Teaching tips

Originally published in the Instructors Bulletin: American Red Cross Bay Area

Lesson planning

A good lecturer uses a variety of teaching techniques, which may include leading questions, guided discussion, brainstorming, and games or exercises for the class. But all teaching should be interactive, keeping the class involved; and all teaching requires preparation. So you need to go through the process of preparing your lessons, until you have them clear in your mind, and can focus on your students with just an occasional glance at the plan.

            Preparing a lesson has three steps:

•  Doing research.

•  Teaching the topic to yourself.

•  Doing mental rehearsals.

You may ask why you have to do research - aren't the textbooks and instructor manuals supposed to give you everything you need to teach the course? Perhaps. But do you really understand everything that you will be teaching to your students? And do the textbooks give students everything they need not only to pass the tests , but also to prepare for real emergencies? Better work all this out before you find yourself in front of a class that is asking you questions you cannot answer.

            The next step after doing research is to teach the topic to yourself.   Ask yourself the kinds of questions that students may ask you, questions that require you to make connections and explain things, not just parrot information. For example, if a patient has lost a lot of blood, how does the circulatory system react, how will it make the patient feel, and what observable signs will it produce?   Remember that your job in lecture/discussion lessons is to not to dump information on the students, but to train them to use it. In other words, lectures should be skill sessions too. The only difference is that students are learning skills that they do with their brains, not their hands: recognizing, describing, listing, explaining.

            Notice that these words are all verbs for student behavior that you can observe in class. These are the kind of words to use for a lesson's goals or objectives, because they express what students can do by the end of the lesson. Words like "know" or "understand" are meaningless in a lesson plan, because they express only what may be going on in students' minds, and unless you are telepathic, you have no access to that. Also, it doesn't do students any good to watch you "cover the material." They must actually learn to perform the mental as well as physical skills needed to pass the tests and cope with a real emergency, and you must see or hear them perform both.   

            So begin planning your lesson by asking how you are going to get the students to the objectives, and how you will know that they have made it. This is the third stage of preparation, the mental rehearsal.   Try to visualize how the class will work, how the students will respond. Who are you teaching? What is their starting point? What kind of teaching techniques will work best for this particular class? How much time will it take? If your students have previous training or medical background, you should be able to get more out of them in discussion, for instance. But for students who are novices, you will have to lead more.

            At first your classes may not resemble your mental rehearsals very much, but if you know   where you want the students to be by the end of each lecture/discussion lesson, and have thought about how to get them there, you'll be able to find alternate routes if one way doesn't work. So long as you focus on the students and keep the class interactive, your lectures should become mental rehearsals for your students, which prepare them to practice emergency care skills more effectively.



We all know the instructor's motto: KISS (Keep It Simple, Stupid). It applies not only to what we teach, but also to the way we teach it. Let's look at one of our basic skills-teaching methods, drill. It seems very simple. All that an instructor has to do is give instructions, and students perform the skill by following the instructions, step by step. Then when students go into reciprocal practice, they take turns coaching their partners, emulating the teaching technique which the instructor has modeled for them.

            Instructors do not always do drills as effectively as they could, however. As a result, they can make what should be a simple teaching technique complicated, not just for themselves, but for students as well. For example:

•  They may not follow the sequence of steps the way they are shown in the textbook.

•  They may not describe the steps clearly.

•  They miss student errors during drills because they need all of their attention to remember the steps.

•  They may pause to correct an error, and it turns into a lecture/demonstration, interrupting the drill.

•  They may never begin the drill because they start lecturing or demonstrating instead.

When we are performing a skill that we have practiced many times, we don't have to describe it to ourselves. Muscle memory makes the steps almost reflexive. When are standing in front of a class and directing students, however, muscle memory is not activated. So we must be able to visualize the skill, remember the next step without cues, and find the right words to describe it. How can we develop these teaching techniques?

            Analyzing a skill before teaching it helps. An instructor who knows why we check pulse in an unresponsive victim only after checking for breaths (and giving breaths if necessary) is less likely to get that part of the sequence wrong, or to miss a student error. Students often ask why they should not check pulse along with breathing, when they find someone unresponsive.

            The simplest answer is that pulse status would not make a difference in what a rescuer did next. Even if there were no pulse, the next step would still be to give breaths. By analyzing skills in this way, instructors make the sequence more coherent and logical in their own minds, hence easier to remember. This frees their attention to observe and correct student errors, as well as enabling them to answer student questions more easily.    

            Even when the sequence of steps is so ingrained that instructors don't need to think about it, however, they still need to work on describing the steps to students. Giving clear and unambiguous directions is one of the hardest parts of drill to learn - more difficult than lecturing, because in a drill instructors must describe the steps in the fewest possible words, clearly enough so that all the students can do them. If an instructor rambles or fumbles for words, the drill stops, and it is hard to resume in a coordinated way.

            Some instructors also tend to distract the class from the drill by trying to do too much: lecturing, explaining, or demonstrating. But the main purpose of a drill is to walk the students through a skill once or twice, correctly, and at the pace that they would normally perform it. So it is important to keep the drill moving, correcting errors on the fly (e.g. by repeating an instruction emphatically while looking at an erring student). In a class that also uses reciprocal practice, the secondary purpose of drill is to teach students (by example) how to coach their partners. If the instructor interrupts a drill to lecture, students will tend to imitate that behavior, and do more talking than practicing.

Most CPR training is now done with videos, which act as a more effective drill master than an instructor in the classroom can do. Videos show students the skill on a large screen so that they can follow the video step by step. Videos can also show students what the skill does, e.g. how pushing on the chest moves blood to the brain. By studying the CPR videos and analyzing how they work, we can improve our technique for drilling students in other skills.

            Drill is an essential teaching method, especially for skills that must be performed with precision. If done effectively, drill can greatly speed up the learning process, and improve skills retention. To make drill work, however, instructors need to keep it moving, avoid adding anything unnecessary, and above all, remember the instructor's motto: KISS.


Teaching CPR

When citizen CPR training started in 1974, there were optimistic predictions of a 40% to 60% save rate for out of hospital cardiac arrests. As most instructors know, it didn't happen. One probable reason is the ineffectiveness of most CPR classes, documented by many studies. Researchers found that most instructors did not follow the course plan, spent much class time lecturing and telling war stories and too little time on skills practice, did not correct errors, and did not do realistic skills testing.

Most CPR courses these days are video-driven, which means that the video does most of the teaching (if we let it). What does that leave for us to do as instructors? We still need to set up the room so as to facilitate skills learning. We still need to test student skills. And we still need to identify and correct student errors during skills practice; but we can make that task easier by anticipating and preventing common errors.   One way to do that is by clarifying important aspects of the skills that students often miss. When testing skills, however, we should just give students their cues, e.g., "Not breathing!" "No pulse!" One of the most common instructor errors is to tell students what to do in what should be a test.

Here are some tips garnered from many instructors for making our CPR training more effective:

Setting up the room : All manikins should be oriented the same way, with clear sightlines so you can see what students are doing and quickly spot any deviations.

Coach the coaches : Have students monitor each other as they take turns practicing on the manikins. For example, have them watch and feel the manikin's chest and tell their partners if the chest is rising when they ventilate.

Checking the scene : Have students always make the scanning gesture (hand over eyes). Then have them make the umpire's gesture and say "The scene is safe!" Muscle memory will remind them to do it at a real accident scene.

Check for responsiveness : Have students start talking as they approach the patient, then go down on the knee farthest from the patient (facing towards the patient's head), so that the near knee is up, to protect them if a sleeping patient wakes up swinging. Make sure that students tap and talk, no shaking - there may be spinal injury.

Opening airway : Scan the room during drill, and check the angle of the heads. Too little head tilt is the most common error with adults.

Checking the pulse : Have them feel their own carotid pulses, and their partner's. At least two fingertips on the artery, make students count 10 thousands. Watch for the "muggers grip" - no hands across the trachea.

Chest compressions hand position : The nipple line may vary with age and build, so tell students to sight on the line between the patient's armpits.

Chest compression depth : Tell students they must see the center of the chest caving in under the heel of their hand every time they push (on a manikin or a real person). It is hard to gauge the depth of your own compressions in inches.

Chest compressions technique : Show students how to lock their elbows by rotating them inward towards the body after interlacing their fingers.

Counting : Make sure that students form the habit of counting aloud when practicing chest compressions. Not only will it help them (and others on the scene) keep track; it will also ensure that they do not hyperventilate or forget to breathe in the stress of a real emergency.

Conscious choking adult : Have students practice abdominal thrusts on themselves first, then simulate on a partner. Make sure that they loudly signal their intentions: "Are you choking?" May I help you?" I'm going to go behind you." Show students how to find the landmark: Slide horizontal forearms over the top of the patient's pelvic bones, then rotate one fist thumb inward. The old techniques of trying to feel the navel under clothing, or measuring down from the rib notch, are not very practical.

Giving breaths : Remind students to keep the edge of their hands off the trachea, and turn their heads to look at the chest between breaths, so that they inhale fresh air (not the patient's exhaled breath).

Respiratory emergencies : To experience what a respiratory emergency is like, have students try to breathe in and out through their closed fists.

Ventilating with a bag valve mask : Everybody over-ventilates! This can not only pump air into the stomach and induce vomiting; it also builds up pressure in the chest, squeezing the heart and reducing blood and oxygen circulation. Remind students to stop squeezing the bag when they see the chest begin to rise.

Rescue breathing : When students practice rescue breathing for a patient who has a pulse but is not breathing adequately (or at all), make them count by thousands between ventilations: 5 one-thousands for an adult; four for an infant. Otherwise they will form the habit of ventilating too fast (as studies show that most medical and EMS professionals do).

Choking infant : Show students how to pick up a baby and support the head, front and back; then brace the forearm against the bent thigh for back blows & thrusts. Standing, sitting, or kneeling, the thigh must be bent so that the infant's head is angled downwards.

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