Expanding your scope of practice
Last month, in the January report 2008, I gave you a quick and efficient questionnaire so
that you could identify conditions in your patients that they may not associate within your
domain. The two reasons for using the questionnaire was to help identify all the causative
factors involved with their chief complaint and secondly to uncover other conditions you
could treat, hence creating the need for more service by you.
Chiropractic practices are diminishing in the USA for more than one reason, but the
narrowing of our scope by are own poor thinking and procedures are a big part. I expect
25% of my new patients to have early O.A. of the hip joints revealed by a positive Fabere
sign. Even a mild positive is very significant, as hip, hypo mobility leads to degeneration
after years of eccentric dysfunction. The hip dysfunction causes abnormal movement in
the lumbar spine which in turn causes compensation in the whole spinal, closed,
kinematic chain.
I saw motion x-ray studies in 16 mm, film format in 1962 presented by Dr. Fred Illi of
Switzerland. He showed patients walking on a treadmill that had a positive Fabere sign.
They had compensated in the lumbar spine by becoming hyper mobile at the lumbo sacral
joints and formed a C curvature to one side on alternative steps. Once the hip
manipulations restored a normal range of motion the 2nd series of motion film showed the
lumbars remained steady and no curvature formed.
Dr. Illi stressed, that we always had to consider if we were treating a primary dysfunction
or a compensation dysfunction. We need to often treat the cause of the cause of pain.
Many researchers have stated, “If you treat the pain source you are probably not going to
the real cause of the inflammation. In Dr. Illis’ hip dysfunction patient, the compensated
low back was where the patient complained of pain.
So often, when I have a headache patient with severe sub occipital muscle tension and
upper cervical joint dysfunction, the real cause is in the upper thoracic region, first rib,
costo transverse, joint dysfunction and not so uncommonly a sacroiliac dysfunction.
On the first visit examination, I like to palpate and test the range of motion of all the
joints. How else can you discover the faults in the locomotor, closed kinematic, chain?
Patients never complain that one is too thorough.
Often patients will say, “No wonder I haven’t got well, No one found that hip problem,
before”.
I adjust the hip as demonstrated on the videos and add a figure four stretch to be done 4
or 5 times a day. The patient sits on a chair and crosses their right ankle on to the top of
their left knee and leans forward while pushing the right knee down and away towards
the floor. This stretch is held for 30 seconds and the patient breathes out slowly.
S.A.I.D. of this stretch causes a gradual increase in the soft tissues restricting hip
movement.
Recently, Dr. Ove Lind of Sweden showed me some interesting video of a patient hyper
extending the lumbar spine in order to rise from leaning forward. He then fully
manipulated and stimulated the ankle joints in this patient, especially to restore the severe
loss of dorsi flexion of the ankle mortise joints. He adjusted the joints and then used a
Thuli drop mechanism to repeatedly recoil the mortise joint. His rational is to cause
afferentation that has been missing, back to the brain. When he retested the action of
bending forward and rising back up, the lumbo pelvic rhythm was normal no hyper
extension occurred.
Dr. Brett Winchester an MPI Instructor demonstrated at the November Advanced
Seminar, a test for poor dorsi flexion of the ankle. Patients with this dysfunction rotate
their foot, toe outwards, in order to step down a step. For example a right ankle dorsi
flexion, hypo mobility causes the right foot to toe out when the left foot is stepping down.
In my little rehab area, I have steps that I ask the patients to step down from.
These patients often walk with their toes out to the side more than 15 degrees.
Don’t miss these significant dysfunctions in the kinematic chain of locomotion.
The patients that answer questions of organ dysfunction present a problem unique to us.
Since we don’t manage pathology diseases of the organs, we need to discern if the
pathology is reversible. We also need to ascertain if we are restricting the patient from
receiving a better, therapeutic approach. There are therapeutic and ethical questions to be
answered.
I recently, successfully helped a young woman return to normal from a severe case of
Irritable Bowel Syndrome. I not only adjusted her but I got her to read “The Stress of
Life” by Hans Selye, M.D. I counseled her in some significant lifestyle changes and I got
her to take some supplements that swung her urine pH from 5 to 7.5.
Her condition was reversible and her previous treatment was ineffective. A holistic
approach was ethically correct and like many others she responded well. She referred two
patients within a week of getting better. She understood my adjustments were designed to
lessen the facilitation of the sympathetic nervous system. When I adjusted her upper
thoracics, she got a flushing (hyperemia) of her neck and ears. I had her lay still for a few
minutes to feel the “relief” of the tension occurring and the heat the adjustment caused. I
made her “feel” the reaction to the adjustment. She knew something was happening; she
didn’t have to wonder if something happened.
Make sure your patients experience a feeling of something has changed after you
adjusted them. Often, on re motion palpating after the adjustment I make sure they can
feel the change I can feel has occurred in their range of joint play motion. This is the
reason I use two stools to palpate a patient sitting. It separates the diagnostic palpation
from the adjusting table palpation and adjustment.
Patients like it when I re motion palpate and point out the changes. I end by saying; we
shall see how that region is on Wednesday.
Wednesday starts with my opinion of how the changes improved a little, a lot or none at
all. None means it was secondary compensation that had to recur. A little means we
persevere and a lot means we move on to the next most fixated area.
Treatment is always a series, not only to restore the dynamic function of the closed,
kinematic system but to maintain that normal function, long enough for decompensating
to occur. Patients understand this fact; I often wonder why so many doctors are confused
about this issue. They want to discharge patients when the pain is relieved, well before
the tissues can change, that were in the dysfunctional motion unit. Even a monthly check
up is better than being discharged. In this way you can review their home rehab program
and lifestyle changes for a few months.
Healing is truly an inside job, just not as simple as above down and inside out, like our
forefathers hypothesized.
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Thursday, June 25, 2009
Website Repor t January 2008 - Expanding Your Scope of Practice
The following new- patient, health- review, questionnaire is important for a number of reasons. Every patient
comes to your office with a chief complaint that is affecting their quality of life, enough to make them seek
help. Often it is an obvious spinal condition like back, neck or joint pain. For them it is a simple matter. They
don’t know that early heart conditions cause neck and shoulder pain. They don’t know that gall bladder stones
can cause a nagging pain in the right scapula and lower rib region. There is so much they don’t know, that they
would never mention, when filling in a form asking for their symptoms.
When you study the following questionnair e, you will realize that these few questions, will uncover most of the
disease areas and allow you to direct your consultation questions to specific, suspected, secondary conditions.
These secondary conditions may be very significant causal factors, in the chief complaint. Often, the
questionnaire reveals a condition you can tr eat, that the patient wasn’t aware of came under your scope of
practice.
Make no mistake patients want to be healthy and appreciate your thorough approach and offer to help them with
a condition their previous health care pr ovider failed with.
The more service we can rationally apply, the more patients appr eciate our services. Misdirected doctors feel
they are “selling” their services, instead of having the attitude of providing services that give patients a chance
to heal.
After discussing their problems in the consultation, I explain what the examination needs to look for and why
certain tests need to be ordered. They need to be told that after reviewing all the information, I will be able to
tell them “Whether or not I can help them”. This can be done as soon as all the tests are completed. Usually the
2nd visit as I have x-r ays taken at a r adiologists’ office.
You can copy this questionnair e and start using it. See for yourself if it leads to giving more service to your
patients. Just for fun, get your existing patients to fill it out and see if you missed anything in your initial work-
up.
IT APPEARS BELOW SO THAT IT IS ON A SEPARATE PAGE
HEALTH QUESTIONNAI RE
Patient Name:________________________________________________________________ Date:________________
Yes No Yes No
1. Are you physically active? 22. If yes: Has it increased?
2. Are you troubled with pain in any of 23. Has it decreased?
your joints?
3. If yes, is it worse in the night? 24. Has your weight changed more than 10
Pounds in the last year?
4. Do your joints ever swell?
25. Are you troubled with frequent loos e
5. Do you wake up with stiffn ess or bowel movements?
Ach ing in your join ts or muscles?
26. Are you troubled with constipation?
6. Are you troubled by wakin g in the early
Hours and being unable to go to sleep 27. Have you noticed any bloo d or mucus
again ? in your stoo l?
7. Do you have d ifficulty in go ing to sleep ? 28. Are you troubled with irritation, itching or
burning around th e b ack passage?
8. Do you suffer with backache?
29. Are you troubled with hemorrhoid s?
9. If yes: Is this ever accompanied by pain
down one or both legs? 30. Do you suffer with shortness of breath
on exertion?
10. Is this ever aggravated by cou ghing or
sneezing? 31. Are you troubled by pain or tightness in
your chest on ex ertion?
11. Do you get neck pain?
32. If yes: Is it relieved by resting?
12. Does it radiate to should er, arm or hand?
33. Do you suffer with a cramp-like pain in
13. Do you get any numbness or ting ling in either leg when walk ing
your arms, han ds, legs or feet?
34. If yes: Do you have to s top or s low down
14. Do you ex perience any abnormal noises to relieve it?
in your ears or h ead?
35. Are you subject to blackou t, dizzy spells,
15. Are you often troubled by headaches? or fainting?
16. If yes: Are they throbbing and accompanied 36. Are you troubled with a frequent or
by sickn ess or nausea? persisten t cough?
17. Are you troubled by pain or ach ing in your 37. If yes: Is there a lo t of p hlegm?
sto mach?
38. Do you have any pain or difficu lty
18. If yes: Is it relieved by eating? during urinatio n?
19. Is it relieved by drinking milk ? 39. Is urination more frequent lately?
20. Does it often wake you at night? 40. Have you any lu mps, cysts, or unusual
Swelling anywhere on your body?
21. Have you had any persistent change in your
appetite during the las t th ree months? 41. Have you visited a sub-tropical or
tropical country in the last year?
42. Are you easily d epressed?
WOMEN’S QUESTIONNAIRE
43. How many d ays is it s ince the first date of
your last menstrual period? ____ ___________
YES NO
44. Are your periods: Regular?
45. Slightly irregular?
46. Very irregular?
47. Have the ceased?
48. Are you taking a contraceptive pill, or
wearing a contraceptive patch ?
49. Are you on contraceptive in jections?
50. Are your wearing an intrauterine contraceptive
device?
51. Are your periods accompanied by lower abdominal
pain or d isco mfort?
52. If yes: Is the pain of moderate severity?
53. Is it severe (do yo u take a pain reliever)?
54. Is it severe and incapacitatin g (do you n eed
to go to bed)?
55. Do you notice bleeding in between period s?
56. If your periods have stopped completely, hav e
You since h ad any b leeding from the front passage?
57. Have you experienced any recent vaginal discharge?
58. Have you given birth?
If yes, what ages: _______ ____________________
59. Have you had any gynecological or abdominal
surgerys?
60. Do you ex perience incontinence during straining,
coughing, sneezing or laug hing?
61. Do you have d isco mfort on, or frequen t urination?
62. Have you ever b een treated for a urinary tract infection?
63. Have you a lump in either breast?
comes to your office with a chief complaint that is affecting their quality of life, enough to make them seek
help. Often it is an obvious spinal condition like back, neck or joint pain. For them it is a simple matter. They
don’t know that early heart conditions cause neck and shoulder pain. They don’t know that gall bladder stones
can cause a nagging pain in the right scapula and lower rib region. There is so much they don’t know, that they
would never mention, when filling in a form asking for their symptoms.
When you study the following questionnair e, you will realize that these few questions, will uncover most of the
disease areas and allow you to direct your consultation questions to specific, suspected, secondary conditions.
These secondary conditions may be very significant causal factors, in the chief complaint. Often, the
questionnaire reveals a condition you can tr eat, that the patient wasn’t aware of came under your scope of
practice.
Make no mistake patients want to be healthy and appreciate your thorough approach and offer to help them with
a condition their previous health care pr ovider failed with.
The more service we can rationally apply, the more patients appr eciate our services. Misdirected doctors feel
they are “selling” their services, instead of having the attitude of providing services that give patients a chance
to heal.
After discussing their problems in the consultation, I explain what the examination needs to look for and why
certain tests need to be ordered. They need to be told that after reviewing all the information, I will be able to
tell them “Whether or not I can help them”. This can be done as soon as all the tests are completed. Usually the
2nd visit as I have x-r ays taken at a r adiologists’ office.
You can copy this questionnair e and start using it. See for yourself if it leads to giving more service to your
patients. Just for fun, get your existing patients to fill it out and see if you missed anything in your initial work-
up.
IT APPEARS BELOW SO THAT IT IS ON A SEPARATE PAGE
HEALTH QUESTIONNAI RE
Patient Name:________________________________________________________________ Date:________________
Yes No Yes No
1. Are you physically active? 22. If yes: Has it increased?
2. Are you troubled with pain in any of 23. Has it decreased?
your joints?
3. If yes, is it worse in the night? 24. Has your weight changed more than 10
Pounds in the last year?
4. Do your joints ever swell?
25. Are you troubled with frequent loos e
5. Do you wake up with stiffn ess or bowel movements?
Ach ing in your join ts or muscles?
26. Are you troubled with constipation?
6. Are you troubled by wakin g in the early
Hours and being unable to go to sleep 27. Have you noticed any bloo d or mucus
again ? in your stoo l?
7. Do you have d ifficulty in go ing to sleep ? 28. Are you troubled with irritation, itching or
burning around th e b ack passage?
8. Do you suffer with backache?
29. Are you troubled with hemorrhoid s?
9. If yes: Is this ever accompanied by pain
down one or both legs? 30. Do you suffer with shortness of breath
on exertion?
10. Is this ever aggravated by cou ghing or
sneezing? 31. Are you troubled by pain or tightness in
your chest on ex ertion?
11. Do you get neck pain?
32. If yes: Is it relieved by resting?
12. Does it radiate to should er, arm or hand?
33. Do you suffer with a cramp-like pain in
13. Do you get any numbness or ting ling in either leg when walk ing
your arms, han ds, legs or feet?
34. If yes: Do you have to s top or s low down
14. Do you ex perience any abnormal noises to relieve it?
in your ears or h ead?
35. Are you subject to blackou t, dizzy spells,
15. Are you often troubled by headaches? or fainting?
16. If yes: Are they throbbing and accompanied 36. Are you troubled with a frequent or
by sickn ess or nausea? persisten t cough?
17. Are you troubled by pain or ach ing in your 37. If yes: Is there a lo t of p hlegm?
sto mach?
38. Do you have any pain or difficu lty
18. If yes: Is it relieved by eating? during urinatio n?
19. Is it relieved by drinking milk ? 39. Is urination more frequent lately?
20. Does it often wake you at night? 40. Have you any lu mps, cysts, or unusual
Swelling anywhere on your body?
21. Have you had any persistent change in your
appetite during the las t th ree months? 41. Have you visited a sub-tropical or
tropical country in the last year?
42. Are you easily d epressed?
WOMEN’S QUESTIONNAIRE
43. How many d ays is it s ince the first date of
your last menstrual period? ____ ___________
YES NO
44. Are your periods: Regular?
45. Slightly irregular?
46. Very irregular?
47. Have the ceased?
48. Are you taking a contraceptive pill, or
wearing a contraceptive patch ?
49. Are you on contraceptive in jections?
50. Are your wearing an intrauterine contraceptive
device?
51. Are your periods accompanied by lower abdominal
pain or d isco mfort?
52. If yes: Is the pain of moderate severity?
53. Is it severe (do yo u take a pain reliever)?
54. Is it severe and incapacitatin g (do you n eed
to go to bed)?
55. Do you notice bleeding in between period s?
56. If your periods have stopped completely, hav e
You since h ad any b leeding from the front passage?
57. Have you experienced any recent vaginal discharge?
58. Have you given birth?
If yes, what ages: _______ ____________________
59. Have you had any gynecological or abdominal
surgerys?
60. Do you ex perience incontinence during straining,
coughing, sneezing or laug hing?
61. Do you have d isco mfort on, or frequen t urination?
62. Have you ever b een treated for a urinary tract infection?
63. Have you a lump in either breast?
Practice Article September 2008 – Learning Psychomotor Skills
The following is taken from the National Guidelines for Educating EMS
Instructors – August 2002 – Module 17, pages 139-143
MODULE 17: TEACHING PSYCHOMOTOR SKILLS
Cognitive goals
At the completion of this module the student-instructor should be able to:
17.1 Define psychomotor skills
17.2 Explain the relationship between cognitive and affective objectives to
psychomotor objectives
17.3 Describe teaching methods appropriate for learning a psychomotor skill
17.4 Describe classroom activities used to teach and practice psychomotor skills
17.5 List methods to enhance the experience of psychomotor skill practice in the
Classroom
Psychomotor goals
At the completion of this module the student-instructor should be able to:
17.1 Demonstrate proper facilitation technique when demonstrating EMS skills
17.2 Demonstrate the use of corrective feedback during a skill demonstration
17.3 Create a skill session lesson plan whic h maximizes student practice time
17.4 Create a skill scenario which enhances realism
Affective goals
At the completion of this module the student-instructor should be able to:
17.1 Acknowledge the need to teach the mechanics of a skill before students can
apply higher level thinking about the process
17.2 Value the need for students to practice until they attain mastery level
17.3 Model excellence in skill performance
Declarative
I. Why this module is important
A. Psychomotor skill development is crucial to good patient care by the
EMS provider.
1. Psychomotor skills are used to provide patient care and also to
ensure the safety of the members of the team
2. There are many ways to perform medically acceptable skills
behaviors
a. Need to know steps of skills performance in order to
effectively apply critical thinking skills in situations they will
face in the field setting
B. Instructors plan their approach to teaching students how to perform skills
in order to maximize the student’s abilities
II. Understanding the psychomotor domain
A. Definitions
1. The psychomotor domain involves the skills of the EMS profession
2. Skill, action, muscle movement and manual manipulation
III. Five levels of psychomotor skills
A. Imitation
1. Student repeats what is done by the instructor
2. “See one, do one”
3. Avoid modeling wrong behavior because the student will do as you
do
4. Some skills are learned entirely by observation, with no need for
formal instruction
B. Manipulation
1. Using guidelines as a basis or foundation for the skill (skill sheets)
2. May make mistakes
a. Making mistakes and thinking through corrective actions is a
significant way to learn
3. Perfect practice makes perfect
a. Practice of a skill is not enough, students must perform the
skill correctly
4. The student begins to develop his or her own style and techniques
a. Ensure students are performing medically acceptable
behaviors
C. Precision
1. The student has practiced sufficiently to perform skill without
mistakes
2. Student generally can only perform the skill in a limited setting
a. Example: student can splint a broken arm if patient is sitting
up but cannot perform with same level of precision if patient
is lying down
D. Articulation
1. The student is able to integrate cognitive and affective components
with skill performance
a. Understands why the skill is done a certain way
b. Knows when the skill is indicated
2. Performs skill proficiently with style
3. Can perform skill in context
a. Example: student is able to splint broken arm regardless of
patient position
E. Naturalization
1. Mastery level skill performance without cognition
2. Also called "muscle memory"
3. Ability to multitask effectively
4. Can perform skill perfectly during scenario, simulation, or actual
patient situation
IV. Teaching psychomotor skills
A. Whole-part-whole technique is useful
1. Requires that the skill be demonstrated 3 times as follows:
a. WHOLE: The instructor demonstrates the entire skill,
beginning to end while briefly naming each action or step
b. PART: The instructor demonstrates the skill again, step-by-
step, explaining each part in detail
c. WHOLE: The instructor demonstrates the entire skill,
beginning to end, without interruption and usually without
commentary
2. This technique provides an accurate example of the skill done in
repetition
a. If students were not completely focused on the skill
demonstration one time there are two other opportunities
for them to watch the presentation
3. This technique provides a rationale for how the skill has been
performed
a. Students may or may not be allowed to interject questions as
the demonstration is going on, but generally discussion is
allowed dur ing the middle, step-by-step “part”
demonstration
4. This technique works well for both analytic and global learners
a. Analytic learners appreciate the step-by-step presentation and
global learners appreciate the overview
b. Module 7: Learning Styles has more information on analytic
and global learners
V. Progressing through the psychomotor domain levels of skill acquisition
A. Novice to expert
1. Allow students to progress at their own pace
a. If you move students too quickly they may not understand
what they are doing and will not acquire good thinking skills
2. Although the demonstration may provide information on the
performance of the entire skill from start to finish, students
should be allowed to learn the individual parts of the skill before
pulling it all together and demonstrating the whole skill
3. Students should master individual skills before placing them in
context of a scenario or simulation
4. Students should be allowed ample time to practice a skill before
being tested
5. The need for constant direct supervision should diminish as practice
time and skill level increases
B. From novice to mastery level
1. Demonstrate the skill to students
2. Students practice using a skills check sheet
3. Students memorize the steps of the skill until they can verbalize the
sequence without error
4. Students perform the skill stating each step as they perform it
5. Students perform the skill while answering questions about their
performance
6. Students perform the skill in context of a scenario or actual patient
situation
VI. Providing feedback during psychomotor skill development
A. Interrupt and correct the wrong behavior in beginners to prevent mastery
(muscle memory) of the wrong technique
B. Practice sessions should end on a correct performance or demonstration
of the skill
C. Allow advanced students to identify and correct their own mistakes under
limited supervision
D. Adult learners need encouragement and positive feedback to reinforce
the correct behaviors
1. Adult learners need good role models of correct technique
a. Primary instructors, secondary instructors, skills
instructors, clinical faculty and preceptors are all
important in developing students and these
individuals should be carefully selected for suitability
to their individual roles
E. Allow adults to develop their own style of the standard technique after
mastery has been achieved
1. There are numerous ways to do things right
a. Focus on what is considered medically acceptable behaviors
instead of demanding rote performance or parroted skills
b. Spend time helping students develop high level thinking skills
so they can differentiate between options and adequately
solve problems
VII. Improving psychomotor skill development during a skills session
A. Have all necessary equipment set up before session begins
B. Use realistic and current equipment that is in proper working order
C. Use standardized skills sheets
D. Allow ample practice time in class, at breaks and during other times
E. Always model correct psychomotor skills behavior
F. Keep students active and involved
G. Insist students respect equipment and skills
H. Ensure competence in the individual skills before using scenarios
I. Adding realism
1. Place need for skill in context with a real life scenario or simulation
2. Limit objectives of the scenario to three learning points
a. As students become more sophisticated using critical thinking
skills you can add more dimensions to the scenarios
3. Make the scenario realistic
4. Use actual equipment
5. Consider moulage, props, background noises, etc.
VIII. Maximizing skill session time
A. Assign students in a skill group to each of the following roles according
to the size of group
1. Evaluator: uses a skill sheet or records steps as they are
performed
a. Videotape and audiotape may also be helpful in creating a
record
b. Allowing several students to critique and provide feedback will
illustrate how easy it is for observers to miss steps students
may perform
c. This technique also allows students to improve their own skill
performance as they watch the skill being repeated
2. Information provider: uses a script and supplies information as it is
requested
3. Team leader: primary patient care provider
4. Partner or assistant: performs care as directed by team leader
5. Patient: faithfully portrays signs and symptoms according to
scenario
6. Bystander #1: acts as a distractor or helper
7. Bystander #2: acts as a distractor or helper
B. Distribute a written scenario to be practiced
1. Can use real calls to create scenarios
2. Medical textbook publishing companies have books of scenarios
3. Most textbooks have scenarios in each chapter
4. EMS professional organizations websites have scenarios
C. Begin scenario with the reading of the dispatch information
D. Do not interrupt the scenario
1. Mastery of individual skills should have already been obtained
2. Can comment on timing and decision making later
3. Safety compromises may necessitate your intervention, but do not
interfere if it is not a clear safety danger
E. Group performance evaluation
1. Utilize a positive-negative-positive format
a. Begin with positive statements and general comments
b. Move into constructive feedback and areas for improvement
c. End with positive reinforcement
2. Patient care leader should comment on what he or she did
correctly, then what needs improvement
a. Remember that students are often their greatest critics;
encourage them to look for positive aspects of their
performance
3. Assistant critiques the team’s performance
4. Patient comments on how he or she was treated
5. Bystanders add their observations
6. Evaluator comments on timing, sequencing, prioritization, and skills
performance
7. Students should rotate through each role then begin another
scenario
8. This method keeps everybody active and involved in the skills
practice time
Bibliographic References
Burke, J. Ed. (1989). Competency-based Education and Training. New York: The Falmer
Press.
Kolb, D. A. (1984). Experiential Learning. (1984). New York: Simon & Schuster Trade.
Millis, B., & Cottello, P. (1998). Cooperative Learning For Higher Education Faculty.
Phoenix: Oryx Press.
Watson, A., (1980). Learning psychomotor skills in TAFE. Educational Psychology for
TAFE Teachers.
To learn more visit our chiropracticmentor.com site http://www.chiropracticmentor.com
Instructors – August 2002 – Module 17, pages 139-143
MODULE 17: TEACHING PSYCHOMOTOR SKILLS
Cognitive goals
At the completion of this module the student-instructor should be able to:
17.1 Define psychomotor skills
17.2 Explain the relationship between cognitive and affective objectives to
psychomotor objectives
17.3 Describe teaching methods appropriate for learning a psychomotor skill
17.4 Describe classroom activities used to teach and practice psychomotor skills
17.5 List methods to enhance the experience of psychomotor skill practice in the
Classroom
Psychomotor goals
At the completion of this module the student-instructor should be able to:
17.1 Demonstrate proper facilitation technique when demonstrating EMS skills
17.2 Demonstrate the use of corrective feedback during a skill demonstration
17.3 Create a skill session lesson plan whic h maximizes student practice time
17.4 Create a skill scenario which enhances realism
Affective goals
At the completion of this module the student-instructor should be able to:
17.1 Acknowledge the need to teach the mechanics of a skill before students can
apply higher level thinking about the process
17.2 Value the need for students to practice until they attain mastery level
17.3 Model excellence in skill performance
Declarative
I. Why this module is important
A. Psychomotor skill development is crucial to good patient care by the
EMS provider.
1. Psychomotor skills are used to provide patient care and also to
ensure the safety of the members of the team
2. There are many ways to perform medically acceptable skills
behaviors
a. Need to know steps of skills performance in order to
effectively apply critical thinking skills in situations they will
face in the field setting
B. Instructors plan their approach to teaching students how to perform skills
in order to maximize the student’s abilities
II. Understanding the psychomotor domain
A. Definitions
1. The psychomotor domain involves the skills of the EMS profession
2. Skill, action, muscle movement and manual manipulation
III. Five levels of psychomotor skills
A. Imitation
1. Student repeats what is done by the instructor
2. “See one, do one”
3. Avoid modeling wrong behavior because the student will do as you
do
4. Some skills are learned entirely by observation, with no need for
formal instruction
B. Manipulation
1. Using guidelines as a basis or foundation for the skill (skill sheets)
2. May make mistakes
a. Making mistakes and thinking through corrective actions is a
significant way to learn
3. Perfect practice makes perfect
a. Practice of a skill is not enough, students must perform the
skill correctly
4. The student begins to develop his or her own style and techniques
a. Ensure students are performing medically acceptable
behaviors
C. Precision
1. The student has practiced sufficiently to perform skill without
mistakes
2. Student generally can only perform the skill in a limited setting
a. Example: student can splint a broken arm if patient is sitting
up but cannot perform with same level of precision if patient
is lying down
D. Articulation
1. The student is able to integrate cognitive and affective components
with skill performance
a. Understands why the skill is done a certain way
b. Knows when the skill is indicated
2. Performs skill proficiently with style
3. Can perform skill in context
a. Example: student is able to splint broken arm regardless of
patient position
E. Naturalization
1. Mastery level skill performance without cognition
2. Also called "muscle memory"
3. Ability to multitask effectively
4. Can perform skill perfectly during scenario, simulation, or actual
patient situation
IV. Teaching psychomotor skills
A. Whole-part-whole technique is useful
1. Requires that the skill be demonstrated 3 times as follows:
a. WHOLE: The instructor demonstrates the entire skill,
beginning to end while briefly naming each action or step
b. PART: The instructor demonstrates the skill again, step-by-
step, explaining each part in detail
c. WHOLE: The instructor demonstrates the entire skill,
beginning to end, without interruption and usually without
commentary
2. This technique provides an accurate example of the skill done in
repetition
a. If students were not completely focused on the skill
demonstration one time there are two other opportunities
for them to watch the presentation
3. This technique provides a rationale for how the skill has been
performed
a. Students may or may not be allowed to interject questions as
the demonstration is going on, but generally discussion is
allowed dur ing the middle, step-by-step “part”
demonstration
4. This technique works well for both analytic and global learners
a. Analytic learners appreciate the step-by-step presentation and
global learners appreciate the overview
b. Module 7: Learning Styles has more information on analytic
and global learners
V. Progressing through the psychomotor domain levels of skill acquisition
A. Novice to expert
1. Allow students to progress at their own pace
a. If you move students too quickly they may not understand
what they are doing and will not acquire good thinking skills
2. Although the demonstration may provide information on the
performance of the entire skill from start to finish, students
should be allowed to learn the individual parts of the skill before
pulling it all together and demonstrating the whole skill
3. Students should master individual skills before placing them in
context of a scenario or simulation
4. Students should be allowed ample time to practice a skill before
being tested
5. The need for constant direct supervision should diminish as practice
time and skill level increases
B. From novice to mastery level
1. Demonstrate the skill to students
2. Students practice using a skills check sheet
3. Students memorize the steps of the skill until they can verbalize the
sequence without error
4. Students perform the skill stating each step as they perform it
5. Students perform the skill while answering questions about their
performance
6. Students perform the skill in context of a scenario or actual patient
situation
VI. Providing feedback during psychomotor skill development
A. Interrupt and correct the wrong behavior in beginners to prevent mastery
(muscle memory) of the wrong technique
B. Practice sessions should end on a correct performance or demonstration
of the skill
C. Allow advanced students to identify and correct their own mistakes under
limited supervision
D. Adult learners need encouragement and positive feedback to reinforce
the correct behaviors
1. Adult learners need good role models of correct technique
a. Primary instructors, secondary instructors, skills
instructors, clinical faculty and preceptors are all
important in developing students and these
individuals should be carefully selected for suitability
to their individual roles
E. Allow adults to develop their own style of the standard technique after
mastery has been achieved
1. There are numerous ways to do things right
a. Focus on what is considered medically acceptable behaviors
instead of demanding rote performance or parroted skills
b. Spend time helping students develop high level thinking skills
so they can differentiate between options and adequately
solve problems
VII. Improving psychomotor skill development during a skills session
A. Have all necessary equipment set up before session begins
B. Use realistic and current equipment that is in proper working order
C. Use standardized skills sheets
D. Allow ample practice time in class, at breaks and during other times
E. Always model correct psychomotor skills behavior
F. Keep students active and involved
G. Insist students respect equipment and skills
H. Ensure competence in the individual skills before using scenarios
I. Adding realism
1. Place need for skill in context with a real life scenario or simulation
2. Limit objectives of the scenario to three learning points
a. As students become more sophisticated using critical thinking
skills you can add more dimensions to the scenarios
3. Make the scenario realistic
4. Use actual equipment
5. Consider moulage, props, background noises, etc.
VIII. Maximizing skill session time
A. Assign students in a skill group to each of the following roles according
to the size of group
1. Evaluator: uses a skill sheet or records steps as they are
performed
a. Videotape and audiotape may also be helpful in creating a
record
b. Allowing several students to critique and provide feedback will
illustrate how easy it is for observers to miss steps students
may perform
c. This technique also allows students to improve their own skill
performance as they watch the skill being repeated
2. Information provider: uses a script and supplies information as it is
requested
3. Team leader: primary patient care provider
4. Partner or assistant: performs care as directed by team leader
5. Patient: faithfully portrays signs and symptoms according to
scenario
6. Bystander #1: acts as a distractor or helper
7. Bystander #2: acts as a distractor or helper
B. Distribute a written scenario to be practiced
1. Can use real calls to create scenarios
2. Medical textbook publishing companies have books of scenarios
3. Most textbooks have scenarios in each chapter
4. EMS professional organizations websites have scenarios
C. Begin scenario with the reading of the dispatch information
D. Do not interrupt the scenario
1. Mastery of individual skills should have already been obtained
2. Can comment on timing and decision making later
3. Safety compromises may necessitate your intervention, but do not
interfere if it is not a clear safety danger
E. Group performance evaluation
1. Utilize a positive-negative-positive format
a. Begin with positive statements and general comments
b. Move into constructive feedback and areas for improvement
c. End with positive reinforcement
2. Patient care leader should comment on what he or she did
correctly, then what needs improvement
a. Remember that students are often their greatest critics;
encourage them to look for positive aspects of their
performance
3. Assistant critiques the team’s performance
4. Patient comments on how he or she was treated
5. Bystanders add their observations
6. Evaluator comments on timing, sequencing, prioritization, and skills
performance
7. Students should rotate through each role then begin another
scenario
8. This method keeps everybody active and involved in the skills
practice time
Bibliographic References
Burke, J. Ed. (1989). Competency-based Education and Training. New York: The Falmer
Press.
Kolb, D. A. (1984). Experiential Learning. (1984). New York: Simon & Schuster Trade.
Millis, B., & Cottello, P. (1998). Cooperative Learning For Higher Education Faculty.
Phoenix: Oryx Press.
Watson, A., (1980). Learning psychomotor skills in TAFE. Educational Psychology for
TAFE Teachers.
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