5 steps to teaching and learning psychomotor skills

Testing is a skill our students must learn and many EMS instructors utterly fail in teaching

“Your patient is breathing at six breaths per minute and snoring.”

“In that case, I would open the airway with a head-tilt, chin-lift and look for obstructions or secretions,” the candidate responds confidently.

“Your patient’s breathing improves to 20 per minute, and it appears to be shallow and a bit labored.”

"We owe it to our students to give them the tools to succeed, and first among those tools is the ability to test well, or they’ll never get the opportunity to succeed in the field," Grayson writes. (Photo/Cypress Creek EMS)

Th candidate looks aghast. “I didn’t mean head-tilt, chin-lift,” she explains desperately. “I meant modified jaw thrust!”

“I heard what you said, and I have noted that the modified jaw thrust you actually performed has improved the patient’s breathing,” I smile reassuringly. “Please proceed.”

“I would insert an oro … oralphar … oral airway, and inspect the chest for injuries that might compromise breathing. What do I see?”

“As you find it.”

“I see a large bruise that I suspect may be a flail chest.”

“There is paradoxical motion associated with that bruise,” I confirm.

“Then the way I would apply oxygen is via rescue … positive pressure ventilation using a non-rebreather mask … ”

The candidate looks at the BVM she is holding and seeing my raised eyebrows, stammers, “Um … a CPAP device?” Her cheeks are starting to flush, and she looks visibly frustrated.

“You tell me,” I smile patiently. “How would you manage this patient’s oxygenation and ventilation?”

“I’d use a vee-bee … I mean a … bee vee … vag balve mask device,” she finishes lamely.

I smile encouragingly, and respond, “Your patient demonstrates adequate ventilatory compliance, you notice bilateral chest rise, and his color seems to improve a bit.”

“I would next check vital signs and perform a secondary assessment … ”

I’m sorry to say, she didn’t pass, as she totally skipped checking circulation and managing the arterial bleed until very late in the scenario. It was one of a thousand similar triumphs and tragedies I’ve witnessed from students and exam candidates over the years, as apprehensive neophytes attempt to navigate the complex and artificial ballet that is EMS psychomotor skills testing. [At the end of this article, download a Tip Sheet for teaching and learning psychomotor skills]

Psychomotor skills testing isn’t as artificial as it once was, or even as necessary, but whether performed at a certification exam or as part of a competency portfolio in the classroom, we all still, at some level, have to pass muster in performing those skills under the eyes of an evaluator.

Indeed, testing is a skill our students must learn and many EMS instructors utterly fail in teaching it. We owe it to our students to give them the tools to succeed, and first among those tools is the ability to test well, or they’ll never get the opportunity to succeed in the field. Here are some tips to testing well that are as applicable to instructors and examiners as they are to students.

1. Abandon the ‘that was the classroom, and this is the field’ mentality

This is one of the biggest myths about skills evaluation out there, and it’s often perpetuated by teachers whose students fail the exam, and then blame the examiners. Teachers whose students do well on the exams are derisively referred to as “teaching the test,” but in reality, there should be no significant difference between a skill performed in a classroom or a skill performed in the field. If there is, you’re either teaching it poorly, or someone else is evaluating it poorly. And don’t blame the NREMT for this; at the BLS level, the various states functionally “own” the exams, even if they do use NREMT materials. If an artificial testing standard is applied, it is likely an artificial standard of the state’s examiners themselves, not NREMT policy.

2. The skill sheet is a documentation checklist, not a skills sequence checklist

You don’t have to follow it straight down the list, nor do you have to repeat certain phrases verbatim. Skill sheets work rather like our constitutional system; that which is not specifically prohibited is permitted. In other words, unless it says that you can’t do something, then you can, provided it does not violate the “Bill of Rights” on the bottom of the page. And, like the real Bill of Rights is meant to limit the powers of the government, the critical criteria on a skill sheet are meant to limit the powers of the examiners. The actions on the skill sheet for which points are awarded are meant to be liberally interpreted, and the critical criteria (fail points) are meant to be strictly interpreted.

3. Learn how to eat an elephant: ‘one bite at a time’

Focus on the process of a skill first – each step in the correct order – rather than worry about the procedures you perform. If you’re an instructor, only interrupt the student if they make a process error – getting the sequence wrong, or omitting a crucial step – and worry about critiquing the technique after they’ve completed the skill. Early on in learning patient assessment, for example, I focus on broad concepts; I’m satisfied if the student says, “I’d open the airway,” or “I’d apply oxygen,” or “I’ll control bleeding,” rather than require specific details. As their knowledge base grows, I’ll require more detail on each of those steps.

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4. Think out loud

Effective communication is what makes an ambulance call run smoothly, and it gives your examiner a window into your thought processes when you’re being evaluated. The better you communicate with your partner, the better you manage scene choreography and utilize the talents of the entire crew. The more you think out loud in a skill station, the more likely your examiner is to award you a point when their attention is on the skill sheet. Even if they didn’t see you do it, they heard you do it.  And more than a few times, have I awarded credit when a student did something I didn’t particularly agree with, because I found their thought processes valid.

5. Visualize and ‘pre-game’ the call

In the field, you’re doing this with your partner as you drive to the scene: “If we see X, then you do Y, and I’ll handle Z.” In a skill station, visualize yourself performing the skill from beginning to end, and arrange your equipment in the order you’ll likely need it. As you “use” or verbalize using a piece of equipment, set it aside. If something interrupts your train of thought – like stumbling over nomenclature like the candidate in the beginning of this article – all you have to do is look down at your remaining equipment to get back on track.

If you use these tips in teaching or learning psychomotor skills, you’ll find the evaluation process much less stressful.

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Tip Sheet: 5 tips for teaching and learning psychomotor skills

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