Increased Neuroticism is Associated with Poor Professional Behavior During Paramedic Students Patient Contacts

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


Previously validated personality inventories have linked emotional stability to high functioning law enforcement officers (M5-50 (McCord 2002), NEO Personality Inventory (NEO PI-R; P. T. Costa, Jr., & R. R. McRae, 1992)).  Paramedics work under similarly stressful conditions and must also demonstrate acceptable professional behavior (PB).  Use of these inventories to measure neuroticism in paramedic students may identify hidden temperaments that do not show up on resumes and may influence paramedic student (PS) affective behavior performance during real patient contacts.

Paramedic students (PS) are closely supervised by field preceptors when they are performing real patient care on ambulances.  There is however a genuine potential for harm to real patients should a paramedic student in a clinical setting be aggressive and intend to cause harm outside of the preceptors field of vision. This is especially true during hospital clinicals when students may be delegated tasks in a department where preceptors are monitoring multiple patients and a student is trusted with tasks that have been previously demonstrated and not requiring direct supervision. 

Despite this potential for harm, paramedic programs have done little to identify potential safety risks with paramedic student neurosis.

Serious neurosis is associated with anger, envy, guilt, anxiety, and depressive behavior. In previous projects, it has been identified that paramedic students with high neuroticism scores tend to have lower critical thinking skills and therefore lower ability to pass the National Registry (NREMT) cognitive exam. To our knowledge no other studies have evaluated potential harmful personality traits in paramedic students.


Increased neuroticism in paramedic students is associated with poor professional behavior 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 professional behavior was evaluated by using the NREMT-PCPP 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.

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.

The definition of professional behavior first described in the 1998 National Highway Traffic Safety Administration (NTHSA) Department of Transportation (DOT) Emergency Medical Services (EMS) curriculum, and now included in the current National Education Standards was used.  The categories in this definition were abbreviated as follows by the NREMT on the shift evaluation form (Figure 1). 

To improve inter-rater reliability the definition was included directly on the evaluation form. 

Student and preceptors were given the following definition and performance criteria:

Figure 1.
Professional Behavior Objectives: The student demonstrates they are
- Self motivated: Includes taking initiative to complete assignments, improve/correct problems. Striving for excellence. Incorporating feedback and adjusting behavior/performance.
- Efficient: Includes keeping assessment and treatment times to a minimum, releasing other personnel (first responders) when not needed, organizing team to work faster/better.
- Flexible: Includes making adjustments to communication style, or directing team members; changing impressions based on findings;
- Careful: Includes paying attention to details of skills, documentation, patient comfort, set-up and clean up; Completing tasks thoroughly.
- Confident: Includes making decisions, trusting and exercising good personal judgment, being aware of limitations and strengths;
- Accepts feedback openly: Includes listening to preceptor and accepts constructive feedback without being defensive (interrupting, giving excuses).

Affective domain scores from the EE were then compared the PCPP rating, a dichotomous preceptor rating, acceptable or unacceptable, that evaluated their professional behavior after each patient encounter, using a generalized linear multilevel model (GLMM), a 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 this 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 323 preceptors over a total run volume of 12,375 runs (mean = 165 patient encounter/student).  The mean logit score for neuroticism was -1.53 (SD 1.21; Range -5.11 to 1.70). The results from the model fitting suggested a statistically significant relationship between neuroticism logit scores and professionalism behavior rating received by preceptors (p=.01). The results produced an odds ratio suggesting that for every 1 logit increase in neuroticism, a student was 2.4 times more likely to obtain a negative rating on professional behaviors from a preceptor, controlling for student ability, preceptor rating harshness, and total number of encounters prior to the rating. These ratings were scaled using the Partial Credit Model (Masters,1982).

Regression Results – Neuroticism and Professional Behavior
 Overall Field 
Neuroticism Logit-0.800.33-0.870.32
sqrt (total runs)

Figure 2. Correlation of Positive Rating to Professional Behavior
Neuroticism graph


Increased neuroticism levels of matriculating paramedic students are negatively correlated with professional behavior during field internships. This demonstrates that a student with a high neuroticism score may lack ability to act professional during an encounter with a patient.  Future research is needed to determine if educational interventions can decrease neuroticism and improve emotional stability and professionalism in the field.