There are many challenges associated with training the next generation of EMS providers. One enduring issue is the limited instructional time they can spend with students. Due to time constraints, students are frequently forced to learn at a pace that makes it difficult to fully understand concepts before progressing to the next lesson. This accelerated pace may force students into “academic survival mode.”

Academic survival mode occurs when students primarily focus on “surviving” from one examination to the next. They seldom allow themselves the luxury of celebrating passing an examination, but rather concentrate on what else needs to be memorized and regurgitated.

Students frequently memorize only the key facts needed to pass an examination, then mentally discard those facts to make room for new information. The unfortunate consequence of academic survival mode is that it requires more time, rather than less, to attain comprehension of foundational concepts.1 The Paramedic Academy at St. Anthony Hospital in Lakewood, Colo., recently adopted an instructional scaffolding model. As a result the program literally doubled its instructional content without increasing class hours, while minimizing academic survival mode.

Instructional Scaffolding

Instructional scaffolding was first introduced in the 1950s and expanded upon by Soviet psychologist Lev Vygotsky in 1978.2 This model emphasizes teaching new concepts that would be difficult for students to learn on their own.

According to Vygotsky, instructional scaffolding revolves around the zone of proximal development (ZPD). He suggested the ZPD should focus on learning activities that provide adequate challenges to the learner but aren’t so difficult as to be unobtainable. Students are directed and monitored through learning activities that function as instructional “ladders” that get them to the next level in their educational journey.

The ZPD is a dynamic region just beyond the student’s present understanding and ability level. As the student gains new understanding and skills, their ZPD moves with their development. Vygotsky believed any subject could be taught efficiently by implementing scaffolds into the zone of proximal development.3

There are essentially three components of instructional scaffolding.4 The first is that learning should take place in the student’s ZPD. The instructor needs to be aware of the student’s current level of learning and work to a certain extent beyond that level. The second component is the level of support as the student moves through the scaffold. Support and guidance provided by the instructor is gradually removed as the student becomes more competent and proficient. The third component is interaction between the student and instructor. Interaction should be as collaborative as possible, even during periods that require a more directive approach.

Common Thread

A common thread is a generalized concept that touches the majority of everything intended to be educationally achieved. Although a common thread is not necessary for scaffolding to work, it does facilitate a more continuous flow of learning as the student progresses through the scaffold.

Initially, I believed the common thread for paramedic education was pharmacology, and therefore this subject was the basis on which the instructional scaffold was founded. However, after implementation of the scaffold, an additional common thread was identified that affected even more aspects of paramedic education: human physiology. Physiology touches every aspect of what a paramedic needs to learn.

In retrospect, emphasizing human physiology would have streamlined and strengthened the curriculum-development process. On a positive note, this realization has opened the door to explore how instructional scaffolding can be used to teach EMT primary and continuing medical education. Due to the complexity of the existing scaffold, shifting the emphasis to human physiology has been an ongoing process.

Minimizing Academic Survival Mode

One of the primary reasons for integrating an instructional scaffold was to help minimize the propensity of students to live in academic survival mode. This is accomplished in part by providing significantly more opportunities for students to be exposed to critical concepts before they have to undergo high-stakes testing.

To do this, the amount of time covering physiology with integrated pharmacologic concepts was expanded over a longer period. This portion of the curriculum is now taught over 14 weeks rather than 2½. In the context of the scaffold, high-stakes testing does not occur until after the 13th week of a 23-week course. This allows students more time to gain the knowledge and skills necessary to pass summative examinations. This is called the transition of educational ownership.

Instructional Scaffolding

The instructional scaffold model in the program is built around four modules:

  • Beginning pharmacology (conventional);
  • Pharmacologic physiology (scaffolded);
  • Pharmacologic introduction (scaffolded);
  • Threaded pharmacology (conventional).

Beginning pharmacology is a conventional module that covers basic pharmacologic principles. Pharmacologic physiology is a scaffolded module that introduces students to cellular physiology and how medications influence that physiology. Pharmacologic introduction is the second scaffolded module and integrates information specific to individual medications. Threaded pharmacology is a conventional module and revolves around patient care in the form of case studies. For the sake of illustration, this section will only address the scaffolded modules of pharmacologic physiology and pharmacologic Introduction.

Scaffolded modules deliver information over eight educational lessons. Each lesson follows this sequential format:

  1. Presentation covering the lesson concepts;
  2. First-pass review session;
  3. Second-pass review session;
  4. Lesson quiz;
  5. Third-pass review session;
  6. Lesson-related student teams with academic divisions (STADs) activity;
  7. Summative practicum examination.

Each educational event within the eight lessons is spaced by at least one day. This allows students time to review concepts and learn the information.

Pass Reviews

Students progress through first-, second-, and third-pass review sessions within each of the eight scaffolded lessons. Each pass review provides multiple opportunities for students to be re-exposed to information initially presented in the lesson concepts. The instructor follows specific protocols for each successive review. Every pass review is intended to gradually shift the educational accountability away from the instructor and onto the student. With each pass review, students are encouraged to use their internal recollection of concepts rather than available resources.


Student teams with academic divisions (STADs) are group activities where people within the team are individually accountable for contributing to the overall outcome of the event. Based upon current research, list-based learning is one of the least efficient methods for learning new concepts.5 STADs are designed to move students away from list-based learning and more toward associative-based learning. Associative-based learning is more efficient because it is founded upon associating concepts rather than memorizing a list.

STADs start by dividing students into working teams. Within the teams each student is responsible for completing a small portion of a group STAD. The team later comes together to complete the entire STAD activity as a group. Each student is given a separate low-stakes grade for their individual contribution as well as a grade for the group activity.

Practicum Examinations

Practicum examinations are low-stakes events designed to use an associative-based assessment platform. These examinations revolve around Velcro placards and critical concept tabs. Examinations commence with a collection of critical concept tabs, with the goal to correctly place these tabs on the appropriate location within each of the practicum placards.

Formative Evaluation

Working through the scaffold does not signify that students are not evaluated. On the contrary, students are formatively evaluated more extensively through various modalities. For each of the eight lessons, students receive weighted grades in the following categories: quiz 20%, individual STAD 30%, group STAD 15%, and practicum examination 35%.

If students fail to receive an aggregate grade of 80% for a given lesson, they are required to write a research paper on the specific information associated with that lesson. This helps reinforce information gaps.

Educational Ownership

The transition of educational ownership occurs during the threaded pharmacology module. Students work through a series of eight lessons spanning 41 case studies that illustrate commonly encountered medical conditions. Instructional delivery deliberately moves from a directive to a more collaborative format.

The scaffold by this time has prepared students to make the transition of educational ownership. Starting around the 13th week, students are administered a series of eight high-stakes exams for each of the threaded pharmacology lessons. At the time of this article, more than 150 students have been administered the examinations without any loss of students due to academic attrition.

Observable Results

The instructional scaffold illustrated within this article exhibits results. Here are some observations from its use:

  • Students can learn significantly more information in the same time frame compared to traditional curriculum models;
  • Students understand physiology at a greater depth;
  • Despite the increased amount of information, students retain the information more effectively;
  • The scaffold has been successfully replicated at a satellite campus with a different primary Instructor.

Students have consistently shared these personal observations:

  • The scaffold creates an environment that supports ease of learning;
  • Students initially do not believe they can learn all the associated information within the scaffold but are pleased at how well the scaffold facilitates their learning;
  • Students feel confident they have a stronger understanding of physiology and pharmacology after going through the scaffold.

All these observations are subjective and warrant further objective analysis. Unfortunately, research has been difficult to model due to few studies being associated with EMS or allied health education programs. Wrote one expert, “The limited amount of research has demonstrated instructional scaffolding has great potential as a method for facilitating learning.”6

Due to the scarcity of EMS research, we should welcome any opportunity to discuss how research on instructional scaffolding can be structured to comparatively analyze cognitive/psychomotor outcomes. Discussions on how instructional scaffolding can be integrated into other EMS educational programs are also welcomed.


1. Schwabe L, Wolf OT. Learning under stress impairs memory formation. Neurobiol Learn Mem, 2010 Feb; 93(2): 183–8.

2. Azih N, Nwosu B. Effects of instructional scaffolding on the achievement of male and female students in financial accounting in secondary schools in Abakaliki Urban of Ebonyi State, Nigeria. Curr Research J Social Sciences, 2011; 3(2): 66–70.

3. Yelland N, Masters J. Rethinking scaffolding in the information age. Computers and Education, 2007; 48: 362–82.

4. Lajoie SP. Extending the scaffolding metaphor. Instructional Science, 2005; 33(5–6): 541–57.

5. Committee on Developments in the Science of Learning. How People Learn: Brain, Mind, Experience, and School. Washington, D.C.: National Academy Press, 2000.

6. Dennen VP. “Cognitive Apprenticeship in Educational Practice: Research on Scaffolding, Modeling, Mentoring, and Coaching as Instructional Strategies.” In: Jonassen DH (ed.), Handbook of Research on Educational Communication and Technology. Mahwah, N.J.: Lawrence Erlbaum Associates Publishers, 2004.