A few years ago I ran across this video (attached at the end) from Pat MacNamara, a former SOF operator and instructor. In this video he is talking about firearms training and gunfighting, but I am expanding his definitions to include us in the prehospital medicine world. He made the distinction between outcome and performance based training, and it was one of those things that fundamentally changed the way that I look at training. Specifically training as an FTO/preceptor. I began to see the trainees differently and looked at their performance as just that…performance. I looked at how they did things over a span of time and made sure that it was included in the debrief. I have jotted down a few of my thoughts and proclivities as it pertains to training new folks (new hire or new students) with a performance versus an outcome mindset.
So here we go…
A student or trainee comes to a class or enters into an internship/clearing process with a singular outcome in mind – Pass. Which leaves only one other alternative – Fail. This mindset further crowds the mind of the apprentice (I like this word) with beliefs of “I am a…(failure, bad clinician, stupid person)” or an even worse mindset of “I can’t do this.” As if they are not capable of performing the task or rising to the level of competence/performance and they are going to have to settle for doing something less than what they have set out to do.
How does this happen? A person spends a certain amount of years in the profession and pays their dues, only to get their dream job and find out that they cannot do it. They aren’t good enough to be there?
This does not make sense to me. But let’s take it a little deeper.
An experienced clinician, one with several years of experience, has been given the responsibility of training a young prospect and getting them up to a level where they can operate independently as a member of the crew. This FTO/preceptor evaluates the apprentice’s execution of their duties and provides an assessment: pass or fail. The discussions or debriefs leave much to be desired “too slow on this. This was incorrect. Push deeper on the chest.” Etcetera, etcetera. So the apprentice just begins to chase those things “faster, correct, etc” all in an attempt to… pass.
These young folks/new folks spend months and months with the “masters” of the job (usually as defined by that organization), but they often times leave with far less confidence than when they started, or even worse, no more capable/better at the job than when they started. But they…passed.
Outcome Based Training Mindset
Pass, fail, good, bad… these are training outcomes, and this is the realm of the “outcome based training” mindset. This mindset deals in numbers, grades, quantities, and anything else that can be quantitatively measured to score someone’s job performance. These are sometimes binary, and often times, arbitrary standards from which an instructor or preceptor can pass down a judgement of pass or fail. Pass and fail are often used as surrogates for “good enough to be here.” The really ugly thing about outcome based training is that the preceptor does not even have to be that good, they merely need to be literate. They need only to read what the pass/fail criteria are, compare it to how the individual performed, and then make a checkmark in a box (or circle a number). Standard met, but not one extra ounce of capacity for the work was built in the process.
What the outcome based training mindset does not do is actually address or improve performance issues at their root. There is not a provision for getting to the real source of the problem. In my experience, it is rarely an inability to perform basic math or recall a step in the recipe (I mean protocol). Rather, it is usually an inability to perform those things under the duress of an emergency situation. The preceptor has been trained to evaluate that performance, and likely has not been trained how to coach an individual’s performance. The “coaching” is usually some version of this:
“You missed on this element, go read some studies on it, review the protocol, and that should help you.”
This, I believe, is the crux of the problem. We have a confluence of a person who is not trained how to work under duress with a person who is not trained to coach someone’s performance under duress. The holes in the cheese line up perfectly.
Performance Based Mindset
The performance based mindset requires a completely different approach, one where the preceptor knows the standard for performance, but works to coach the individual’s performance over time to meet that standard. It meets the trainee at their current skill level, and to quote Pat, they have permission to work from that current skill level. When a new kid focuses their execution on the outcome, it completely robs them of their ability to execute at a high level. They just want to…pass. They just want to avoid the embarrassment of failure. In so doing they are less likely to be creative, take some risks (appropriate), or make suggestions for solutions that are outside of the box. There are not many opportunities for them to do much else than just “ get it right.” When they are concerned about performance, on the other hand, they can focus on “how well am I performing this task.” It is not about right or wrong, it is about “am I getting better at it?” “Did I do it better than I did it last time?”
The debriefs for them follow a similar format, and the prudent preceptor will evaluate “have they gotten BETTER over the last few weeks.” “ Are they making the same mistakes over and over, or are there new mistakes to train out?” Is it progress or is it stagnation? If they are screwing up trying to do new things or think differently, that should be CELEBRATED and encouraged. The mistake coached for sure, but they should be encouraged to continue to keep trying to GROW beyond the mindset of “just get it right.”
The performance mindset also breaks down a trainee’s propensity to play small. Sometimes you have a new person assigned to you that has some experience (maybe even more than you), and in an attempt to meet the outcome of “get cleared” they minimize their effort and execution to only what is needed to be successful to that end. They play small because they fear that they will be “wrong” just because they do it differently and won’t get a passing grade. This is what I mean by giving someone permission to operate at their skill level. If they are ready to lead, let them. If they are demonstrating the ability to work independently, let them. Coach their performance from there and help them get better.
Close Out
I think we leave a ton of good stuff out on the table when we train people to only meet an outcome. In actuality, your value as a preceptor/FTO is in your ability to make them better at what they do. The secondary outcome is being able to check some arbitrary box that demonstrates “competency.” Be more than a literate individual. Coach them to be the best they can be.
Perhaps a caveat to close this out…
Maybe it depends on the individual’s level whether or not you can focus on outcome or performance. If the individual is newer to the job, then perhaps task execution and “outcome” based training makes some sense… for a little while.
