Agreeableness is Linked to Improved Communication During Paramedic Student Internships

David Page, MS, NREMT-P; L. Michael Bowen, NREMT-P; Luke Stanke, PhDc.


Teamwork and cooperation are core paramedic competencies that depend on good communication. The Fisdap (Saint Paul, MN) Entrance Exam (EE) contains a portion of the previously validated M5-50 personality trait index (McCord 2002). It describes individual differences, such as being likeable, pleasant, and harmonious in relation with others. People with high instances of agreeableness are described as individuals who strive to maintain social harmony. These are people who might be described by others as "kind", "considerate" and "warm". We are postulating that individuals who score high in agreeableness will perceive providers to me more empathic due to a more positive outlook about social groups. It is also thought that these individuals have a decrease in social prejudices and as a result have more effective methods of conflict resolution.

Educators struggle to measure performance of the so-called “soft skills,” with agreeableness being one of the more difficult to define or teach. These affective behaviors are essential to good bedside manner or customer service, and effective teamwork. Potential employers describe these behaviors as the keys in avoiding patient complaint, and allowing for long term retention of high performing employees. While the M5-50 has been used in law enforcement candidates, little is known of how EMTs seeking paramedic certification will perform on this exam. In this project we postulated that entering paramedic students may already possess some of these helpful affective traits, as measured by the M5-50. We also postulated that having these traits would lead to a more successful completion of paramedic education, particularly during ambulance clinical performance in the field.


Increased agreeableness scores in paramedic students result in improved communication ratings during patient contacts.


All paramedic students consenting to research and participating in both the National Registry of EMTs (NREMT) Psychomotor Competency Portfolio Project (PCPP) and the FISDAP(R) Entrance Exam (EE) were included in this study. The student’s ability to communicate was evaluated by using the NREMT-PCPP rating scale on the new PCPP shift evaluation form ( The evaluation form was completed on each patient contact, first by student, then by preceptor. The evaluation ratings are: NA = Not Applicable; not needed/expected;  0 = Unsuccessful -required excessive or critical prompting; includes rating of “not attempted” when student was expected to try; 1 = Marginal - inconsistent - Not yet competent; 2 = Successful/Competent no prompting. An essay explaining these ratings to preceptors was also made available.

To improve inter-rater reliability directions on the use of this scale are included on the form itself.

The following note was included on the form:
NA = Not Applicable; not needed/expected – This is a neutral rating. (Example: Student expected to only observe, or the patient did not need intervention);
0 = Unsuccessful -required excessive or critical prompting; includes rating of “not attempted” when student was expected to try; This is an unsatisfactory rating;
1 = Marginal - inconsistent - Not yet competent; This includes partial attempts.
2 = Successful/Competent no prompting;
*NOTE: Ideally, students will progress their role from observation to participation in simple skills, to more complex assessments and team leadership. Students will progress at different rates and case difficulty will vary. Students should be active and ATTEMPT to perform skills, assess/treat patients and lead encounters early-on even if this results in frequent prompting and unsuccessful ratings. Unsuccessful ratings are normal and expected in the early stages of the clinical learning process when student needs prompting. Improvement plans MUST follow any unsuccessful or inconsistent ratings.

This form is an adaptation of the state of California shift evaluation form. It was modified in 2008 by the NREMT PCPP committee. The NREMT convened a group of subject matter experts representing a wide range of community stakeholders. This group sought to evaluate the feasibility of using a “prompting” evaluation methodology previously described in the literature (Nepon/Eberly 2008). This form was piloted by 8, then 24 paramedic programs and found to provide high inter-rater reliability and better evaluation validity.

For the purposes of this study, ratings of 0 and 1 were merged as unsuccessful, “NA” ratings were excluded, and 2 was counted as successful. Communication was defined as the ability of the student to effectively communicate with the team, provide an adequate verbal report and thorough written patient narrative. Agreeableness scores from the EE were then compared the PCPP rating, a dichotomous preceptor rating, acceptable or unacceptable, that evaluated their communication skills after each patient encounter using a generalized linear multilevel model (GLMM), a type of regression model. The GLMM included random effects for student and preceptor, and fixed effects for the square root of the total number of patient encounters completed prior to the rating and affective domain scores. The coefficients of the model are discussed in the results section.


A total of 75 students meeting inclusion criteria  were drawn from 7 different programs. These 75 students received ratings from 363 preceptors over a total run volume of 12,375 total patient encounters in the hospital clinical setting and the field setting (mean = 165 encounters). Of those encounters, 9,480 were completed in the field (mean = 126.4 encounters). The mean logit score for agreeableness was 1.33 (SD 1.03; Range -1.33 to 5.25). The results from the model fitting suggested a statistically significant relationship between agreeableness logit scores and ability to communicate ratings received from preceptors (p=.02). The results produced an odds ratio suggesting that for every 1 logit increase in agreeableness, a student was 1.6 times more likely to obtain a positive rating on communication from a preceptor, controlling for student ability, preceptor rating harshness, and total number of encounters prior to the rating.

Regression Results – Agreeableness and Communication
 Overall Field Clinical 
Agreeableness Logit0.520.210.460.211.110.38
sqrt (total runs)

Agreeableness graph


A positive relationship exists between preceptor ratings of communication skills and a student's level of agreeableness. Student’s with increased scores of agreeableness tend to communicate more efficaciously than those with decreased scores. Agreeableness was the focus because this temperament is associated with motives to maintain positive interpersonal relations. To our knowledge no other studies exist linking affective personality traits to paramedic field performance. More research is needed to determine if agreeableness and improved communication can be increased with targeted interventions during paramedic education.