Context
The 4 – and subsequently 5 step model for teaching a skill
in ATLS has been around since the ATLS programme began in 1978, and has
remained one of the most controversial areas of the now global programme. This
paper reviews the history and development of the model, provides previously
unacknowledged evidence for its use and proposes ways in which we can better
communicate and use the model in our ATLS courses.
Introduction
Time for skill acquisition is severely limited on ATLS
courses, and always has been, with priority having been given pre 10th
edition to the dissemination of the knowledge-based areas of the course manual
through lectures. The 2019 10th edition provides a greater emphasis
on skills learning through scenario-based discussions, thereby maximising the
context of psychomotor skills within simulated practice rather than as an
adjunct to the manual chapters. Despite this pedagogical advancement, time is
still restricted and instructors may still be privileging lower levels of
Bloom’s cognitive taxonomy over the acquisition of higher order evaluative
skills and psychomotor competence development. It is acknowledged that the ATLS
Provider (student) course is a two-day course with at least three days’ worth
of learning crammed into the time available. Current challenges include how
much pre course learning can be expected for psychomotor skills and how best to
maximise the time on course we do have to practise.
Rationale
This paper will:
· - Review the nature of and need for psychomotor
skill acquisition in the ATLS context;
- Clarify the psychological processes involved in acquiring a new skill;
- Reflect on a range of relevant literature;
- Offer hitherto unacknowledged evidence for the 4-stage method;
- Clarify the psychological processes involved in acquiring a new skill;
- Reflect on a range of relevant literature;
- Offer hitherto unacknowledged evidence for the 4-stage method;
Psychomotor skills– what are they?
Psychomotor skills are described as “the mental and motor
activities required to execute a manual task,” according to Foley &
Spilansky (1972) in Kovacs (1997) and a concept of “integration of well-adjusted
performances, rather than a tying together of mere habits” (Adams, 1987). “Skills
are both mental and motor and they are learned,” asserts Adams (ibid). He adds,
“any behaviour that has been called skilled involves combinations of cognitive,
perceptual and motor processes with different weights” (p.42).
Singer adds to this: “Skilled motor activity is a function
of Input (sensory and perceptual function) x Central processing (decision and
command functions) x Output (motor functions). The integration of these
processes leads to more purposeful behaviour” (Singer, 1978)
To summarise, psychomotor skills, are behaviours that
require a combination of cognitive, sensory, perceptual, organisational and
motor processes, acquired by novices and practised using all of the above,
until they become proficient (Dreyfus & Dreyfus 1986.)
Psychomotor skills – previous research.
There is a dearth of evidence in this field pertaining to
the medical field. Procedural medicine has been an “assumed activity...without
a formal educational context, living within the cliché: ‘see one, do one, teach
one’ for too long” says Kovacs ((1996, p387). This may be due to the preference
for randomised control trials over other approaches which have yielded better
results in the psychological material. So, we tend not to find studies on
experts and novices in skills acquisition, and there is very little work on how
we teach and learn psychomotor skills. But that does not mean that because
there is no model, and no RCT to support it, we cannot support the approach we
have been using for 40 years in ATLS from other, related fields. The domains of
sports and physical education have some useful work we can draw on and may well
offer a starting point for the much-needed empirical research we need in this
area of medicine.
Three psychomotor domains were created during the 1970s – Simpson
(1972), Harrow (1972) and Dave (1967). Simpson’s model was the
one used by the originators of ATLS, with some adaptation. All three models
aimed to describe what happened when people performed a skill, and did
not focus on the process to acquire the skill or to transfer a
skill from a master to a novice. In short, the 4-stage approach was developed
by George and Doto (ibid) as outlined later in their 2001 paper in Family
Medicine, by extrapolation from Simpson’s work, but there is little
background evidence of what contributed to that model. More recent writers have
adopted George and Doto’s original ATLS 4 stage model (1991) model, even being
erroneously credited for it (Peyton, 1998). Before dismissing the model, should
we not find evidence for its use, and if that is not possible within the
medical community, bound as it is by narrow research preferences, then in other
areas of research?
What do we know about learning psychomotor skills?
Some of the original work in this area is decades old, and
to be found outside of the medical education literature, but with little
evidence given for the ATLS 4/5 stage model, this work is offered to clarify how
and why the 4/5 stage model has been advocated for so long.
1.Singer and Cauraugh (1985) identify the three
elements of learning a skill:
· acquisition,
· retention and
· transfer potential (p104.)
In identifying a model for the acquisition of psychomotor
skills in ATLS I suggest we select a model that enables our students to acquire,
retain and transfer the skill to their practice. If any of these
factors are omitted, the skill will not have been acquired for future use, it
will have merely been replicated from the short-term memory. When we debate a
model for skill acquisition, we need to be mindful that acquisition is only the
first step, and that without retention and transfer the skill has not been
learned and cannot thereby be used safely.
Summary: Skills need to be acquired, retained and
transferred appropriate to patient need. We need a model that enables this over
mere momentary imitation.
2.Barnes (1987) emphasises two principles in the teaching
and learning of psychomotor skills:
i) To prevent learners developing faulty initial
habits which are then very difficult to unlearn
ii) Skill retention correlates with the level of
initial proficiency – thus requiring that the first time a learner practises a
skill it has to be practised accurately.
A similar focus on initial accuracy followed by later
practice for speed is outlined by Smith et al (1997) in their work on learning
to perform fibre optic nasotracheal intubation.
Summary: Skills need to be performed correctly the
first time; if error is permitted retention will be delayed, if achieved at
all. We need a model that best enables correct practice first time round.
3.To achieve the three elements in (1) and the two
principles in (2), Singer and Cauraugh (ibid) categorise learning and
performance strategies as primary and secondary. Primary
strategies relate to conducting the skill, (also called associative
by Gagne & Briggs, 1974.) Secondary strategies allow the primary
strategies to operate more effectively – also called support
(Dansereau,1978). A primary strategy may result in little more than copying,
whereas a secondary strategy leads to better retention, adaptation to other
situations and self-management. I suggest our role as instructors is to equip
learners with the secondary strategies so that they can practise ATLS safely
without our presence. Models to enable this are discussed subsequently.
Summary: the mechanism of acquiring a skill needs to
sustain its practitioner once alone
4.Barnes (1987) who ironically characterises surgery as the
“ultimate body contact sport,” pointed to Lippert and Farmer (1984) in
reminding us that psychomotor development has to take place alongside cognitive
and affective development. Indeed Simpson (1966, 1972), the originator of the
work used by the 4 stage approach creators, George and Doto (1991) also
characterised behaviour in the psychomotor domain as reflexive of the mental,
emotional and physical states of the performer.
Singer & Cauraugh (ibid) acknowledge that: “a great deal
of information processing occurs…..when people attempt to learn/perform complex
motor activities” (p106) and that one of the “primary differences between the
highly skilled and the lesser skilled is the degree and type of conscious
involvement prior to, during and following motor performance” (Singer, Garson
& Kim, 1979).
Summary: Skills acquisition is cognitive, not just
motor. We need a model that allows for cognitive acquisition before, during and
alongside the motor acquisition.
5.We need to be aware of the dangers of adapting only an instructional
strategy whereby a student acquires a skill quickly, but with no agency
over it. Rather we should be using a self-initiated strategy
Whereby the student not only acquires the skill, but
develops a self-generating strategy for its future use. (Singer and Cauraugh,
ibid, p107)
Summary: Developing a schema that allows future use
of the skill is essential
Evidence for the 4-stage model for skills teaching as
used in ATLS since 1978.
This is by no means an exhaustive review of the evidence for
the 4/5 stage approach. What this selection offers is a perspective on skills
acquisition that is to be found outside of the medical field. The domains of
physical education and cognitive psychology have been sampled for this purpose.
The following components are considered vital to any
effective psychomotor skills teaching and learning approach:
The role of context
“Performance in a discrete, procedural task is forgotten
more readily than performance in a continuous task” (Adams & Hufford, 1962;
Ammons et al, 1958; Mengelkoch et al, 1971; Neumann & Ammons, 1975).
The role of cognition
The role of cognitive processes has perhaps been ignored by
detractors of the 4/5 stage approach. For clarity, “a cognitive process is a
control process that is a self-generated, transient, situationally determined,
conscious activity a learner uses to organize and regulate received and
transmitted information, and ultimately behaviour” (Singer, 1980a). We cannot
ignore that people actively seek to control their environments, and are not
passive recipients of situational dictates. We need to recognise and utilise
this in the process of transferring a skill from an expert to a novice. That
means that the learner needs to be an active participant, drawing on their
cognitive processes, with support and guidance from their instructor. Learning
a psychomotor skill is a cognitive strategy which draws on internal
organisation as well as external instruction, both of which govern the
learner’s behaviour. A learner imposes a structure on their movement
information that ensures it is learned and retrieved more efficiently.
The role of visual input
Vision is the dominant modality in the early stages of
learning (Fleishman & Rich, 1963) but gives way to other sensory modalities
later on in the learning process.
The role of verbal description
The development of those organisational pathways outlined
above can be mediated by the external support of the instructor. This support
is enacted largely through language, or verbalisation.
“the ability to succeed in motor performance may very well
be related to the ability to apply external and internal words to motor acts” says
Singer in O’Neil (1978).
Not only are words spoken by the instructor important but
also the words spoken by the learner to guide themselves. This has been variously termed: verbal
mediation, conceptualisation, ideation and thought processing.
There is a long history of recognition of the importance of
verbal support for motor skill acquisition. In 1953 McAllister found that
verbal learning transferred positively to motor learning, and verbal pre-
training transferred to motor responses in visual-motor tasks. In 1955 Goss
acknowledged that “verbal mediators were seen as implicit agents contributing
to movement regulation.” However verbal
pre-training is a transfer theory, and is a highly empirical domain, not in
favour with medical education researchers. Whilst interest in mediation and pre
training theory died in the late 1960s and early 1970s, sadly it does not mean
that a better theory for the verbal regulation of movement has emerged since
(Zivin, 1979). We would benefit form some empirical research in this area.
The need for closed loop learning (Adams, 1971)
A closed loop system has feedback from the response, error
detection and error correction. Central
to closed loop theory is the student acquisition of capacity to detect and
correct errors, and the growth in this process is central to the learning
process. It rejects Thorndike’s
behavioural and unconscious view of learning which posits that skills are
merely habits to be acquired without agent consciousness. The axiom
underpinning this is that motor learning is at heart a perceptual process. The
use of error information and the feedback -perceptual trace comparison is a
verbal and cognitive activity. Feedback ‘in-situ’ is vital to this process.
The role of Feedback in-situ
Feedback (auditory, proprioceptive and visual) is an
integral part of motor control. The identification and correction of motor
errors is highly dependent on it (Keele, 1982.) Closed loop learning without
feedback in the moment, is not effective. Error detection and auto correction
is essential to closed loop learning. Furthermore, if we use secondary
strategies within the closed loop learning system, we show that an internal
reference for judgment of error develops. Students become over time, their own
self corrector.
Kovacs (1997) acknowledges that “although ‘correction and
reinforcement’ is listed as a separate stage, in his work, and is often seen as
the fifth stage in the ATLS model, it
should be incorporated into each of the preceding steps because it provides a
form of feedback for knowledge of results.” (p390). We consider the role of in-situ feedback to be
an inherent and essential part of stages 3 and 4, and not a separate stage.
Early evidence of the 4-stage approach
1) Hall 1978
Perhaps the earliest evidence of the 4-stage approach can be
found in Hall’s work (1978) which suggests students need to:
- Think about or imagine motor responses or movement patterns in particular situations.
- Attach verbal labels to each of a series of movements
- Selectively attend to relevant components of the task
- Verbally rehearse a sequence
2) Singer & Suwanthada, 1984
This model was intended for self-paced skills – those which
are proactive, not reactive:
- Readying – obtaining an optimal mental – emotional state for task and situation
- Imaging – the role of self talk
- Focusing – excluding extraneous information
- Executing – using the self talk to guide practice and focus.
3) Kovacs (1997)
Kovacs acknowledges the need to divide the skills acquisition
process into two stages:
(i) A cognitive one whereby the learner
conceptualises the “broader context of the skills” (p390) which relate to both
the visual stage 1 of George and Doto’s (1991) model and the verbal stage 2.
(ii) A more active, motor stage whereby learners both
verbalise and perform the procedure from start to finish, which relate to
stages 3 and 4.
It is not difficult to see where the 4-stage approach to
teaching a skill had its roots.
There is a dearth of evidence in the medical literature or the medical education literature, but that does not mean that we should not look to other areas of professional expertise for clarification. This review is only the beginning of a process that is long overdue.
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