). Like other US agencies, MFD providers are required to write a PCR for patient interactions, but, despite this prominence of report writing, the academy, like many US programmes, lacks an evidence-based mechanism to teach PCR writing. This research project was designed to address that gap by first understanding the writing that students complete, how they complete it, and what they learn from it. Second, this study will test a 3-year writing curriculum intervention to see what impact the curriculum has on students' report writing skills. This article reports on the first part of the study, focusing on how writing supports students' disciplinary learning.
Research methods and data analysis
This article reports on a portion of findings from the 6-year longitudinal study with the MFD. In the first 2 years, classroom observations were conducted, and survey responses from 18 students were collected. Six students of those 18 who were this study's focal participants. Focal participants completed one 40-minute one-on-one interview and two 30-minute focus groups where they discussed their writing process. All writing completed by the focal participants was collected, which included their class notes, clinical notes, and practice reports. Additionally, participants were observed during paramedic field training, where they worked under MFD paramedics and practiced their report writing skills, totalling 48 hours of field observations.
In addition to the practice reports participants completed for class, focal participants kept a separate paper notebook, the ‘study-assigned notebook,’ that was designed to support and facilitate their writing process. In this notebook, participants documented patient interactions using a newly developed model of report writing, which is currently being tested for another research study. The notebook also included a space for reflection so that participants could develop disciplinary meta-awareness, also known as thinking about their own thinking (Bizzell, 1982; Taczak, 2015; Tinberg, 2015). Four focal participants also kept their own notebooks during field training, which were collected and analysed.
Data were triangulated by collecting survey responses, transcripts from one-on-one interviews and focus groups, participants' classroom and field writing, and field notes from classroom and field training observations. Given the various types of data, analysis included textual analysis and grounded theory, which rely on inductively identifying patterns across data and are similar to Howlett's qualitative methods for analysing paramedic students' reflection practices (Howlett, 2019). Textual analysis, a method common to writing studies, allows researchers to note patterns, such as word choice, sentence structures, and content (Nowacek, 2011; Yancey et al, 2014). This method was used to analyse participants' notebooks and practice PCRs. Analysis of observational field notes, interview transcripts, and survey responses involved grounded theory, a common method in qualitative research in which researchers build a theory from repeated themes across data (Corbin and Strauss, 2008; Farkas and Haas, 2012). These repeated themes echoed the threshold concepts outlined above, and as such, these concepts informed the second round of data analysis and the findings in this article.
Findings
Participants' personal field notebooks, the study-assigned notebooks, interviews, and focus groups provided participants with an opportunity to develop their understanding of how report writing is done and what writing can do. At their core, the findings suggest that participants learn at least two overarching threshold concepts when writing during paramedic training: ‘writing is a way of enacting disciplinarity’ (Lerner, 2015) and ‘writing is a knowledge-making activity’ (Estrem, 2015). In other words, students demonstrated that they were acquiring and making sense of EMS-specific knowledge. Specifically, participants enacted EMS disciplinary skills and created knowledge when they reflected on their writing choices, identified specific audiences who would read their reports, and met certain genre expectations, like showing their decision-making.
Writing allowed participants to reflect on disciplinary knowledge. Written reflection allowed students to integrate knowledge (Nowacek, 2011; Estrem, 2015; Taczak, 2015), and participants demonstrated this concept in their study-assigned notebooks and in focus group discussions. For example, in the study-assigned notebook, a participant, Joel, reflected on appropriate tone in report writing. Joel wrote that a patient's ‘parent/mom seems to have no care in the world as to what is going on,’ and in his reflection, he wondered if his report was ‘too subjective.’ This reflection indicates the participant's meta-awareness of appropriate tone in report writing; he knows reports should not be subjective, and by asking that question, he acknowledges his report might not use an appropriate tone.
Another participant, Helen, wrote about her report's organisation, commenting that her report writing felt ‘unorganised’ and that she was ‘missing details.’ When asked about this comment during field observations, Helen was unable to expand, but knew that something felt ‘off.’ This inability to articulate developing knowledge is common when novices enter a discipline, suggesting they are meeting a new threshold of learning (Beaufort, 2004; Kellogg, 2008). This comment suggests, by contrast, Helen knew writing had to meet certain disciplinary expectations, like following a structure and including certain details. As participants continued to write in field training and met in focus groups, they demonstrated that their writing practice supported their disciplinary knowledge.
Participants wrote to specific audiences. Effective writing addresses specific audiences (Lunsford, 2015), and in EMS, audiences include healthcare providers who use reports to continue patient care. Participants' writing and reflection allowed them to illustrate this skill. James made notes in his study-assigned notebook that explained medical terminology, for example, ‘Albuterol causes muscle relaxation and bronchodilation.’ When asked about it in focus groups, James stated that he wanted to make sure that the information was understood by a reader. In making this choice, this participant demonstrated two threshold concepts. First, he understood that writing is for an audience, someone who will read and act on the written text (Lunsford, 2015; Roozen et al, 2015), and second, he integrated his own developing medical knowledge about albuterol with this audience awareness (Lerner, 2015).
In focus groups, participants reflected on their writing, sharing how their audience awareness was emerging. Joel discussed the response where he thought the mother showed ‘lack of caring.’ He added direct quotes in his report from the 15-year-old patient, writing ‘we skipped school to drink tequila and smoke’. In the focus groups, Joel shared that he added this detail ‘in case social services or police could get involved’ with the family situation, thus demonstrating his awareness that his report might impact his patient's continuum of care.
Participants followed report genre expectations. Genres refer to a structure that a text follows so that an audience's expectations are met, and when writers meet these expectations, genres facilitate action (Schryer, 1993; Opel and Hart-Davidson, 2019). In EMS writing, genre expectations include writing a narrative in a chronological format, demonstrating decision-making, and describing scene dynamics, pertinent negatives, and care provided. In turn, a well-written report allows healthcare providers to continue effective patient care.
Participants' writing demonstrated their developing genre awareness by writing in a chronological order and recording decision-making. Their writing followed a chronological order of the response, starting with dispatch information (‘Responded to 36 y/o F complaining of syncope episode’), scene arrival and patient disposition (‘Pt was found laying [sic] by the wall in her bedroom’), care provided (‘Vitals were normal,’ ‘Did a stroke test, negative’), and ending with transport details (‘Transferred to BLS care’). This order showed traces of decision-making, the step-by-step process a crew made about patient care. In the example above, the participant, James, documented that vitals were normal, the crew performed a stroke test with negative results, and they transferred care to a lower level of care, which is protocol for his department.
Another participant's writing showcased her emerging decision-making capacity by using cause- and-effect relationships. When responding to a 48-year-old female patient who had an allergic reaction, Erica documented her assessment and explained decisions: ‘Because of the swollen tongue, we gave 25 mg of Benadryl via a 22g in the left AC.’ By using the subordinating conjunction ‘because,’ this participant demonstrated a relationship in reasoning, specifically her disciplinary knowledge of pharmacology and medical guidelines. Her writing illustrated that her observations, ‘a swollen tongue,’ prompted action, ‘gave 25 mg of Benadryl…’ In doing so, the decision-making was visible to readers who may need evidence that Benadryl administration was appropriate and effective.
Implications for paramedic training
These findings suggest that writing is a powerful learning tool, in which paramedic students practice foundational skills of paramedic practice, including disciplinary knowledge, reflection, and decision-making. As such, writing should be purposefully integrated into and throughout paramedic training, and students should be given ample opportunity to write and receive feedback.
To support writing development, instructors can scaffold multiple, low stakes writing opportunities throughout a curriculum (Puntambekar and Hubscher, 2005; Mitchell et al, 2017). Low stakes writing assignments are typically not assigned for a grade, and instead, instructors read them to offer formative feedback. These assignments encourage learning and risk-taking without the consequences of a low grade. Examples of low stakes writing assignments include posting to online discussion boards, completing in-class writing, submitting reflections (Epp, 2008; Montagna et al, 2010; Goldberg et al, 2015; Howlett, 2019), creating discussion questions that synthesise readings, or keeping field notebooks where students track their questions and progress.
Instead of a grade, low stakes writing opportunities utilise formative feedback from instructors and peers (Mackiewicz and Thompson, 2014). This feedback focuses on a writer's general strengths, patterns, and areas of improvement, like use of evidence, organisation, and tone. As an example, this could be something like: ‘You're writing a lot about patient's vitals and interventions the team provides. Good work on noticing those details and recording that information. Your writing doesn't mention scene dynamics, though. As you continue training, pay closer attention to them. What are you observing that might influence vitals or the team's determine treatment decisions?’. This kind of feedback, especially when offered regularly, supports students' disciplinary learning and reflection.
This study focused on one paramedic training programme in the US. To address this limitation, future research directions include studying how paramedics learn threshold concepts in other programmes, like 2-year colleges where students might have more exposure to explicit, purposeful writing instruction. Future directions might also explore how paramedic students learn other threshold concepts during paramedic training.
Conclusions
Writing in EMS is often taught only as a product–what it is instead of what it can do and how it is done. Using threshold concepts, this study helps frame writing as a learning and teaching tool in paramedic training, focusing on what writing can do. In turn, writing provides an opportunity for paramedic students to learn critical skills, demonstrate their learning, and reflect on their own skills. To harness writing's transformative power, paramedic training programmes can integrate multiple writing opportunities into their curriculum so that providers see writing as an integral part of their healthcare role and the patient's continuum of care.