I recently made a social media post asserting the following: paramedic and EMT completers refuse to attempt the certification exam because they cannot overcome their fear. A discussion started…is this even true?

So, since I know you EMS educators are drowning, I’ve taken it upon myself to dredge the literature looking for nuggets.  Specifically, I’ll be looking for action items we should consider implementing.  Full disclosure: I am aware of my bias and will be looking to destroy it.  Even so, this is part literature review and part essay.  If you just want the good stuff, scroll down to Action Items.

How big is the issue?

I sought articles which might negate or validate my observation that this generation of students have not had enough opportunities to develop resilience, grit, and courage during critical developmental times–all the characteristics needed to overcome fear–especially the fear associated with such a high-stakes exam.

So what does it actually take to overcome fear? According to Psychology Today there are seven skills needed.  I’ve directly quoted them here as I suspect they will contribute to our list of Action Items to help our own students:

1. Learn to trust yourself-trust that you will make good decisions, research and learn what you need and if you make a mistake you can correct it.
2. Take ownership of your life-Taking purposeful action rather than reacting to events.
3. Identify the components of your fear. (Rejection, failure, so on).
4. Neutralize the above components. Know and trust that If one of those things happen you can deal with it or you can find help with it. Don’t suffer it before it has happened.
5. Build your self-esteem. Learn to like yourself. You forgive mistakes by others, why not yourself?
6. Know that you can learn whatever you need to succeed at what you are afraid of-whether they are practical skills or emotional skills, you can master them if necessary.
7. Believe at your very core that this can be done. This is not just for other people. This is for you. You are just as good as the next person.”

As we look at these 7 factors, we can contrast Gen Xers who were forced into a (possibly) premature independence and negotiating challenges alone in the streets (and thus maybe failing to develop the BEST techniques) with younger folks who have been more closely shepherded through childhood–protected and sometimes over-committed to supervised “activities”.   The second group has not had the breadth of decision-making and consequence-experiencing that the first group had.  Gen Z and Gen Alpha have had far more 2-dimensional (electronic) experience and less of the painful challenges to self-definition.

We grow most in times of discomfort. It simply stands to reason then that the more comfortable we are, the less coping skills we attain. The more times we are faced with struggle, the deeper we grow in knowing who we are and how to overcome challenges…like fear.  Additionally, we have less opportunities to develop self-confidence.

I wondered: do today’s youth then start off at a disadvantage?

In reviewing generational mental health, I learned that “Com­par­isons across gen­er­a­tions are tricky because it is dif­fi­cult to tease apart what might be actu­al gen­er­a­tional dif­fer­ences from demo­graph­ic pop­u­la­tion shifts or age-relat­ed fac­tors, such as devel­op­men­tal phas­es and dif­fer­ences in health care access.” That said, the understanding that Gen Zers are experiencing increasing indicators of mental health issue is reviewed here. In summary, it appears that they might struggle more based on trends, but they are also possibly more forthcoming than prior generations.

And while most young peo­ple are phys­i­cal­ly and emo­tion­al­ly healthy, trends in youth sui­cide, men­tal health ER vis­its, depres­sion and anx­i­ety have been on the rise over the past decade or more. This cri­sis has affect­ed younger chil­dren and mil­len­ni­als, too.  —Generation Z and Mental Health

Literature review–mental health as a barrier?

In specific, much attention is given to text anxiety with one article even coining a new term: “examiety” where an informal survey indicates 86% of those students experience test anxiety.  Any educator knows this is not a “new” phenomenon, and whether it is growing or not is a little irrelevant–we’ve all had that one student who would be a great medic if we could just get them past the test anxiety–I need no more validation than that to make it worth being prepared for that student.

However, I found only two studies directly examining correlations which might predict the graduate’s intention to sit for a certification (licensure, boards) exam with any underlying characteristic, belief, or psychology.  The remainder of the papers are included for insights which can assist us in our planning.  Both the introductory literature reviews and the conclusion sections may be worth a visit for you.

INDICATORS AFFECTING THE EXAMINEES IN TAKING THE BOARD EXAMINATION FOR CRIMINOLOGY  (2022, Philipines)– N=? (“graduates” of BS Criminology–99 in

Can we externally influence a candidate’s “Passion”? https://eprajournals.com/IJMR/article/7209/abstract

2024 as estimate), questionnaire not previously validated, student impressions–“passion” refers to OF students (vs that conveyed by faculty).  MAJOR effects: student passion, family support (morale, financial, prep time), teaching methods aiding in efficient learning, mandatory attendance review sessions, mock boards

Student Perceptions of Barriers to Professional Exam Success (2020, USA) N= 104 graduates Medical Laboratory Science, validated survey, primarily interested in improving pass rates.  However, did find some info on the 5 who had not yet attempted the exam which included yet another reference to mock boards: “Most respondents
(71%) also reported that they would like to have had a better idea of what to expect about the testing process” and of those passing 50% thought the most helpful was online exam simulator.  71.4% of the unsuccessful students cited “Knowing what to expect of the testing process” was most helpful in preparing for successive attempt(s).

A subset of survey sent to 104 Med Lab Science graduates.

“Using this information, allied health programs, or any programs whose graduates are required to pass a comprehensive professional exam, may be able to better mentor students on additional resources that are available to them, such as exam simulators and comprehensive review manuals, as well as designing a useful timeline of within three months after graduation to take the exam, and helping them to deal with stress before attempting a professional exam. Faculty can let current students know more of what to expect, which may help decrease their stress levels and test anxiety. Faculty should also advise students to anticipate their potential barriers and have strategies in place to deal with them.”

The Impact of Stress and Resilience on Students Appearing for Competitive Exams for Their Under Graduation in India (2024, India) N=300 (age 17-19); using 2 validated self-assessments: Perceived Stress Scale (PSS) and Nicholson McBride Resilience Questionnaire. Resilience does not reduce stress so much as it is a factor is dealing with it once it arrives. The literature review at the beginning is worth looking at. Action items (mostly from the introductory literature review).

Distressing testing: A propensity score analysis of high-stakes exam failure and mental health (2023, Norway):N=65,901 lowest scores in high stakes exit exam.  Cross-

Incidence of mental health dx of Norwegian students aged 17-21 before and after failing or lowest-passing-score high stakes exit exam.

referenced against national health database of primary care visits–for dx within 1 year of exam.  Results showed a 21% increase in odds of receiving a psychological diagnosis among students who failed the exam. MY question: result or context?  mental health issues prior? They checked–no.

Academic Buoyancy: Overcoming Test Anxiety and Setbacks (2023, Review) : good context review and semantic definitions with introduction to the concept of “academic bouyancy”.  “…resilience is an attribute required or developed once adversity presents in order to offset or manage risks to wellbeing. In contrast, academic buoyancy is a more proactive approach to managing typical educational adversities before they escalate. Accordingly, buoyancy is proposed at the ‘frontline’ of one’s academic development and progress, and resilience as the robust ‘backline’.”

Included Studies

Action Items

Herein I’ve stitched together my own experience as an educator with indicators and support from the literature.  How can we increase the likelihood that our graduates will sit for the certification exam?

• Make sure your educators are aware–if only you are aware of the student need for mental health development, your program will only inconsistently provide holistic development.  Ensure that your entire team knows we need to help students build confidence and resilience–then teach them HOW to do it.  For example, uneducated or unaware educators can give “over the top” simulations that can crush students’ delicate self-confidence when the actual need is to nurture and build it–gently, systematically, and with the best of intentional direction.
• Leadership by example–consistently model passion, imperfection, self-kindness; students will grow in respect and then mirror what you give them.  Level of internal passion correlates with likelihood of taking the exam.  Additionally, we must recognize the affective domain needs a lot more attention than in times past.
• Believe in your students and make sure they know it.  Until I became an educator, I never realized how many people have never had someone they respect say, “I believe in you” and mean it in a way which stuck.  YOU must be that person.  Your expressions can happen in quiet moments and loud expressions–whatever will be most beneficial to the specific student and their needs.
• Resilience-building and value of “failure”: students MUST learn that they have the ability to get back up. Self-confidence has a positive correlation with willingness to take boards. Every quiz, exam, skill, and scenario is an opportunity for discomfort and growth–WE educators must be the voice with gentle redirects, firm confidence in student ability, and fabulous celebrations upon success building self-confidence.
• Help your students replace negative self-talk–many times, we are our own worst enemy (me, video a few years ago).  Empty self-affirmations are unlikely to change anything.  Instead, we must encourage students to be as kind to themselves as they are to others.
• Involve social supports–involve friends and loved ones BEFORE graduation.  Since outside support correlates with taking high-stakes exams, we should nurture that. We always need victims for various activities–make education an activity which includes students’ friends and family. Use social media to highlight specific student achievements (without violating FERPA example: on first field tube, the student is awarded a big decorated necklace made out of ETT–ask them to post it and send you a screenshot for extra credit)
• Put exams into proper context–they aren’t real monsters and don’t actually kill people.  I did a 3-video series making this exact point and supplying mental exercises to ease anxiety.  Here is the first one.  The other two can be found in the Student Playlist.
• MOCK Boards (especially computer simulated ones)–fear is a multi-faceted beast.  “The Unknown” is among the most potent.  The literature says get rid of the unknown and student are more likely to go test.
• Resources to offer–structured preparatory time especially with motivated peers has shown to boost student confidence.  Additionally, you could supply study manuals to be borrowed.  If there is a vendor of online supports (study or simulated exams), many times you can secure a bulk rate to supply these to your students.
• Other–if it is possible, taking the students as a group to exams increases the probability they will go.  Another suggestion I’ve seen: if you collect fees to pay for the first exam attempt, encourage students to go without letting a bunch of people know–this reduces external pressures and resulting hesitancy.

A better future for our graduates?

Helping our students develop resilience can only benefit them in life. 

A 2023 study in Japan indicates the top three reducers of the likelihood of burnout are resilience, teamwork, and feeling safe while depression and anxiety both decrease resilience. It is always so sad to see someone who has invested all the required time, effort, and study required to become a healthcare provider become miserable in their profession.

The same is true of leaders who do not have the fortitude to thrive.  As any of you in leadership know it can be a lonely road where, sometimes, you only have yourself to pick yourself up and get through the challenges. 

So, even putting aside the need and pressures for more prehospital providers, we educators have wonderful reasons to support and guide our students to a healthier internal world–one that can take whatever life throws its way–and one that can overcome.

References