Imitation to Naturalization-A Practical Approach

By: Christi Montellato, NREMT-P

Introduction
With a sigh of frustration, I circled the “Fail” box on the skills test sheet for the sixth student in the last hour. Looking up into the worried eyes of the student in front of me, I informed him that he had not passed his exam. I didn’t understand. All ten students had been able to demonstrate this skill flawlessly in yesterday’s station but, for some reason, six of them had missed the mark in scenario testing today. Over the years, I have, regrettably, seen this same situation numerous times in EMS Education. Teaching psychomotor skills to healthcare providers has become a one-dimensional process that neglects to address the challenge of performing perfect skills in a less-than-perfect situation. The problem then ensues that students are able to mimic skills taught to them in a controlled environment but often lose that ability when faced with a dynamic scenario or, worse, a real patient. In an era where abbreviated skills labs and condensed courses have become the accepted norm, it is increasingly important for EMS Educators to have a well-founded understanding of how to utilize skills stations to their maximum potential.

The Five Levels of Psychomotor Skills
The NHTSA documents five phases of psychomotor skill retention in the National Guidelines for EMS Education: Imitation, Manipulation, Precision, Articulation and Naturalization. While the first phase is perhaps the most well known, a closer look will show that each step of this process is necessary in progressing from imitation to naturalization.


Imitation:
This is defined as a student’s ability to mimic a skill that is demonstrated for them through instruction, video presentation or other method of observation. As boring as it may feel, it remains very necessary to allow students to establish this infrastructure. By far, this is the most elementary phase in the progression. In fact, some even refer to this level as “Monkey see, monkey do” because of the basic pattern of repetition. Educators should be careful to demonstrate proper technique consistently and be diligent in correcting wrong behaviors quickly. (Whitefield, 1993) While it may be tempting to stop instruction at this phase, we cannot succumb to that urge. For, one can teach a student to perfectly mirror an intubation attempt on a manikin but this is no proof that he understands the process, could trouble shoot problems that arise or is at all capable of performing the exact same skill in an irresolute environment.

Manipulation:
Understand It: Over the last forty years, an immeasurable amount of research has been done to evaluate different types of learning styles. And yet, I never cease to be amazed at the various channels each person uses to grasp an underlying concept. In training psychomotor skills it is important to remember that we are not striving to create robots but rather healthcare providers who are capable of understanding the rationale behind a method and, further, who are able to utilize their expertise to problem solve any issue that may arise. When students are at the level of manipulation, it is the educators’ ideal opportunity to encourage them to ask questions, make mistakes and work through their confusion.
Personalize It: Give twenty Paramedic students a roll of tape during a circulatory skills station and you will, inevitably, see twenty different ways to tape an IV in place. It is at the manipulation phase of psychomotor skills instruction that we begin to become mentors. As natural as it may feel to force students to do things “The way I was taught” it is critical to allow them to develop their own personal preferences. Naturally, the educators experience will often offer much in the way of advice for a better technique but as long as students are demonstrating “medically acceptable” behaviors, (NHTSA, 2002) let them experiment!


Precision:
The old adage “Practice Makes Perfect” could not be more appropriate than for discussion of psychomotor skills. It is at this level that the student has performed the skill to the extent of being able to demonstrate accuracy in multiple performance attempts. By this phase, negative behaviors have been long corrected and the educator is able to observe and fine-tune. However, at this time, students are often limited in their ability to diversify the skill. “Example: Student is able to splint a broken arm if the patient is sitting up but cannot perform with the same level of precision if the patient is lying down.” (2002, NHTSA)

Articulation:
I remember waking up at three in the morning on my Paramedic Internship with my preceptor holding a well-worn manikin and yelling dispatch tones in my ear. “Get up! Get up! Three year old child, back seat passenger of a mid-sized convertible involved in a 75 mph roll-over collision. Show me what you’d do!” Despite how I disliked those early morning scenarios, I now realize the ingenuity in my preceptor’s approach. For, by taking me out of my comfort zone and forcing me to perform not only psychomotor but also cognitive and affective processes, he prepared me for a real-life, dynamic environment. Once a student has demonstrated the ability to imitate a skill, manipulate it through understanding and personalization and perform it with repetitive precision, it is time to begin to articulate. A student in the articulation phase of psychomotor skill retention is able to contextualize the skill with ease. In other words, he/she can demonstrate the “who, what, where, when, why and how” of a skill set. This phase, perhaps the most difficult to grasp, is a key element in training students who will be successful in maintaining positive psychomotor behaviors in a field environment.

Naturalization:
National guidelines define skill naturalization as “Mastery level skill performance without cognition” or “Muscle-Memory”. This phase, our ultimate goal in teaching psychomotor skills, is well worth the effort to achieve. If you have ever uttered the phrase “Been doing it so long, I don’t even think about it anymore… it just happens” you may have mastered the skill of which you were speaking. To be a successful EMS provider, the student must eventually reach this phase. But what role does the EMS Instructor play in this process?



Equipping Educators with Proper Technique
A few months back, I walked past another instructors’ classroom and cringed as I heard him tell a student “Just memorize it this way, get through the test and when you get out there you’ll see how it is really done.” Unfortunately, this has become a common mentality in EMS education. When we see students come in day after day requesting only the information that they need to pass the final exam, it is easy for the educator to begin mimic that behavior. But, sadly, when we allow this attitude we are not only crippling our students but also setting them up for failure in a real patient care setting. It is imperative that each EMS educator have a repertoire of techniques to aid them in leading students to their ultimate psychomotor goals. After studying National Guidelines and other educational resources, I firmly believe that there are four major categories that are frequently over-looked by EMS Educators.
Commanding a psychomotor skill liberates the cognitive and affective domains to perform other functions and, as a result, refines the patient care that we deliver. It is essential that every EMS instructor have a strong understanding of the importance of each step between imitation and naturalization. Educators should be conscious of how simple variations such as culture, gender and experience level might affect the way different students learn skills. You may already be aware, however, that the road to naturalization is riddled with difficulties. Whether we are combating a students’ learning disability, our own pre-conceived notions or merely diminished standards in our facilities, it can feel like a never-ending battle. If we do not equip ourselves as educators, how can we possibly lead our students to successful skills naturalization?

Preparation
No discussion of psychomotor skills would be complete without mention of advance instructor preparation. Prior to facilitating any skills station the lead instructor should create a material checklist. Items on that checklist might include: pre-written scenarios, stop watch, recording/note taking material, handouts, guidelines for student completion and any equipment necessary. When a station is not adequately prepared it is often painfully obvious to the students and can become a distraction. The National Guidelines for EMS Educators offer many practical suggestions to appropriately prepare for a skill station.

Demonstration
NHTSA recommends the use of a technique called “Whole-Part-Whole”. This form of skill demonstration benefits both global and analytical learners. First, it is recommended that the student is able to observe a skill in its entirety. (Start to finish with no interruptions) Secondly, the skill is broken down, step by step. During this time, students are encouraged to ask questions and clarify points. Finally, the skill is demonstrated one more time in its entirety without interruption. The educator should focus on providing accurate demonstrations and keeping every student involved. However, this technique, while extremely useful, cannot be the sum of our demonstration capabilities. I have, on many an occasion, watched students do the minimum amount of hands-on work that is allowed. It is the educator’s responsibility to encourage tactile learning and, further, to endeavor to make each scenario as realistic as possible.

Feedback
“Ok, how do you think you did?” I asked the experienced Paramedic in front of me. It was a skills recertification course and these Paramedics were all very capable. “Awful” was her surprising response. I remember looking at her, slightly surprised, and asking “Ok, well what do you think went wrong?” I watched as she struggled to pinpoint a problem area and finally interrupted with a different question. “How about you tell me at least three things that you did right?” This question seemed to be much easier for her to answer. With the next two students I repeated the same process until they started looking for the good things in their own performances without being prompted. It was then that I realized how an emphasis on the positive can open doors to providing more effective corrective feedback. Performing skills in front of peers, whether for the first or the hundredth time is never an easy task. This is where an educator needs to be familiar with the “Sandwich Technique”. This method of feedback provides positive reinforcement first, then offers corrective feedback and eventually finishes with an emphasis on the actions that were performed correctly. The concept of sandwiching negative feedback between positive reinforcement is not a new one but can be difficult to grasp.

Creativity
Expansive bodies of research now suggest that gender, cultural background, age and experience level will affect students learning styles. The EMS instructor, like anyone else in the field of education should be familiar with the evidence produced by these studies. This ground-breaking research opens many doors for EMS educators to further perfect their psychomotor instruction. While there is much to be said for repetition in the classroom, somewhere along way we seem to have lost sight of creativity. The mere knowledge that different cultures, genders and experience levels will have different learning preferences should inspire us anew to refresh our outdated instructional methodology. If we were to teach these skills in a way that would be remembered, perhaps we wouldn’t need quite as much repetition. Could it be that the future of EMS education utilizes a more multi-dimensional approach to psychomotor instruction?

Conclusion
Commanding a psychomotor skill liberates the cognitive and affective domains to perform other functions and, as a result, refines the patient care that we deliver. It is essential that every EMS instructor have a strong understanding of the importance of each step between imitation and naturalization. Educators should be conscious of how simple variations such as culture, gender and experience level might affect the way different students learn skills. You may already be aware, however, that the road to naturalization is riddled with difficulties. Whether we are combating a students’ learning disability, our own pre-conceived notions or merely diminished standards in our facilities, it can feel like a never-ending battle. If we do not equip ourselves as educators, how can we possibly lead our students to successful skills naturalization?

References

1. National Highway Traffic Safety Administration (NHTSA, 2002):
National Guidelines for Educating EMS Instructors-Module 17 Psychomotor Skills

2. National Highway Traffic Safety Administration (NHTSA, 2005): National EMS Core Content

3. National Highway Traffic Safety Administration (NHTSA, 2000): Education Agenda For The Future: A Systems Approach

4. Whitefield, Tony (1993). The Learning Styles Approach to Teaching. Compak, November, pp 12-17.

5. Jonassen, David and Grabowski, Barbara L. (1993). Handbook of Individual Differences, Learning and Instruction.

6. Bennett, Christine (1995). Comprehensive Multicultural Education: Theory and Practice, 3rd ed.

Further references available upon request.

Christi Montellato worked as an EMT-Paramedic for ALS ambulance services in three counties in northern California prior to becoming a full-time educator. Utilizing her field experience to fuel the courses that she writes and teaches, she currently acts as a Course Director at a training center that does both initial certification and continuing education for healthcare providers.
Email the author at cmontellato@heartsharetraining.