ATLS ®

Advanced Trauma Life Support®

Section 3: ATLS Instructor Training
BRIEF CONTENTS

SECTION 3: ATLS INSTRUCTOR TRAINING

CHAPTER 1: TEACHING ATLS 353

Lesson 1: Introduction and Course Overview 353

Lesson 2: Adult Teaching and Learning 357

Lesson 3: Interactive Teaching in ATLS 365

Lesson 4: Questioning Techniques 371

Lesson 5: Feedback 375

Lesson 6: Preparing to Facilitate a Micro

Scenario-Based Teaching Session 382

Lesson 7: Principles of Teaching a

Psychomotor Skill Station 383

Lesson 8: Skill Station Practice during

Instructor Course 388

Lesson 9: Initial Assessment 389

Lesson 10: Initial Assessment Skill Station

Practice during Instructor Course 393

Lesson 11: Summative Student Assessment 394

Lesson 12: Looking Back, Looking Forward

399

CHAPTER 2: TEACHING THE ATLS INSTRUCTOR COURSE 403

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Chapter 1

TEACHING ATLS

LESSON 1: This course is a team-teaching interactive learning

experience with the course director, an ATLS educator,
Introduction and Course Overview and experienced ATLS instructors. In this experience,
the course participants will acquire an understanding
of the adult education principles that are used in the
Le sson S tatement design and delivery of ATLS learning and teaching.
Course participants are then provided an opportunity
The Advanced Trauma Life Support (ATLS) instructor to put them into practice using the principles during
course is one of the key contributors to the quality and practical training sessions. This structured team-
outcomes of the ATLS student courses. teaching experience employs the newest concepts of
adult education to optimally prepare new instructors
for their roles as teacher, facilitator, instructor, and
Le a r ning Objec ti v e s mentor of an ATLS student course. The approach of the
instructor course is closely aligned with the pedagogy
used in the 10th edition ATLS student course (interactive
By the end of this session, participants will be able to: discussion and hands-on experience).
mATLS, or mobile ATLS, is a new option for parti-
1. Discuss the mission of the ATLS instructor course. cipants to complete an ATLS provider course. Through
2. Describe the concepts taught in the instructor this hybrid education option, the student can complete
course and what participants will learn. the lecture-/scenario-based group discussion portions
of a provider course (10th edition) via any mobile
3. Recognize specific requirements for successful device. This option provides the student with scenarios
instructor course completion. and lessons in the same order as a traditional ATLS
provider course.
At the end of the computer-based learning, the student
Introduc tion completes an online self-assessment. He or she then
moves to the in-person portion of the hybrid course
and completes the scenario-based skill station group
This chapter is written primarily for the instructor discussions, initial assessment scenario stations,
candidate. It includes detailed information about each the initial assessment evaluation station, and final
lesson of the instructor course. written evaluation exam offered exactly the same as a
The goal of the instructor course is to prepare doctors traditional course.
as instructors to teach the ATLS student course. Over In summary, mATLS replaces the traditional lectures
the years, the ATLS course has evolved to include of the 9th and previous versions of ATLS and replaces
greater emphasis on interactivity and small group the scenario-based large group discussions of the 10th
learning. This 10th edition of the instructor course edition ATLS traditional provider course with the same
is based on the strong foundation of the previous written and initial assessment (IA) evaluation process.
editions, adding essentially two aspects: how to ATLS instructors are able to teach in either version of the
use scenario-based teaching principles and how to 10th edition. The decision to offer a hybrid or traditional
facilitate student learning, moving away from “sage course is up to the course director, and each course must
on the stage” and embracing the role of “guide on be designated either a hybrid or a traditional course. An
the side.” addendum to the 10th edition faculty manual will be

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­354 SECTION 3 n ATLS Instructor Training

published for the mobile learning process. Instructors for instructor will adapt his or her actions to the level
the hybrid course will be required to undertake a standard of students to help them progress to the next
ATLS instructor course and instructor candidate course. level. Facilitating learning is something you do
with the learner, not to the learner.
•• Support the team teaching process. Teaching
De s c r ip tion of K e y Role s in ATLS is done as a team in which duties are
shared to help students progress in their learning
During the ATLS course, the course faculty fulfills of the important principles of trauma care.
different roles, varying from instructor, facilitator, The idea of a team extends to not just fellow
teacher, to mentor. The following explains each role: instructors but also to the course coordinator and
team that supports the faculty and students.
•• Instructor—someone who provides direction to
the learner with clear goals
•• Facilitator—someone who actively helps
the instruc tor course
learners identify and personalize goals, uses
questioning to gain information from learners, The instructor course is specifically designed to
and helps learners apply their knowledge optimally prepare the future instructor to conduct ATLS
•• Teacher—someone who works with learners to training. The objectives of the course are to ensure that
future instructors:
achieve their learning goals through facilitation,
instruction, feedback, and assessment
•• Understand the roles of the course director, course
•• Mentor—someone who supports learners in coordinator, and faculty in a student course.
their growth through one-on-one coaching,
•• Understand and apply key adult education concepts.
learning support, and guidance
•• Be aware of how the ATLS course design uses
The emphasis and focus is highly dependent on adult education concepts.
the learning goals and character of the learning
process that needs to be fostered. Consequently, •• Incorporate contemporary adult education
the use of these four descriptions varies throughout principles to facilitate learning in interactive,
this manual. scenario-based discussions, skill stations, and
initial assessment practice sessions.
•• Understand the importance of constructive
Mission of the atls instructor feedback to optimize learning and apply
principles to provide this feedback.
The following best describes the ATLS instructor’s •• Understand the principles of adequate
mission: assessment and the role of an instructor when
testing a student’s performance.
•• Stand behind the ATLS concepts. The ATLS
concepts are at the center of the ATLS teaching The student course relies on the following concepts:
and training. Instructors need to endorse the
ATLS way of taking care of the trauma patient •• Standardized curriculum (teaches one way, the
“ATLS way”)
in the first hour, as well as the ATLS educational
principles and format. The instructor’s level of •• Context (“first hour” of trauma care)
confidence in ATLS concepts affects how well •• Skills (one, safe method)
participants learn.
•• Interactive teaching
•• Walk with the learner. The educational
•• Feedback and assessment
principles at the heart of the ATLS courses
consider the learning of the students as a process The instructor course will prepare the future instructor
that will be facilitated by the ATLS instructors as to play an active role in the student courses. Participants
they accompany the learner on this journey. The in the instructor course start by engaging with an

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 CHAPTER 1 n Teaching ATLS 355

educational foundation, emphasizing the principles 3. Conduct an Initial Assessment station (practice)
of adult teaching and learning, generic skills of the as the facilitator.
interactive teaching, and the skill of facilitating a
4. Demonstrate the course affect consistent with
feedback conversation. Participants will then discuss and
practice the skills necessary for the various components the ATLS facilitator mission statement.
of a student course, covering the instructor roles in the
interactive group discussions, the skill stations, and
initial assessment. They will also be introduced to the Initi a l Asse ssment
concepts of assessment and evaluation of the students’
performance. True to the ATLS spirit, participants in the
Te ac hing Pr epa r ation
instructor course will actively practice these skills and
receive feedback on areas for improvement. In order to Teaching the Initial Assessment Skill Station requires
make this possible, they will play the role of instructor, the same amount of preparation and organized approach
feedback facilitator, and student. as teaching any other component of the course. You
The participants who demonstrate positive attitudes will be assigned a patient scenario. (See the instructor
and aim for a high level of achievement during the course schedule for your assignment.)
course, especially in the interactive discussions, skill The following sections will help you prepare for this
stations, and initial assessment station, will be the ones skill-teaching experience:
who benefit the most. The course faculty, consisting
of the course director, educator, and experienced 1. Section 2, Chapter 2: Preparation for Initial
instructors, serve not only as instructors but also as Assessment Skill Stations (assigned patient
role models in this course. scenario)
To qualify for instructor candidate status, participants 2. Section 4, Part C: Initial Assessment Evaluation
need to: Form

•• Attend the entire course.

•• Actively participate.
Assignment
•• Willingly apply adult education principles.
You will conduct your assigned initial assessment
•• Support fellow participants.
teaching station as you would in a provider course.
•• Show professionalism, including being punctual
and prepared for the course.
Setting
If this sounds demanding, it is. However, it is also a
memorable and enjoyable course that many instructors You will be in a room with the standard equipment
recall many years later as an outstanding experience for your skill station, with a moulaged patient and a
that changed the way they teach—both within and nurse. You will perform in the presence of two other
outside ATLS. participants and one faculty member.

Pr epa r ing for the Expectations

Instruc tor Course You are expected to run an initial assessment teaching
station with the patient scenario you were assigned.
For your preparation prior to the instructor course, you You will go through the scenario with one designated
must have studied this chapter, which outlines not only student. It is expected that you will run the station
essential content for being an effective ATLS facilitator, according to the principles presented in Section 3,
but also the evaluation requirements. In summary, you Chapter 1, Lesson 9: Initial Assessment.
will be required to:

1. Demonstrate facilitation of an interactive discussion Evaluation Criteria

(including environment, set, dialogue and closure).
2. Demonstrate scenario-based practice of an ATLS Each course participant is evaluated for his or her
skill using the 5-step model. performance as instructor using the criteria listed on

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­356 SECTION 3 n ATLS Instructor Training

the ad hoc form in Section 4, Part C: Forms for Evaluating •• Micro scenario-based discussion session
Instructor Course Participants. •• Skill station session
•• Initial assessment session
Feedbac k prov ider
Expectations
An essential role of the facilitator is to provide
effective, constructive feedback to foster learning. You You are expected to structure your feedback according
will be asked throughout the course to function as to the principles presented in Lesson 6.
feedback provider. There are no specific preparations
needed except to review Section 3, Chapter 1, Lesson
6: Preparing to Facilitate a Micro Scenario-Based Evaluation Criteria
Teaching Session.
Each course participant is evaluated for his or her
teaching performance using the criteria listed on
Assignment the forms in Section 4, Part C: Forms for Evaluating
Instructor Course Participants.
You will provide detailed feedback on the teaching
performance of one of the other course participants in
following situations:

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 CHAPTER 1 n Teaching ATLS 357

LESSON 2: and what we know or do as we acquire these new

learning sets.
Adult Teaching and Learning
What Is needed for Learning?
Le sson S tatement
Educational literature informs us that, for effective
Effective learning requires content relevance, positive learning to occur, there needs to be:
motivation, and a supportive environment, as well
as opportunities to practice with feedback. Effective •• Attention—learners need to be actively engaged
teaching is more than good intuition; it relies on in order to maintain their attention. Attention
understanding the principles of effective learning. You is necessary for developing the neural pathways
can learn to become a better instructor or facilitator. that allow information to be stored in memory.
•• Memory—learners need to be able to transfer
Le a r ning Objec ti v e s new concepts, skills, and attitudes to their
long-term memory. In order to do this, they need
opportunities to practice retrieving information,
By the end of this session, participants will be able to: which has been shown to strengthen neural
connections (Dunlosky, Rawson, & Marsh, 2013).
1. Define learning and the three domains of
learning recognized within the ATLS program. •• Motivation—learners need to be motivated to
learn. This topic is discussed in more detail later
2. Discuss examples of effective teaching.
in this lesson.
3. Define the characteristics of effective teachers.
•• Feedback—one of the most crucial requirements
4. Explain the importance of motivation in education. for learning is feedback. Learners need to be
able to identify both strengths and gaps in their
Understanding the principles of effective adult
knowledge, skills, or attitudes, and this comes
learning is essential to ensure that the education
provided by ATLS instructors is of a quality that through receiving feedback on their performance.
will result in the achievement of the ATLS desired •• Socialization—learners learn from each other
learning outcomes. Effective teaching and learning as much as from the teacher. Social interaction
requires excellent instructors, and the aim of the plays a crucial role in cognitive acquisition.
ATLS instructor course is to support its instructors
to achieve this high standard in their teaching. •• Appropriate learning environment—learners
This lesson outlines the principles and theory need to be supported in their learning by
of learning and teaching, the domains of adult the creation of an appropriate learning
learning, and the importance of motivation in environment. Learners should feel safe to try
adult education. new knowledge, skills, and attitudes.

W h at Is Le a r ning? Theories of Adult Learning

There are many definitions of learning in the There are many theories of learning. For the purposes
educational literature; however, the working of the ATLS instructor course, a few of these have been
definition of learning for the purposes of chosen to clarify the educational foundation of the
the ATLS course links various concepts and program for the new instructor.
principles together.
Learning is a process of acquiring attitudes,
knowledge, and skills (learning sets) that, Social Constructivism
together, enable a person to know or do something
new or different. This process results from the In the constructivist model, learning is built on
interaction of preexisting and new learning sets previous experience, and learners are characterized

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­358 SECTION 3 n ATLS Instructor Training

as “active constructors of learning.” This model stresses Armstrong, 2016). There are three key components to
experiential learning (e.g., problem-based learning) deliberate practice:
and is a developmental (i.e., constructive) rather than
a repetitive process. Dent and Harden (2005) explain 1. Clear goals
that “students actively construct or develop their own 2. Individualized training activities to assist in
learning from the range of experiences available to achieving these goals, which are supervised by an
them.” Therefore, the teaching needs to be planned instructor
to provide the important experiences to allow these
constructs to be made. The link to prior knowledge is 3. Repeated practice with feedback from the
also crucial. instructor
Vygotsky’s social development theory is one of the
foundations of constructivist learning theory (Wertsch Evidence is clear that time alone does not result in
and Sohmer, 1995). Vygotsky’s theory has three learning. Deliberate practice is required, which helps
main themes: the learner to reduce the gap between where they are
and the success criteria (Hattie & Yates, 2013).
1. Social interaction plays a crucial role in cognitive ATLS incorporates this theory by providing mul-
development. tiple opportunities for the participants in the student
2. The more knowledgeable other is someone with course to practice and receive feedback. Instructors
more understanding or a higher ability than need to be clear on the goals of the specific learners
the learner. and assist them to achieve these goals by providing
individualized targeted feedback.
3. The Zone of Proximal Development is the
distance between the learner’s ability to perform
a task with assistance from peers or the more Cognitive Load Theory
knowledgeable other and the ability to perform the
task independently. Vygotsky suggests that this Cognitive load theory (CLT) suggests that the human
zone is where learning occurs. brain can process only a certain amount of information
at one time (Gooding et al., 2016). Learners acquire
In an ATLS course, effective instructors will use new information continually through their senses
the experience within a group to promote peer and initially store this information in their short-
learning. This can be very effective in the small term working memory. This short-term memory
group skill stations. Also, instructors can challenge has a finite capacity, and ultimately information
learners to take risks within a safe learning needs to be transferred to the long-term memory,
environment and with the support of instructors where it is stored as schema that can later be recalled
and peers. and used.
The social learning aspect of constructivism CLT suggests that there are two types of load: (1)
emphasizes the role of social interaction in enhancing intrinsic load, which refers to the information to be
learning. In social constructivism, social interaction learned, and (2) extrinsic load, which refers to the
plays an important role. There are two parts in this load required to process the information. Intrinsic
theory: social identity (e.g., to the ATLS program) load can be reduced by providing simpler examples
and social imitation. Based on actual neuroscience first before moving to the complex and by breaking
experiments, there are “imitation neuronal circuits” information into manageable bits for the learner.
in many areas in the brain, so the humans were Extrinsic load is further divided into germane load (the
“preprepared” to imitate many behaviors (e.g., motor work required to organize information into schema)
skills, verbal and nonverbal communication, and affect; and extraneous load (the effort required to process
Iacoboni & Dapretto, 2006). information based on how the information is presented).
Learning is enhanced in a supportive social context There is a need to minimize the extraneous load for
such as occurs in small-group discussions in the learners wherever possible by reducing distractions and
ATLS course. improving attention.
ATLS instructors need to be mindful of cognitive load
by ensuring an appropriate environment with minimal
Deliberate Practice distractions, allowing opportunities for learners to
discuss and learn from each other (reinforcement) and
Deliberate practice has been shown to be neces- recognizing complex tasks that require breakdown for
sary for achieving expertise (Gooding, Mann, & the learners.

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 CHAPTER 1 n Teaching ATLS 359

can be activated by applying the basic principles of

Fac tors Influenc ing adult education.
Adult Le a r ning Beh av ior Extrinsic motivation comes from outside of the
person and represents someone or something else
that makes the student be more prepared to learn.
The theories of learning provide us with some insight Exams, documents of successful completion, and job
into the factors that are required for adult learning: requirements are examples of external motivators
that may cause a learner to attend an ATLS course.
•• Learning depends on motivation. Identifying these external motivators can further
enhance the desire to learn.
•• The adult learning experience must be meaning-
Positive motivation involves rewarding behavior,
ful, experiential, and applicable to real life. whereas negative motivation implies a punitive process.
•• Learning depends on the active involvement These concepts are sometimes referred to as the “carrot-
of learners. and-stick” approach.
Intrinsic and extrinsic motivations are both effective
•• Learning depends on the adult learner’s for stimulating learning. Because ATLS is a peer-to-peer
evaluating his or her preexisting learning set to program, there is a preference for positive and intrinsic
determine the need for change. motivation to drive the learning process. In addition,
•• Learning is enhanced in a social context. extrinsic motivators may fade, whereas intrinsic
motivation may persist. Rewards and punishments
•• Learning must be purpose-oriented, and goals may evoke intrinsic or extrinsic motivation. An external
must be set. reward (e.g., a certificate of achievement or a promotion)
•• Learning effectiveness depends on constructive may be a strong extrinsic motivator. Fear of failure may
feedback. be a strong intrinsic motivator.
The link between motivation and the affective domain
•• Learning requires a supportive and yet is strong and ultimately influences performance.
challenging learning environment. Learners have feelings, emotions, and moods that they
bring to bear on a task. Students are more motivated
when they feel optimistic about their goals and the
Motivation chances of meeting them; when students are more
excited after success, they are more willing to engage
The first and probably most significant principle of in the behavior again.
adult learning is that learning depends on motivation. ATLS instructors should be aware of their influence
Motivation is something that engages, directs, and on motivation and the effect this may have on learning.
sustains behavior. It is often reflected in personal Learners must be motivated to learn, and ultimately
investment and cognitive engagement, but environment the desire to learn must come from within themselves.
can also enhance student motivation to learn. Motivation The course director, course coordinator, and instructors
affects learning and behavior. It directs behavior toward are responsible for creating an environment that
particular goals, leads to increased effort and energy, activates the learners’ intrinsic motivation to learn.
and increases initiation of and persistence in activities.
It enhances cognitive processing; determines what
consequences are reinforcing and punishing; and, when Meaningfulness
it is high, leads to improved performance.
Motivation refers to the desire to work toward a The next principle, related to the previous one, is that the
goal, the valuing of that goal, and the readiness and educational experience must be meaningful. Learners
willingness to learn and act. There are two basic types must feel that the educational experience relates in some
of motivation: intrinsic and extrinsic. way to problems they encounter or perceive. The actual
Intrinsic motivation is the desire to learn that comes course offering must be suited to the individual learner’s
from within a person. If a student has an intrinsic age, interest, readiness, and capacity to understand.
motivation to learn subject matter, he or she will Unless learners see the relevance of the course content,
work tirelessly to achieve that goal and display a they will be unable to apply it effectively to their own
positive attitude. An effective instructor seeks to situations. Learners and instructors are both responsible
help students discover within themselves the need to for creating a climate in which the learners can find
learn the subject matter, thus engaging the intrinsic meaning. This is a creative process for both learners
motivation of the student. Intrinsic motivation often and teachers.

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­360 SECTION 3 n ATLS Instructor Training

This principle deals with establishing relevance and If learners are called on to be active, they profit from
contextualizing the learning. Examples of this in ATLS the specific activity only to the extent that it makes
are where the instructor uses real-life experiences to sense to them. The essence or central idea behind the
provide context and where clinical scenarios are used activity must relate to what the learners perceive as
in the skill stations. their interests and needs, either in the present or in the
The instructor’s challenge is to help provide the relatively near future. When the activity is perceived as
optimal kinds of experiences that relate to the course relevant, the knowledge that it is intended to convey is
content. This principle also deals with the learning learned much more quickly and permanently than that
being experiential. Kolb (1984) suggests that learning which is absorbed passively.
“is the process whereby knowledge is created through
transformation of experience.” He suggests that
learning is an iterative process, with knowledge being Evaluation of Preexisting Learning
continuously derived and tested out by the learner. Set
Kolb also proposes a four-stage experiential learning
cycle that includes the following: The adult learner must evaluate his or her preexisting
learning set (attitude, knowledge, and/or skills) to
1. Stage 1: Concrete experience. The learner has determine the need for change. Once adult learners
a new experience or reinterprets an existing realize their need for change, they are able to establish
experience. realistic goals for new knowledge and skills. Identifying
2. Stage 2: Reflective observation. The learner this need usually presents a more goal-oriented approach
considers any differences between the new or for the adult learner.
reinterpreted experience and his or her previous
experience.
Social Interaction
3. Abstract conceptualization. The learner analyzes
and forms new conclusions. Social interaction plays a major role in adult learning.
4. Active experimentation. The learner tests new The opportunity to share individual experiences and to
hypotheses. place those experiences in a social context enhances the
ability of the student to see the relevance and application
The learner may enter the cycle at any stage; however, of his or her learning.
effective learning only occurs when the learner is able
to cycle through all four stages. It should be noted that
this is a continuous cycle, and completing each stage Explicit and Personalized Learning
does not signify the end. The structure of the ATLS Goals
course provides such opportunities when the learner
experiences interactive discussions, skill stations, Learners must be involved in setting the goals for
and initial assessment practice. It is very important learning and participate in the organization of the
to ensure that each component of the ATLS course learning situation. This can be difficult to achieve in
actively engages learners and provides experiences the context of a prepared course or workshop. However,
for them to reflect and reassess in order for learning instructors need to find opportunities to involve
to occur. the learner in goal-setting. This can be achieved by
asking the learners what they are hoping to get out of
a particular session and comparing this to the actual
Active Involvement learning objectives.

Active involvement in the learning process is

fundamental in creating and maintaining interest in Constructive Feedback
learning new knowledge and skills. When adults are
kept in a passive-dependent role in which the teacher Learning effectiveness depends on feedback. Evaluating
tells them what they should know, their interest rapidly the progress toward goals is very important, particularly
dwindles. Several reported experiments indicate that when goals are set for the learner. The functional
active learners are more effective learners than passive feedback process requires some indications of success
learners. However, it is important to recognize that or failure, a frame of reference for determining the
activity is not something to be carried out just for the adequacy of problem solutions, corroboration that the
sake of presenting an activity. road to learning is not a dead end, and reality factors

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 CHAPTER 1 n Teaching ATLS 361

with which to assess one’s achievement against one’s synthesis, and evaluation. Since then, Krathwohl (2002)
level of aspiration. has modified Bloom’s taxonomy, and it is now more
The basic intention of feedback is to motivate widely used by educators. Krathwohl’s taxonomy
learning. Feedback motivates by rewarding learners refers to:
through recognition of their contributions to the
class, validation that they are achieving the goals and •• Remembering—retrieving relevant information
objectives established for the session, and identification from memory.
of additional knowledge or skills needed to enhance
both their self-satisfaction and value as students. The •• Understanding—developing the meaning of
learning situation must be constructed with liberal information.
opportunities for positive feedback. Instructors •• Applying—carrying out a particular procedure
have the critical responsibility for developing these in a relevant situation.
opportunities. Lesson 5 is dedicated to feedback.
•• Analyzing—breaking down information
into component parts and developing an
Supportive and Challenging Learning understanding of how parts relate to each other.
Environment •• Evaluating—making judgments based on
criteria.
Learning needs to occur in an environment that is
supportive of the learners, which means that instructors •• Creating—putting elements together to make a
need to create this environment from the outset. novel or unique whole.
Learners need to feel that they are allowed to ask and
answer questions without embarrassment, supported
as they identify learning gaps, challenged to try new
things, and encouraged to embrace new concepts.

Le a r ning Dom a ins

There are three learning domains that govern all learning

activities: cognitive, psychomotor, and affective. This more contemporary approach to the cognitive
domain recognizes the student’s prior knowledge and
provides a useful tool for the instructor to analyze
the ATLS components and where they sit within the
taxonomy of cognitive learning. In the ATLS instructor
course, a three-step simplified Krathwohl taxonomy
is presented that includes remembering, applying/
understanding, and evaluating.
When designing a course like the ATLS student
course, these steps are used in sequence. The
beginning step ensures that all students have the
basic knowledge required for successful completion
of the course. Interaction during the discussions
provides for comprehension of the material. Skill
stations allow students to apply what they have
learned from the discussions. Triage scenarios help
students to critically analyze hypothetical situations.
The initial assessment skill station affords students
Cognitive Domain the opportunity to practice synthesis and evaluation.
The taxonomy of the cognitive domain provides the
The cognitive domain includes all of the mental conceptual framework for the underlying sequencing
activities involved in learning something new. Bloom of educational activities in the ATLS student
first developed a taxonomy in 1956 that included six course and justifies why the sequence should not
steps: knowledge, comprehension, application, analysis, be changed.

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­362 SECTION 3 n ATLS Instructor Training

Psychomotor Domain addressed. It deals with attitudes, motivation,

willingness to participate, valuing what is being learned,
and ultimately incorporating the values of a discipline
into a way of life.
Research into affective neuroscience has done much
to discover the role affect plays in learning. Deep,
emotional attachment to a subject area allows a richer
understanding of the material; therefore, learning
occurs and lasts. When one is reading, the emotions
he or she is feeling in comparison to the emotions being
portrayed by the content affects one’s comprehension.
Someone who is feeling sad will understand a sad
passage better than someone feeling happy. Therefore,
a student’s emotional state plays a significant role in
the learning process.
People have feelings about what they do (or what is
being done to them) and develop attitudes toward the
The psychomotor domain is used in teaching experience. If the experience is pleasant, enjoyable, or
psychomotor skills, such as in skill stations (also see rewarding, people develop positive attitudes toward
Lesson 7: Principles of Teaching a Psychomotor Skill it. If the experience is painful or unpleasant, reactions
Station). A taxonomy for the psychomotor domain is will be negative and can lead to dislike, avoidance, or
presented in the ATLS instructor course, based on the rejection of whatever is associated with the experience.
work by Krathwohl (2002). However, if the experience means little or nothing to
In the course, a stepwise approach is used, which people, it is neither positive nor negative, and acquires
ensures that learners move from conceptualization neither an attractive nor an aversive quality. In short,
(understanding when and why the skill is used, there is little affect or similarly minimal effect.
as well as indications and contraindications), to The effect of the affective domain on learning should
visualization (understanding what the skill looks also be considered in regard to courses such as ATLS.
like in real time) to verbalization (practicing the If students develop a positive attitude regarding the
cognitive elements verbally before doing), to practice course, they are more likely to retain and practice what
with feedback. they have learned. If they acquire a negative attitude,
Instructors need to recognize that learners will come they are more likely to disregard the experiences to
to the ATLS course with different abilities for each of which they are exposed in the course, and learning
the ATLS skills. Some participants will be learning will not occur. Faculty members are role models for
the skill for the first time, whereas others will already attitudes. If they display positive attitudes about the
have skill mastery. As an instructor, it is important to content of their presentations and the philosophies
gauge the level of experience of each participant before and principles of the course, students are also likely to
beginning to teach the skill. develop positive attitudes.
The ATLS provider course aims to give all learners an
understanding of the ATLS approach to skills and to
provide an opportunity to reach the stage of practicing
the skill and receiving feedback. ATLS cannot ensure
application of the skill in real practice after the course,
nor does it purport to get learners to the skill mastery
level. Participants need to be encouraged to continue
to practice what they have learned in the course when
they are back in the workplace and to continue seeking
feedback so that their skill acquisition continues
to develop. A taxonomy for the affective domain is presented
in the ATLS instructor course, based on the work by
Krathwohl (2002). The five major categories are listed
Affective Domain from the simplest behavior to the most complex:

Of the domains, the affective is the most important and 1. Receiving—awareness, willingness to hear,
critical for learning. However, often it is not specifically selected attention.

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 CHAPTER 1 n Teaching ATLS 363

2. Responding—active learner participation.

Attends and reacts to a particular phenomenon. The Definition of Teaching
Learning outcomes may emphasize compliance
in responding, willingness to respond, or The definition of teaching links directly to the definition
satisfaction in responding (motivation). of learning: Teaching is the process of presenting
3. Valuing—the worth or value a person attaches opportunities for experiences that enable a person to
to a particular object, phenomenon, or behavior. acquire attitudes, knowledge, and skills (learning sets)
This ranges from simple acceptance to the more that are new or different. Effective teaching is a planned
complex state of commitment. Valuing is process, and the effective facilitator of learning “selects
based on the internalization of a set of specified strategies that will allow the learners to become actively
values, while clues to these values are expressed engaged with the construction of their learning and not
in the learner’s overt behavior and are be a passive tool of teaching” (Clapper, 2010).
often identifiable. Part of the teaching process involves planning social
interaction, encouraging dialogue, and allowing the
4. Organizing—organizes values into priorities by identification of “teachable moments” by the instructor
contrasting different values, resolving conflicts during the learning experience. The teaching process
between them, and creating a unique value involves recognizing the gap between the student’s
system. The emphasis is on comparing, relating, present learning set and the set to be achieved. In a
and synthesizing values. way, teaching may be seen as a “contract” between
5. Internalizing values (characterization)— the instructor and the student in which each has
has a value system that controls learners’ responsibilities to the other. Components of the contract
behavior. The behavior is pervasive, consistent, may be categorized as the objectives to be taught and
predictable, and most importantly, characteristic learned, the processes to achieve those objectives, and
of the learner. the evaluation of learning outcomes. To fulfill the
obligations of that contract, the instructor must identify
A simplified, three-level taxonomy is referred to the learning set; organize the content and media;
in the instructor course: be receptive, respond, and conduct the session; and evaluate learning outcomes,
internalize. Hopefully the affective domain presented giving positive feedback. The student’s obligation is to
in the ATLS course would see learners internalize the recognize his or her initial learning set, focus on future
relevant affect. learning needs, actively participate in the learning
process, provide input to guide the instructor’s teaching,
and show evidence of achieving the learning outcomes.
Teacher–Learner Reciprocity In essence, teaching should provide opportunities for
student experiences so that they build new or different
learning sets based on meaningful interaction between
In teaching–learning situations, attitudes and emotions what they already know and what they are experiencing.
of both teacher and learner often have a reciprocal
effect. If a teacher is anxious, that anxiety is often
transmitted to the learners. If a teacher is calm, learners
are calmer. During potentially stressful situations
W h at M a k e s a n Effec ti v e
in the ATLS course, a calm and patient instructor Teacher?
often reduces the overall anxiety in the course and
improves the learning climate. Conversely, learners’
affective behaviors may influence the instructor’s Newble and Cannon (2001) suggest that there is evidence
affective behavior. that demonstrates a relationship between the teacher’s
In situations where learner behavior is disruptive approach and the student’s learning outcomes. As
to the learning climate, an instructor might resort such, instructors need to be aware of the impact of
to negative affective behavior to attempt to change their teaching on the learner. Research has shown that
the climate. At times intimidating behavior might be effective teachers exhibit similar characteristics:
employed. Since ATLS is a peer-to-peer teaching model,
such negative instructor behavior is inappropriate. •• Awareness of the need to provide a supportive
ATLS instructors need to be aware of their affect at environment for learning
all times, as it has a powerful influence on learning. As
Henry Brooks Adams said, “A teacher affects eternity; •• Use of effective verbal and nonverbal
he can never tell where his influence stops.” communication skills, making certain that

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­364 SECTION 3 n ATLS Instructor Training

information is presented in a way that all ed. Robert J. Armstrong. Tucson AZ: Educational
students understand Innovators [Link] J, Harden R, eds. A Practical
•• Ability to stay on topic and be focused (obvious Guide for Medical Teachers. Edinburgh: Elsevier; 2005.
planning)
•• Demonstration of enthusiasm for the topic and Dunlosky J, Rawson KA, Marsh EJ, et al. Improving
information presented students’ learning with effective learning techniques:
promising directions from cognitive and educational
•• Ability to show students how information psychology. Psychol Sci Public Interest 2013;14(1) 4–58.
or skills taught apply to their “real-world”
experiences
Gooding HC, Mann K, Armstrong E. Twelve
•• Demonstration of empathy and understanding Tips for Applying the Science of Learning to
for each student; being a good listener and Health Professions. Medical Teacher. http://
responding to questions [Link]/doi/abs/10.1080/014215
ATLS teaching is “peer-to-peer” teaching, and good 9X.2016.1231913. Published 2016.
teaching behaviors reflect an understanding and respect
for students. Courses such as ATLS, which have high- Harrow A. A Taxonomy of Psychomotor Domain: A
order goals in terms of changing clinical practice, Guide for Developing Behavioral Objectives. New York,
require excellent teachers/instructors. ATLS instructors NY: David McKay; 1972.
therefore require an understanding and appreciation of
the factors that influence learning and the impact they
have on learning outcomes. Hattie J, Yates G. Understanding Learning: Lessons
An appreciation of the need to provide relevance, for learning, teaching and research. ACER Research
opportunity for practice and reflection, constructive Conference; 2013.
feedback, and social interaction will enhance learning
within the ATLS course. Essential to this is the Iacoboni M, Dapretto M. The mirror neuron system
instructor’s affect and the influence that this has on
and the consequences of its dysfunction. Nat Rev
the learner.
Neurosci 2006;7:942–951.

References Kolb DA. Experiential Learning: Experience as a Source

of Learning and Development. Englewood Cliff, NJ:
Prentice Hall; 1984.
Bloom BS, Engelhart MD, Furst EJ, et al. Taxonomy of
Educational Objectives: The Classification of Educational Krathwohl D. A revision of Bloom’s taxonomy: an
Goals. Handbook 1: Cognitive Domain. New York, NY: overview. Theory Pract 2002;41(4).
David McKay; 1956.
Newble D, Cannon, R. A Handbook for Medical
Clapper T. Beyond Knowles: What those conducting Teachers. Dordrecht, Netherlands: MPG Books; 2001.
simulation need to know about adult learning. Clin
Simul Nurs 2010;6:e7–e14.
Wertsch JV, Sohmer R. Vygotsky on learning and
development. Hum Dev 1995;38:332–337.
Dave RH. Developing and Writing Behavioral Objectives.
RJ Armstrong, ed. Educational Innovators Press; 1975.

Dave, R. H. (1970) "Psychomotor Levels." In

Developing and Writing Behavioral Objectives,

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 CHAPTER 1 n Teaching ATLS 365

LESSON 3: apply and further develop the knowledge they have

gained from reading the textbook.
Interactive Teaching in ATLS Scenario-based discussions differ from case-based
discussions. Case-based discussions present a full case
with situation, assessment, findings, and actions taken.
Le sson S tatement The discussion is then based upon the actions taken or a
critique. In contrast, scenario-based discussions present
only the situation and involve the student in assessment,
Learning is highly improved and more enjoyable findings, and actions taken. Students are engaged in
when students are participating in an interactive scenario-based skill stations that require hands-on
way. Effective interactive teaching can be planned activities and discussion. The initial assessment station
and structured, using the themes of environment, set, provides an opportunity to apply all major concepts and
dialogue, and closure (ESDC), along with management skills and provides a realistic simulation of a trauma
of group interaction. The ESCD structure can help scenario. This station also includes dynamic active
facilitators plan and organize all of the sessions they participation. Other components of the course are based
will facilitate. on significant discussion and involvement.
Good scenario-based discussions make learning more
personally relevant and interesting. The interaction with
Le a r ning Objec ti v e s the other students and the facilitator makes the learning
more effective, leading to greater understanding of the
content and the transfer of learning to clinical practices.
By the end of this session, participants will be able to: It helps them to guide their discovery of new learning
through reflection.
1. Identify the role of the essential elements of Students learn through many modes: listening,
environment, set, dialogue, and closure in an talking, reflecting, seeing, and doing. Each is included in
interactive session. the learning process in ATLS. Although each component
2. Explain the factors involved in managing independently provides a degree of learning, the
interactive sessions. inclusion of all enhances learning overall. Students
are invited to participate in the social interaction of the
3. Describe the importance of the facilitator’s role course through active discussions and participation at
in managing group dynamics. every stage of the course.
4. Explain the role of scenario-based teaching in
ATLS.

The En v ironment, Se t,
introduc tion Di a lo gue, C losur e
S truc tur e
The fundamental approaches of the ATLS student
course are experiential learning and interactivity. This Every ATLS educational format includes four essential
involves the active participation of all students in all elements that help facilitators structure their interactive
parts of the course to enhance their learning (Haidet, teaching: environment, set, dialogue, and closure. This
2004). Experiential learning and interactivity enhance structure is relevant regardless of which element of
the ability of the student to apply the knowledge and ATLS you are teaching: an interactive discussion, a skill
skills gained. station, or the initial assessment station practice session.
There is one introductory lecture that should be In order to maximize learning, the environment, set,
presented in an interactive way, engaging students in dialogue, and closure structure needs to be implemented.
the discussion of major concepts. A major change in The general aspects of each element are described below.
the 10th edition is the introduction of interactive group
discussions that use unfolding scenarios and stimulus
questions to guide students to make decisions and Environment
apply the knowledge they have gained from reading
the student manual. This change requires a shift from Prior to the actual teaching, the facilitator needs to
the traditional lecture, in which a facilitator provides coordinate the teaching environment, which consists
content, to a discussion that encourages learners to of the physical environment, facilitator environment,

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­366 SECTION 3 n ATLS Instructor Training

and learning environment. It is important to take the time both the scenario progression and discussion
to get to know the students at the start of the course and questions.
find out what experience and expectations they bring to it.
•• Adjuncts such as a whiteboard or flipchart can
Not every aspect can be changed or influenced, but it
be used where appropriate to further enhance
is the facilitator’s responsibility to do the best to create
a positive teaching and learning environment: the learning process.

Physical environment: Adjust the room

temperature, ensuring optimal ambient Set
temperature (e.g., ensure good ventilation if the
room does not have air-conditioning); minimize The set is the introduction part of the session and has
four main components:
disturbing noises; optimize the visual comfort
(e.g., avoid direct sunlight on the screen, minimize
1. The facilitator needs to introduce the content of
glare with the use of window coverings, avoid the session and gain the students’ attention. This
darkness); arrange seating to foster interactions involves establishing not only the content but
(e.g., arrange tables in a U shape), and so on. also the relevance of this specific content to
the students.
Facilitator environment: The facilitator needs to 2. The facilitator needs to establish the roles and
master the teaching environment. That means responsibilities with the students. This involves
he or she needs an optimal preparation of the discussing how the session will run, who does
teaching content (i.e., student course manual, what, and when there will be time for questions.
additional literature, clinical scenarios) and the This is part of setting up an appropriate
teaching format (i.e., handling of audiovisual learning environment.
equipment, teaching equipment at the skill 3. The facilitator needs to clearly articulate the
stations, evaluation and assessment forms, specific session learning objectives for the
schedules). The facilitator should also maintain a students. This helps to focus the students and
positive affect throughout the facilitator/teaching/ provide them with realistic expectations.
leader roles of ATLS education. 4. The facilitator needs to identify students’ prior
experience, so he or she can adjust for the level
Learning environment: The facilitator needs to create of the lesson. This will also allow the facilitator
to use learner experiences as appropriate
a positive learning environment. A key to creating
throughout the session and to direct questions to
this positive learning environment is the facilitator’s
those individuals with experience or otherwise.
affect. This entails discussing expectations, inviting It is also important to establish a link to prior
questions and collaboration, and expressing an learning—whether from previous ATLS sessions
expectation that all are present to learn from each or previous learning outside ATLS.
other. The issue of respect should be discussed
to ensure that all participants feel safe to answer
questions and to participate in discussions. Dialogue
Effective use of ATLS PowerPoint (PPT) presentations Once the context has been set and the students’ attention
in facilitating scenario-based discussions is an example gained, the facilitator proceeds to the central part of the
of mastering the teaching environment: lesson, which is the dialogue or interactive teaching. In
ATLS, all teaching sessions are based on the interactive
•• PPT slides have been developed with scenarios approach. Students are expected to actively participate,
and discussion questions to facilitate the and the facilitator guides the session by using different
discussion of ATLS principles and assist the interactive strategies, including supplemental key
facilitator in maintaining the educational questions, which are prepared in advance. He or she
needs to sequence the content appropriately in a logical
direction of the group.
order (for the students), and the content should directly
•• The facilitator should not directly read from the flow from the objectives presented during the set.
slides. This necessitates preparation prior to the The interactive approach makes time management
session so that the facilitator is familiar with an essential skill for the facilitator to master. This

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 CHAPTER 1 n Teaching ATLS 367

responsibility may be shared with another instructor SBT in ATLS involves students working their way
who gives the facilitator a warning time signal. through a structured scenario in an interactive
The interactive discussions are structured with discussion format. Scenarios are also used in the skill
trauma patient scenarios and stimulus questions for station (see Lesson 7).
the participants to answer. Facilitators need to avoid Each scenario unfolds—that is, it starts, followed
answering the stimulus questions themselves and by questions that the participants answer—and then
falling into the trap of providing a didactic lecture. If it continues. The scenarios are designed to elicit
the students are unable to answer the stimulus question, responses, which involves the application and synthesis
the facilitator should break the question down to elicit of the cognitive areas gained from reading the ATLS
responses. For example, the stimulus question may ask, book. Thus ATLS students immediately call on their
“How do you assess whether this patient has an adequate cognitive and psychomotor experience, as well as their
airway?” The content expected from the students is not affect, to determine the assessment, prioritization of
forthcoming, so the facilitator then asks, “What bedside interventions (ABCDE), and management plan.
monitoring could be used?” This SBT teaching process also begins the
“conditioning” to the environment of SBT used in the
initial assessment teaching and evaluation station at
Closure the end of the course. SBT provides numerous feedback
opportunities for all of the participants in the group,
Closure is an essential part of a teaching session, serving based on the patient assessment, interventions chosen,
to consolidate the key points. Sufficient time should and their prioritization of the chosen interventions they
be allocated for this often-neglected component. may make at each stage in the process. Students should
The following three steps make for an optimal and be encouraged to use their MyATLS mobile app during
effective closure: SBT, such that they exercise the educational principle
of “Knowledge is recognizing what you may not recall
1. Question: First ask the students if they have but know where to find it.”
concerns or lack clarity. Invite questions on the
content discussed, but do not address any new
content at this point. It is very important to ask Supporting Theory
for questions and concerns before summarizing.
2. Summarize: When all student concerns have been Scenario-based teaching is based on the principles of
addressed (or time is up), the facilitator summarizes situated learning theory (Lave & Wenger, 1991), which
key points, reemphasizes critical content, and argues that learning best takes place in the context in
links to objectives and other parts of the course. which it is going to be used, and situated cognition, the idea
Summarizing after questions gives the facilitator full that knowledge is best acquired and more fully under-
control of the take-home messages for the students. stood when situated within its context (Kindley, 2002).
The cofacilitator may deliver the summary. Scenario-based teaching is also a method that can be
used by the facilitator to determine the students’ attitude
3. Terminate: Clearly terminate the session to toward ATLS principles (e.g., ABCDE) or the immediate
ease the transition to the next part of the course transfer of trauma patients with an ABCDE issue before
(e.g., by thanking the audience or inviting the diagnostic studies are performed. Immediate feedback
participants to take a break). to the course coordinator and course director is very
important with regard to any substandard performance,
knowledge, or lack of positive affect toward
S c en a r io - B a sed Te ac hing ATLS principles.
in ATL S In addition, it is thought that the SBT experience
increases the retention of the content and likelihood of
transference of knowledge and skills outside the course
Scenario-based teaching is a significant component of to properly apply ATLS principles in the first hour of
the ATLS 10th edition. trauma patient care, but this is yet untested.

Defining Scenario-Based Teaching Possible Pitfalls

Scenario-based teaching (SBT) uses specific trauma The first pitfall is turning SBT into a lecture. Hence, as
patient scenarios to support active learning strategies. a rule of thumb, if the facilitator is speaking more than

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­368 SECTION 3 n ATLS Instructor Training

one-fifth of the time, the session is at risk of turning for being at the course. The facilitator needs to be
into a lecture. Another potential pitfall is the failure committed to inclusivity (supporting the learners) and
to manage time, which may lead to some students use his or her facilitation skills to appropriately manage
not participating or learning during the SBT. Skillful, student participation.
effective facilitators are aware of the time constraints Managing group dynamics is part of the facilitator’s
as well as the need to cover relevant content. This role in the dialogue component of the lesson. The
stresses the importance of being well prepared in order following section highlights group facilitation issues
to manage time constraints. that the facilitator may experience.
It is important to know what to do if there is no
response to the stimulus questions. The facilitator needs
to ask additional questions to elicit knowledge from the Fac ilitator Fac tors
participants. The facilitator should avoid answering
the question themselves and allowing the discussion
to become a lecture. Preparation is essential; it will help the facilitator focus
on the learning experience of the group (group dynamics)
and the students (learning process) instead of struggling
with the content. The facilitator must be familiar with
Adva ntag e s of the scenarios and stimulus questions, anticipate any
Inter ac ti v e Te ac hing difficult questions, and plan for how to break them down
if necessary. The confidence that a facilitator gains by
mastering the content will transmit to the group (see
As seen in Lesson 2: Adult Teaching and Learning, also “Teacher–Learner Reciprocity” in Lesson 2), helping
interactive teaching is highly valued in a socio- the facilitation process. Time management is often
constructivist approach to foster learning. Apart from possible by focusing the discussions on the objectives
those considerations, interactivity serves to: and the core material (the ATLS way, the first hour
of treatment , etc.).
•• Allow course participants to get to know each In the interactive discussions, the facilitator should
other and share ideas and opinions. focus on eliciting the content from the participants,
rather than delivering the content to the students.
•• Reinforce specific objectives by identifying
misunderstandings.
•• Emphasize problem-solving and application Effec ti v ely Fac ilitating
of knowledge.
Dis cussions
•• Relate subject matter to the facilitator’s or
students’ experience.
•• Explore and discuss attitudes about the ATLS An effective discussion facilitator:
core content.
•• Works with the group in attempting to solve
problems. The facilitator is not dictatorial, but
C h a lleng e s of at the same time does not let the discussion drift
Inter ac ti v e Te ac hing along without proper guidance. He or she keeps
the objectives of the discussion uppermost in
mind to ensure that they are achieved.
The interactive teaching style is effective but demands •• Helps to unveil mental models (clinical
more from the facilitator, because he or she is responsible reasoning) that are inconsistent with ATLS
for guiding the interaction. Different factors need to be principles and become apparent from the
considered to lead the discussions. The ATLS instructor participants’ responses to a question. Further
course aims to help prepare the facilitator to manage guided questions can be used to assist the
student factors and enhance facilitation skills. students to explore their reasoning and identify
Students are likely to participate differently in the
the mismatch with ATLS principles.
interactive discussions. This is due to a variety of
reasons, such as preexisting knowledge/experience, •• Tries to minimize unpleasant personal en-
attitudes, level of precourse preparation, and motivation counters by keeping the discussion on the issue.

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 CHAPTER 1 n Teaching ATLS 369

•• Adjusts questions as required to ensure that either in the classroom or during the skill stations.
all learners are challenged appropriate to The group discussion facilitator is responsible for
their current knowledge and experience level. managing the discussion and keeping it on track so
Learners can and do learn from each other as the learning objectives can be achieved. This can be
well as the teacher; however, care must be taken done by careful use of questioning; use of nonverbal
behaviors, such as eye contact and body positioning;
to ensure that the more experienced learners
and by reminding participants of the supportive learning
are still challenged, while encouraging the
environment expectations.
less experienced learners to stay engaged and
participate in the scenario. This requires the
teacher to scaffold the questions to account for Encouraging Participation
all levels of learner knowledge and experience.
•• Asks discerning, thought-provoking questions, The interactive discussion facilitator should provide the
aiming at unraveling the underlying values, opportunity for everyone to participate. However, the
facilitator should not be alarmed if no one is talking;
experiences, and/or potential misconceptions
this may just be an indication that people are thinking.
that might explain why some students don’t
As a rule of thumb, wait 10 seconds before you pose
accept or find it hard to consider adopting the question: for example, “What might help to get the
specific ATLS content and principles. (For discussion going? Let’s try and level with each other on
further reading on this topic, see, among others, X.” A group member need not participate to learn and
Argyris [1978] in the concept of single- and should not be repeatedly asked to participate.
double-loop learning.)
•• Has ideas and knows facts and does not hesitate
to contribute them, but seldom takes sides when
Supporting Quiet Students
controversies arise. Students who are quiet and unforthcoming in
•• Does not dominate the discussion, and does not their participation for whatever reason may need
permit others to do so. encouragement to join in the discussion. The facilitator
should offer them a chance to be actively involved
•• Attempts to be objective, rather than without forcing them to do so. One good way is to
opinionated; patient, rather than anxious; address such students by name first, comment on their
stimulating, rather than dull; and restrained, importance, and then ask for their opinion. For example,
rather than dogmatic. “Dr. Jones, you were the chair of a similar study in your
•• Allows for “golden silence” by not feeling hospital. Can you outline some of the problems the study
obligated to speak except to contribute to the identified?” This method demonstrates that the leader
thinks Dr. Jones’s comments are important to the group
group’s efforts.
and provides the student with the opportunity to speak
Essentially, the group discussion facilitator leads from experience. If necessary, the leader can stimulate
without being obvious about leading; he or she is not further participation from Dr. Jones by asking additional
the pilot of the plane but the air-traffic controller who questions. Usually, a reticent person continues to
keeps the plane on target. Questioning and summarizing participate after making an initial contribution.
techniques are valuable aids in stimulating any The reticent student also may speak softly and
discussion. While facilitating a group discussion, a unclearly, be unable to find the right words to express
variety of problems may be encountered. Examples of a thought, or have difficulty in readily conveying
several types of these students as well as techniques to ideas. The facilitator can help this student by giving
control some students’ behavior and prevent them from time and showing patience, repeating the idea(s),
disrupting the group’s learning process are included summarizing the idea(s), and protecting the student
in this section. from embarrassment.

Maintaining Control of the Redirecting Talkative Students

Discussion
The student who talks too much and has little to say
There may be one or two difficult students or may cause a problem by monopolizing the discussion
problems that inhibit the group discussion process and preventing others from joining in. The facilitator

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­370 SECTION 3 n ATLS Instructor Training

should not embarrass this person, because the rest of Managing Negative Student Affects
the group may respond negatively. If the talker is not
receptive to subtle hints from the facilitator that the Students may display affects or behaviors that disrupt
discussion is a joint endeavor, the facilitator may politely the group discussions and affect other students’
interrupt the student and suggest that another member learning. This can include expressing disagreement
be allowed to respond. After another member of the or arguing with the ATLS principles, overemphasizing
group concludes, the facilitator directs the discussion their expertise, demonstrating inflexibility, or expres-
to yet another participant without letting it return to sing grievances with processes or systems. Facilitators
the talkative student. If the talkative student interjects should avoid making presumptions about the reasons
again, the facilitator may choose to ignore the comment, for the behavior; rather, they should use their facilitation
introduce a new idea, summarize, or ask other students skills to redirect, keep the discussion focused, and
to give their opinions. ensure learning objectives are achieved. This may
Types of talkative students the group leader may be accomplished by acknowledging experience or
encounter include the following: variations in opinions, reiterating ATLS principles,
and encouraging peer moderation. At times a one-on-
•• The student who is always quick to answer may one private conversation outside the group discussion
well have the right answer to every question, environment (during a break) with the student by their
but it prevents others from responding. mentor or the course director can assist in managing
This student’s behavior can be controlled by persistent behaviors that are disruptive.
directing the question specifically to another
student, asking for several opinions, using
the student to summarize the discussion, or
References
ensuring that the student knows the help
is appreciated.
Argyris & Schon, 1978. Organisational Learning:
•• The “rambling” talker tends not to focus on A theory of action perspective. Addison Wesley
the topic being discussed and uses too much of Longman Publishing Co.
the time allotted for the discussion. This type
of student can be controlled by interjecting
when the student pauses to take a breath Haidet P, et al. A controlled trial of active versus
by rephrasing the student’s comments and passive learning strategies in a large group setting.
redirecting the discussion, or asking direct Adv Health Sci Educ 2004;9:15–27.
questions of other students.
Kindley, R (2002). Scenario based e-learning: A step
•• Another type of talkative student is the one
beyond traditional e-learning. ASDT online magazine
who carries on a second conversation while the
learning circuits. [Link]
group is attempting to discuss a topic. While
this student’s conversations may be related, kindley-rw2002-scenario-based-e-learning-a-step-
they are distracting to the rest of the group. The [Link]
facilitator can control this student by one of the
following methods: Lave J, Wenger E. Situated Learning: Legitimate
Peripheral Participation. Cambridge: Cambridge
-- Address the student by name and include him
University Press; 1991.
or her in a discussion with a direct question.
-- Stop the group discussion and let the talkative
student talk until the student realizes the dis-
ruptive nature of the independent conversation.
-- Address the student by name and ask if he or
she has something important to add to the
group discussion.
-- Nonverbal behaviors of the facilitator may
also assist, such as turning away and avoiding
eye contact.

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 CHAPTER 1 n Teaching ATLS 371

LESSON 4: •• Increasing the level of cognitive complexity

(according to Krathwohl’s taxonomy) by asking
Questioning Techniques more complex questions.
•• Increasing understanding by exchanging
different views and doing something with what
Le sson S tatement they are learning.
•• Increasing learning from each other. It is
One characteristic shared by most outstanding almost always possible for the teacher to learn
teachers is the ability to engage students in productive from the students and for students to learn from
discussions. Good discussions make learning more
each other.
personally relevant, more exciting, and certainly
more interesting. Discussions also make it easier for To fulfill the different reasons for asking questions, the
students to fit new content with what they already instructor needs to use different types of questions.
know, thereby leading them to greater understand-
ing of the content and its applications to their
clinical practices.
Obviously, the outstanding teacher’s success in
Que stions th at Ta rg e t
stimulating group discussion is in part related to Co g niti v e Le v el s
personality. However, certain skills also have an
important role. Among them is the skill of questioning.
Developing this skill requires understanding of basic As explained in Lesson 2, the cognitive domain can be
principles, practice, and conscious effort. stratified in different levels. Each of those levels can
be addressed by certain types of questions. By default,
the tendency is to ask questions only on the lowest
Le a r ning Objec ti v e s cognitive level (i.e., remembering), which is insufficient
within ATLS courses. Special effort must be made by
the instructor to prepare questions for the other levels.
By the end of this session, participants will be able to: n TABLE 1-1 provides examples of questions that target
various cognitive levels.
1. Explain the different types of questions and their It is also important for the instructor to change the
application in the ATLS course. level of the question depending on the evolution of the
2. Prepare and analyze a question. discussion. Some choices in attending to the cognitive
levels of the questions include the following:
3. Describe different questioning techniques,
including response strategies and pitfalls. •• Ask for facts. This is good for ascertaining
students’ knowledge base, but it seldom
promotes discussion.
Reasons for Asking Questions
•• Ask for impressions or applications. This
requires the students to do something with the
Questioning is not just about asking questions. It’s a information they have received.
crucial skill for the instructor to facilitate the learning
process by: •• Ask why. This gives insight into the students’
levels of understanding.
•• Involving the students by encouraging •• Ask for opinions. This is a way of showing that
interaction. the instructor values what students bring to the
•• Gaining and maintaining attention, guiding the discussion.
students out of passivity. •• Ask for personal experiences. This allows
•• Assessing levels of understanding by asking students to put learning into personal contexts.
students to verbalize their understanding of •• Ask for preferences. This gives the students a
what they have learned. It’s the easiest way to chance to express the value they place on what
determine if the instructor is being understood. they are learning.

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­372 SECTION 3 n ATLS Instructor Training

table 1-1 examples of questions that target various cognitive levels

KRATHWOHL’S SIMPLIFIED
TAXONOMY TAXONOMY EXAMPLES

Remembering Remembering What is shock?

(Asking for facts that can be answered by pointing to the answer in the book)

Understanding Applying/ Why is this patient in shock?

Understanding (Asking for an explanation in the student’s own words regarding content
learned)

Applying Applying/ How would you treat this patient in shock? (Asking for application to a
Understanding practical case)

Analyzing Applying/ What class of shock is this, and why?

Understanding (Asking the student to analyze a new situation and explain the findings)

Evaluating Applying/ What complications might result from this shock state? How do you prevent
Understanding and manage them?
(Asking for the student to reflect on, weigh, or prioritize different options and
to express founded preference)

Creating Evaluating What other approaches might you take to manage this patient in shock? What
causes you to think about alternative management strategies?
(Asking the student to create new solutions and approaches that were not
discussed before)

•• Ask students to solve a problem. This requires Divergent questions are open questions; they require
synthesis, the ultimate goal of the ATLS course. insight, creativity, independent thinking, and/or
different perspectives on a given topic.
Failure to change the level of questioning will result in
less learning and frustration by some learners. The goal
is to move the learner up the taxonomy from knowing to Convergent Questions
applying and ultimately to problem-solving (creating).
This is particularly important in a course such as ATLS, Convergent questions usually aim at lower levels of
in which the goal is to support application of knowledge cognition (remembering) and do not usually require
and skills outside the course and see learners applying comprehension or higher cognitive thinking. They
the ATLS principles to the management of the trauma are useful for a discussion based on acceptable or
patient in their work environments. The instructor is known facts. This type of question asks generally
aiming to influence the affect of the learner such that for a discrete length of response (e.g., yes/no, small
the ATLS principles are valued, adopted, and retained. number of facts in a list); they will shorten discussion,
as a common agreement on the correct answer is
easily achieved.
Con v erg ent a nd
Di v erg ent Que stions Divergent Questions
Divergent questions aim at higher cognition (applying,
The ATLS instructor will be well served by understanding analyzing, evaluating, creating), generally require
two major types of questions: convergent and divergent. thoughtful consideration, and often rely on past
Convergent questions are closed questions—that is, experience or preexisting knowledge on which to build.
questions with specific and usually factual answers. Divergent questions require usually complex and longer

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 CHAPTER 1 n Teaching ATLS 373

answers; they are useful for sharing different ideas and and refocus discussion, the instructor can ask a
opinions and stimulating problem-solving skills. convergent question.

Strategic Use of Convergent and Directing the Questioning

Divergent Questions
In the ATLS student course, a mix of convergent and In the previous lesson, strategies for managing student
divergent questions is often helpful. It is important to interactions were discussed. The choice of questions
understand which type of question to ask, to ask the is also influential in managing student situations, and
question correctly, and to give students opportunities the instructor needs to choose his or her questions with
to respond. Sometimes the use of a convergent question this in mind. Some choices in deciding how to direct
may establish known facts that will lead to a more active the questions include the following:
discussion through a series of divergent questions
that follow. The following questions are examples of •• Ask a question and then name the student. This
a mixture of convergent and divergent questions that may lead to embarrassment for the student who
are useful in this course: is not paying attention or who does not know
the answer. If an instructor wishes to use this
•• Is this patient in a coma? (convergent)
technique, he or she should offer an option for
•• Why, or why not? (divergent) the student who doesn’t know the answer to
•• What is the patient’s Glasgow Coma Scale score? avoid embarrassment; for example, by allowing
(convergent) students to discuss the answer with the person
next to him or her.
•• Will you intubate the patient? (convergent)
•• Name the student and then ask the question.
•• Why, or why not? (divergent)
This may be less threatening than the previous
•• How will you treat this patient? (divergent) choice, depending on the nature of the question
•• What principles governing increased and the questioning style of the instructor.
intracranial pressure does this patient •• Ask a question and choose a volunteer. The
represent? (divergent) answers are usually better, but the instructor
needs to draw everyone into the discussion.
The strategic use of both types of questions is effective.
It is important for the ATLS instructor to avoid asking a It is important to ask questions in a way that does not
divergent question when he or she expects a convergent embarrass students. Once a question is asked:
answer. For example, “What else can be done for this
patient?” is a divergent question that may lead to many •• Give students time to answer. Students require
diverse responses. However, “What is the next step some time to understand the question and
to manage this patient’s airway problem?” is a more formulate the answer. Give a few seconds for
specific and convergent question.
students to think (5 seconds is usually enough).
A series of convergent questions, one after the other,
is often interpreted as a type of “oral quiz” to evaluate •• Look at the student who is answering, and
preexisting student knowledge. If the purpose is be attentive. Maintain eye contact with the
to evaluate preexisting knowledge, then a series of student—it is more engaging and often makes
convergent questions is appropriate (although this is the student feel that the instructor is more
usually not necessary in an ATLS course). Interactive interested in his or her answer.
dialogue and discussion are better generated by a
carefully crafted series of divergent questions with a few •• Respond with appropriate gestures. The
convergent questions to keep the discussion focused. instructor may use appropriate gestures (e.g.,
One method of generating discussion through a nods, smiles) to indicate acceptable responses
question is to ask for a case example: “Who recently to questions.
saw a patient in severe shock? What were the patient’s
clinical signs?” will more effectively lead to discussion •• Acknowledge and comment on every response.
than “What does the ATLS manual say are the clinical Every response from every student should be
signs of shock?” To regain control of the interaction acknowledged with an appropriate comment

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­374 SECTION 3 n ATLS Instructor Training

so that the student and the rest of the class and to make sure to reemphasize the correct answer at
can recognize whether the response is correct, the end of the process.
incorrect, or requires clarification.
•• Paraphrase the student’s response. If the
student response is not exactly what the
Que stioning Pitfa ll s
instructor expects, paraphrasing it may help to
provide clarification. The following are some pitfalls to avoid when asking
•• Provide clear, unambiguous feedback. questions:

•• Lengthy questions. Succinct questions are more

The ability of questioning to stimulate discussion and focused and easier for students to answer.
active engagement of the learners cannot be emphasized
enough. However, the manner in which responses to •• A question within a question. Ask one question
questions are managed by the instructor also impacts the at a time.
likelihood of ongoing engagement. Handling incorrect •• Embarrassing or ambiguous questions. These
or unexpected answers largely determines the climate often result in negative reactions.
of the interactions. It is important for the instructor to
consider those answers as unique learning opportunities •• Overuse or underuse of particular students. The
for the students who expressed them. Exploring the goal is to involve everyone.
reasoning behind the wrong answer may help the
student and the instructor understand where the root of Remember, the instructor is responsible for maintaining
the misunderstanding lies. This exploration can first be control of the core content throughout the discussion
done with the student who gave the incorrect answer and that emanates from the questioning. Ensuring adequate
later with the group. It is crucial to do this exploration in coverage of the content is the instructor’s primary goal.
a constructive, supportive, and nonjudgmental manner

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 CHAPTER 1 n Teaching ATLS 375

LESSON 5: student to change his or her performance by

stimulating reflection and discussing strategies
Feedback to alter or improve future performance.
•• Comparison: ATLS provides one safe way for
taking care of trauma patients that is specified in
Le sson S tatement the manual and more specific in, for example, the
critical decision points for all patient scenarios.
Feedback is one of the most powerful and evidence- During the provider course, faculty stimulates
based tools in effective learning and teaching for students to experience how applying the ATLS
clinical practice. standard works and can best be integrated in
their professional performance. In the feedback,
the focus is on ways for students to learn from
Le a r ning Objec ti v e s their experiences by comparing their actual
performance with the ATLS standard.
By the end of this session, participants will be able to: •• Specific: Feedback is useful when it addresses
specific observed aspects, tasks, or behavior.
1. Define feedback in the context of learning and This is one of the most important and yet most
teaching. “violated” principles for effective feedback.
2. Explain the importance of feedback for learning. This manual will revisit this topic later when
describing principles for effective feedback.
3. Apply principles of effective feedback.
4. Identify potential pitfalls of feedback.
5. Explain the importance of involving the learner Imp orta nc e of Feedb ac k
and using a structured approach to optimize
feedback.
Research consistently ranks feedback as among the
strongest interventions at teachers’ disposal to affect
student achievement. When asking various groups of
Definition of Feedb ac k professionals when they learn the most, the answer is
usually something like, “By doing my job as well as I can
and at some points, discussing the whys and hows with
Literature provides many definitions of the term others—peers, experts—in order to get better.” This is
feedback. In the ATLS context, feedback is “a two-way exactly what happens in an ATLS course.
process in which specific information is exchanged Feedback is a powerful tool to promote reflection on
about the comparison between students’ observed learning, performance, and ways to adjust or improve
performance and a standard given, with the intention these. Effective feedback can give a huge boost to
to encourage students to improve their performance.” learning and professional growth by stimulating
students to experiment, move out of their comfort zone,
•• Two-way process: This refers to the fact that and be allowed to make and correct mistakes.
feedback is more than just telling the student Note that this works not only for the student, but also
what he or she did well and what could be done for the instructor. Instructors often report experiencing
better. It implies mutual interaction between this when preparing for and supporting learning and
the student and the instructor and between teaching. Supporting students can be a very stimulating
fellow students in which each, from his or her and effective way to become aware of and refresh their
own perspective, reflects on the experienced or own tacit knowledge, routines, and opinions.
observed performance of a student. Constructive feedback helps students to consciously
accept and integrate positive new behavior in their
•• Intention to support: This follows directly from “minds and hands.” Feedback should not focus
the main principle of creating a supportive exclusively on the cognitive domain, but can be given
learning environment in all ATLS courses, in all three learning domains—cognitive, psychomotor,
including the instructor course. It’s about affective. Constructive feedback also helps students
offering students optimal chances for to correct less effective or incorrect behavior as soon
professional growth. An instructor supports the as possible.

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­376 SECTION 3 n ATLS Instructor Training

in which allocated time and place to discuss is

pr inc iple s of effec ti v e available. Establish with the group how feedback
Feedbac k will be facilitated. For example, arrange a few seats
in a circle in the corner of a classroom. Or look for a
private room if you want to address something more
Looking at the growing body of evidence on effective sensitive—for example, a student’s attitude during the
feedback, it is obvious that giving and learning from course. Note that a respectful environment is needed
feedback is a complex and dynamic process that is for all feedback situations, not only when addressing
influenced by many factors. Each instructor will areas for improvement. A respectful environment
probably have experienced examples of very effective also means a respectful attitude from the instructor
and ineffective or even hostile feedback. Giving good toward the student with the intention of aiding the
feedback takes more than just following a few tips and learning process and not judging the person. The
tricks. It takes practice and reflection to hone these instructor can be tough on the subject, but not the
important skills. Knowing this, the following principles student personally.
are useful for facilitating effective feedback:

•• Feedback works two ways between students Timely Feedback

and instructors.
The power of feedback is most effective when facilitated
•• Feedback is given in a respectful environment. as soon as possible after the performance. With fresh
•• Feedback is provided as soon as possible. memory of what actually happened, it’s easier for the
instructor to be specific and for the student to reflect
•• Feedback is constructive, specific, and based on
on his or her performance. It also makes it easier for
direct observation. the student to implement the change if feedback is
•• Feedback is balanced. based on recent experience. One exception, however,
is when the student is upset. In this case, he or she
•• Feedback is reflective.
may first need some time to overcome emotions before
•• Feedback is focused. actually being able to listen to the feedback (Ericsson et
al., 1993).
•• Feedback is aimed at a clear and agreed
action plan.
Constructive, Specific Feedback Based
on Direct Observation
Two-Way Feedback
Constructive refers to the main principle of providing a
Research has shown that the more the learner is actively safe and supportive learning environment within ATLS.
involved in the feedback process, the more effective the Feedback is a powerful tool to demonstrate that and
feedback will be. This means that a two-way feedback should be facilitated with the intention of supporting
will actually have more impact on students’ acceptance students’ growth, overcoming barriers and difficulties,
and use of the feedback in the future (within the course learning to master new skills, and applying a systematic
and in clinical practice). approach to situations they are facing or will be facing
Depending on the situation and the model used in clinical practice. Before actually facilitating feedback,
for facilitating feedback, the feedback process the instructor needs to think carefully about what was
can be an interaction between one instructor and observed and what she or he really needs to explore
one student, or it can involve other instructors with the learner about the performance in order to help
and/or students. the student improve.
In order for the student to be able to learn from
feedback, it must refer to precise behavior and address
A Respectful Environment specific possibilities for change or improvement.
Although at first it might be very nice to get feedback
Even if instructors respect and apply all rules for like “You did a great job” or “You followed the ABCD
supportive feedback, participating in the feedback structure very well,” a student may wonder what
process can still be challenging for the student. exactly was so right about the job and what made
Taking the feedback process seriously, including the the approach so successful. The student may wonder
persons involved, requires a respectful environment why there weren’t any points for discussion or further

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 CHAPTER 1 n Teaching ATLS 377

improvement. Specific feedback is a prerequisite if one Causal Feedback

expects students to be able to apply the feedback in
their next skill station and/or in their daily practice. In Behaviors are the result of different thought processes.
other words, praise might make learners feel good, but To concentrate the feedback only on observed behavior
positive and specific feedback helps them to understand is missing the opportunity to explore why an important
exactly what in the performance was effective. Direct behavior has been performed correctly or incorrectly.
observation is a necessary condition for both the Sometimes students do the right thing with the
instructor and the student. It’s hard, if not impossible, wrong thinking or the other way around. Asking
to facilitate specific feedback when the instructor hasn’t the question “Why did you choose to do that?” will
actually seen the student perform. From a student’s help to address the underlying reflection that led to a
perspective, feedback is easier to accept if it is from particular behavior.
firsthand observation (not “hearsay”) and specific in
referring to precise moments, such as, “At that point
I saw you put in the needle, where exactly did you Focused Feedback
place it?”
It helps a student to apply feedback if it addresses a
limited number of aspects of the performance. As a
Balanced Feedback rule, think of a maximum of two or three points. From
a longer list of points, focus on the most important
In general, feedback should consist of both positive ones that will most likely improve performance,
points to reinforce behavior and points for change or the next best learning steps. It’s no use giving
improvement. Addressing positive points is not about them all since this overloads the student, who then
“being nice,” but about supporting effective learning by might not apply anything next time or focus on
emphasizing and reinforcing positive, effective learning minor aspects.
and/or behavior. The learner should be informed
explicitly on what behavior he or she should continue
to have. Conclude with an Action Plan
Most people tend to focus immediately on what
went wrong. It is important for an instructor Feedback is not just looking back, but also looking
guiding the feedback process to consistently address forward to a student’s next performance in similar future
what went well despite this tendency not to talk situations. After elaborating on the performance just
about it. completed, it’s important to help the students identify
But what if a student performs really poorly—for main points to incorporate in the next performance
example, making major mistakes in an initial assessment and translate these into clear and specific points for
scenario? The answer really depends on a variety of action. Again, this should focus on the two to three
factors, such as the situation, the student, and the quality most important issues.
of support given. On the one hand, respectful feedback
should be genuine and frank. Students immediately
realize if an instructor has to look for one tiny positive Selec ted feedback models
aspect of their performance. Furthermore, it’s important
to acknowledge a poor performance. There is a danger
that feedback might be given in such a positive manner There are many models or methods to give feedback.
that the learners fail to recognize the danger or a problem Different models are presented here that differ in the
in their performance. This is even more important when way in which students and instructors fulfill their
you consider that research has shown that, in general, roles and solicitation in the reflection and feedback
students in the lower quartile of performance tend to of a student’s performance. These models can be
overestimate their performance, whereas students in viewed as a progressive approach to master the art of
the upper quartile tend to underestimate this (Lipsett giving feedback, from the simplest feedback sandwich
et al., 2011). model to the more elaborate, natural, and highly
On the other hand, do not forget the basic principle effective dialogue approach. The more experienced
of positive feedback by running over a student with you are, the more you will appreciate the elaborate
a list of all that went wrong. Again, if not positive, and more effective models. The instructor
feedback should at the very least be constructive in course will focus on one model or the other,
order to facilitate learning from any experience during depending on the local practice, but all models are
the course. presented hereafter.

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­378 SECTION 3 n ATLS Instructor Training

Feedback Sandwich quite a while. It gives a set sequence for giving feedback
by exchanging with the learner, emphasizing beginning
The feedback sandwich model consists of three steps: with and further elaborating on what went well before
moving to describe what could or should have been
1. The instructor comments on positive aspects of done differently.
the observed performance. The Pendleton rules involve the following six steps:
2. The instructor details the observed aspects that
need to be modified or improved. 1. The instructor asks the student to identify what
went well, to list the points he or she is satisfied
3. The instructor makes some final positive comment. with. The student answers. The instructor makes
sure that the student doesn’t jump directly to the
The feedback sandwich (aka “cookie, lemon, cookie” weaknesses, thus omitting the strengths.
sandwich) is a simple and compact model for giving 2. The instructor discusses what went well by
feedback, guided by the instructor. It forces balanced confirming what the student said and adding his
feedback and invites the instructor to be specific, but it or her own observations, if needed.
lacks the two-way approach, so the instructor doesn’t
know what the student understood or agreed upon. 3. The instructor asks what the student would like
The feedback provider controls the time, as he or she to improve for next time and what went less well.
is the only one to talk. 4. The instructor discusses points that can be
The difficulty with the feedback sandwich is for the improved by confirming what the student said
instructor to avoid the transition from Step 1 to Step 2 and by adding his or her own observations,
occurring by using the word “but.” The word “and” is when necessary (i.e., if key elements for student
more appropriate. Used repeatedly, this feedback model learning have not yet been addressed).
may become too predictive, and the feedback-receiver
5. The instructor asks the student to summarize
may not listen to the first step on the positive aspects
major points, adding options for change.
anymore, waiting just to hear the areas of improvement
in Step 2. 6. The instructor compliments the student’s
To address the problem of the feedback sandwich summary, if needed.
being a monologue, a modified version can be used:
Stay alert to what people bring in at each step to avoid
1. The instructor asks the student to describe what people repeating the same feedback points. If a student
went well and what could be improved, and identifies the main issues, it is not necessary to mention
listens to the student’s answers. (“echo”) these again; it’s sufficient to acknowledge that
2. The instructor confirms what the student has the student did a good job at identifying the major
said and adds his or her own observations, issue(s) of his or her performance.
if needed. This model involves the performing student as well
as fellow students in a more active way. Although the
3. The instructor asks the student to list two to three model initially may appear to be somewhat mechanistic
key areas for improvement based on points 1 and 2 and predictive, practice of it often results in a form of
and adds his or her own suggestions, if needed. discussion that is more relaxed and natural.

This model retains the compactness and simplicity

of the feedback sandwich model but incorporates most Pendleton “Plus”
of the Pendleton rules (see hereafter) that encourage a
meaningful dialogue between instructor and student. The Pendleton model described above can be elaborated
For new instructors, the modified feedback sandwich on a bit further to become more of a conversation
is a reasonable way to build feedback skills. between the student and the instructor with the help
of the concept that the development of a novice to an
expert occurs in four stages:
Pendleton Rules
1. A novice is unconscious of his or her
The Pendleton rules are based on the feedback sandwich incompetencies.
model, adding the two-way approach and being more 2. The beginner becomes conscious of his or her
precise in the exploration of the learning experience. incompetencies.
The model has been used within medical education for

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 CHAPTER 1 n Teaching ATLS 379

3. The advanced learner is conscious of his or her the reasons for their actions. This kind of reflective
competencies. feedback can develop understanding of practice and
4. The expert is unconscious of his or her result in greater behavioral changes in the longer term.
competencies. The following is the roster of feedback according to
the “Pendleton plus” model (Allan 2012):

COMPETENCIES INCOMPETENCIES •• Insight—Instructor Asks: “How do you think

that went?” to determine the level of insight of
Conscious 3. Advanced 2. Beginner the learner.
•• Headline—Instructor Tells: “ I thought
Unconscious 4. Expert 1. Novice
that was excellent | very good | good | okay |
slightly problematic | problematic. Let’s go back
Applying this simple grid to a learning experience shows through what you did and look at each part, as
that the student will present a mix of competencies and this can be improved.”
incompetencies that are conscious and unconscious.
•• What went well:
The aim of the feedback is then to actively explore
all four quadrants in a dialogic mode. The instructor -- Instructor Asks: “Let’s look at what you
leads the feedback by exploring first the competencies, think went well.” Add “why” and “how did
asking the student to discuss the conscious parts and you do that?” questions where relevant to
complementing with the unconscious parts. The promote analysis.
instructor then moves to the incompetencies and asks
the student to talk about them, complementing these by -- Instructor Tells: Do not just say “what” but
addressing the instructor-observed unconscious parts. also “why” and “how”
What most distinguishes Pendleton plus from the •• What to improve:
original Pendleton’s rules is the inclusion of a range
of questions that promote deeper reflection. Sandwich -- Instructor Asks: “Let’s look at what you
models and Pendleton’s rules tend to focus on “what” want to improve or develop.” Add “why” and
questions—“What went well?” and “What can be “How would you do that?” questions where
developed?” In Pendleton plus, other, deeper questions relevant to promote analysis.
are asked, such as “Why did you choose to do that?” -- Instructor Tells: Do not just say “what” but
and “How might you approach that differently?”
also “why” and “how”
“What” questions help to identify certain aspects of
good and subpar performance, whereas “How” and •• Action Plan—Instructor Asks: “What will you
“Why” questions promote thinking about choices do to take this forward?”
around those aspects. This deeper form of reflection,
•• Action Plan—Instructor Tells: Suggestions
sometimes referred to as “double loop learning” (Argyris
for change and development in terms of follow-
& Schon, 1978), enables learners to examine and discuss
up actions, not just advice.

COMPETENCIES INCOMPETENCIES

Conscious What went well? What could you do

Dialogic Feedback
How did you do better?
Dialogic feedback is a newer, more elaborative
that? How would you do
approach to giving feedback. Especially when used
Why did that that? in an inadequate, “mechanic” way, models explicitly
work? Why would you do prescribing a set sequence of “first positive, then
that? what could be better” sometimes are regarded as too
structured and unnatural once students and instructors
Unconscious What I thought What I think you recognize the repeating pattern. This might make some
did well. can develop. students reluctant to accept the feedback, because it
How you did it. How you can it. is not regarded to be a genuine reflection on the main
Why it worked. Why it is important issues in their performance.
to do it. Dialogic feedback, or a learning dialogue approach,
implies an interactive feedback process in which the

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­380 SECTION 3 n ATLS Instructor Training

topics for feedback are selected by the student and then The feedback process is fundamentally the same,
discussed. It is defined by Carless in Boud & Molloy (2013) and the models presented above fully apply. In order
as “an interactive exchange in which interpretations to incorporate feedback from the peers, respect
are shared, meanings negotiated, and expectations the sequence:
clarified.” It requires trust between the learner and the
feedback provider, such that instructors must ensure 1. Student’s self-evaluation
that a supportive atmosphere is provided. Carless also 2. Peers’ feedback
suggests that it requires “openness and transparency
in assessment procedures, reliability of judgments, 3. Instructor’s feedback
honest feedback which identifies weaknesses as well
as strengths, goodwill and generosity of spirit from the It is important that you as instructor be the last person
feedback provider.” An example of dialogic feedback is to talk. This will ensure that peers contribute more
the learning conversation (Bullock et al, 2015). easily, and it gives you the last word to control the
Using a dialogic feedback approach involves the closing of the feedback. Also note that feedback during
following: assessment is done differently (see Lesson 11: Summative
Student Assessment).
1. Get the conversation started with an opening
phrase, looking back on the student’s
performance. Think of phrases such as:
Pa rtic ipating in the
•• “So, that looked pretty tough. Shall we run Feedb ac k Pro c e ss
through the scenario to see what actually
happened while you took care of the patient?”
•• “That seemed to run pretty smoothly. Can you This lesson has focused thus far on how to facilitate
describe to me what your plan was and whether it feedback as an instructor. However, participating in
actually did or did not go according to your plan?” the feedback process as a student is also a skill. Some
•• “Let’s look back. What did you feel were your students may be very adept at requesting, seeking,
specific challenges in this scenario?” and receiving feedback, whereas others may not be
as comfortable with participating in the feedback
2. Look and listen carefully and actively to the
process. Instructors need to be alert to or aware of
student, and ask clarifying questions to identify
feedback-avoidance behaviors. All ATLS students
key issues for discussion, which can be both
need to participate in feedback on their skills, their
strong points as well as areas for change. This is
application of ATLS knowledge and principles, and
about helping the students to judge their work
their performance in the initial assessment station.
and asking for specific feedback.
Learners in the ATLS course are not explicitly taught
3. Explore these issues with all group members, how to participate in the feedback process; however,
using observations and suggestions from all. it is important that they all engage in this process.
4. Ask whether there are any remaining questions Therefore, instructors need to establish an environment
or issues. After briefly addressing these, in which feedback is the norm and participants feel safe
summarize and terminate the session. to discuss their performance and learn from feedback.

Please note that the choice for applying a given feedback

model may be made by your course director or on References
regional or national levels or, alternatively, be left up
to the individual instructor to choose the model he or
she feels most comfortable with. Algiraigri AH. Ten tips for receiving feedback
effectively in clinical practice. Med Educ Online
2014;19(1):25141.
Feedb ac k w ith a G roup
of S tudents Allan H. ATLS-Europe Meeting, Berlin, 2012.

Argyris, C Schon. Organisational Learning: A Theory

As an instructor in an ATLS provider course, you will of Action Perspective. Reading, Mass: Addison Wesley
most often find yourself with a group of students. Longman Publishing; 1978.

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 CHAPTER 1 n Teaching ATLS 381

Boud D, Molloy E. Feedback in Higher and For those interested in feedback, the following
Professional Education: Understanding It and Doing additional references are suggested:
It Better. London: Routledge, 2013.
Archer J. State of the science in health professional
Bullock I, Davis M, Lockey A, et al. Pocket Guide education: Effective feedback. Med Educ
to Teaching for Medical Instructors. 3rd ed. Oxford: 2010;44:101–108.
Wiley-Blackwell/BMJ Books; 2015.
Bing You RG, Trowbridge RL. Why medical
Ericsson KA, et al. The role of deliberate practice in educators may be failing at feedback. JAMA
the acquisition of expert performance. Psych Rev 2009;302:1330–1338.
1993;100:363–406.
Kogan JR, et al. Faculty staff perceptions of feedback
Hattie J, Timperley H. The power of feedback. Rev to residents after direct observation of clinical skills.
Educ Res 2007;77(1): 81–112. Med Educ 2012;46:201–215.

Lipsett PA, Harris I, Downing S. Resident self- Wigton RS, et al. The effect of feedback in learning
other assessor agreement. Influence of assessor, clinical diagnosis. J Med Educ 1986;61:816–822.
competency and performance level. Arch Surg
2011;146(8):942–951.

van de Ridder JMM. Feedback in Clinical Education

[PhD thesis]. University Medical Center, Utrecht,
Holland, 2015.

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­382 SECTION 3 n ATLS Instructor Training

LESSON 6: The micro scenario-based teaching is taught as though

other students have no prior exposure to the content,
Preparing to Facilitate a Micro apart from having read the student manual.
Feedback from peers, the educator, and the course
Scenario-Based Teaching Session director provides better understanding of how the
facilitator is perceived by the audience.
The students get an external view of their teaching
Le sson S tatement through a video of themselves. The video makes apparent
the student’s strengths and areas for improvement.
This leads to self-assessment, which is fundamental to
The purpose of this lesson is to prepare new instructors improved teaching.
for their role in guiding the interactive discussions in Students also learn from each other. By watching and
the ATLS student course, by practicing a micro scenario- analyzing the facilitation behaviors of others, students
based teaching session. get a clearer understanding of how to improve their
own facilitation skills.

Le a r ning Objec ti v e
Mic ro S c en a r io - B a sed
By the end of this session, participants will be able to: Te ac hing
1. Prepare a micro scenario-based teaching session.
Preparation for the micro scenario-based teaching
presentation must be done prior to the course.
Depending on the schedule, 10 to 15 minutes prior to the
Pr inc iple s of sessions will allow participants to refine their interactive
S c en a r io - B a sed Te ac hing discussions and, through interaction with peers and the
educator, develop strategies for encouraging meaningful
student participation during the discussions.
The emphasis of the micro scenario-based teaching The actual time allotted for each participant is 15
session is on facilitation techniques, not on medical minutes: 8 minutes for the presentation and about 7
content. The clear emphasis on how to facilitate minutes for debriefing, which consists of discussion,
as opposed to what to teach gives the doctor clear feedback, evaluation, and—if the presentation was
insight on how to become a more effective facilitator. videotaped—viewing the video (depending on the
Each student is assigned an interactive discussion instructor course schedule, this may be done at
topic (e.g., airway, shock, abdominal and pelvic another time).
trauma, etc.).
The scenario-based teaching episode is a scaled-down,
or reduced-in-size teaching session of approximately E va luation
8 minutes. Even though each episode is limited in
time and content, all of the essential organizational
characteristics of a complete ATLS student discussion The educator and course director will evaluate each
(i.e., environment, set, dialogue, and closure) must participant using the Micro Scenario-based Teaching
be demonstrated. The educator will provide the Assessment Form for Faculty in Section 4, Part C: Forms for
topic and the Guidelines for Micro Scenario-Based Evaluating Instructor Course Participants. Participants,
Teaching Episode. In line with the 10th edition format, one time as a presenter of the 8-minute micro scenario-
students are asked to develop a brief interactive based teaching session and one time as the feedback
discussion based on a case scenario they develop provider to one of the peer presenters. The results from
which unfolds at least twice in the eight minutes. the micro scenario-based teaching episode are used in
Slide presentations do not need to be developed, as the the overall evaluation of participant performance in the
emphasis is on the interactive discussion, not the use instructor course.
of slides. The students can choose to use a whiteboard
if available.

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 CHAPTER 1 n Teaching ATLS 383

LESSON 7: a new intervention is identified and the participants

then learn that skill. That method continues until the
Principles of Teaching a scenario conclusion. During a skill session, the scenario
unfolds in subsequent steps, with episodes of dedicated
Psychomotor Skill Station practice in between, focusing on the specific skills that
are performed while taking care of the patient in that
step of the scenario.
Le sson S tatement

Effective psychomotor teaching requires a structured

Definition of
approach, including the essential components (i.e., Psyc homotor Sk ill s
environment, set, dialogue, and closure), hands-
on practice, and feedback in order to facilitate skill
acquisition. Psychomotor skills refer to those skills that require
discrete motor functions. They have a cognitive element
to them, including knowledge of the procedure,
Le a r ning Objec ti v e s indications, contraindications, and so on. These are
distinct from more cognitive skills such as reading a
chest x-ray, which do not have a motor component.
By the end of this session, participants will be able to: Some of the psychomotor skills that students are
required to perform are endotracheal intubation, venous
1. Identify the principles of psychomotor learning. access, surgical cricothyroidotomy, chest tube insertion,
2. Understand the core components of teaching a among many others. These and all of the ATLS skills are
psychomotor skill. taught in an integrated fashion in various skill stations.
In Harrow (1972), Simpson states that the psychomotor
3. Recognize the challenges arising in teaching a domain includes physical movement, coordination, and
psychomotor skill. use of the motor-skill areas. Development of these skills
4. Identify the essential components (i.e., requires practice and is measured in terms of speed,
environment, set, dialogue, and closure) to teach precision, and procedures or techniques in execution.
a skill station. An understanding of the basic principles of
psychomotor learning helps to explain the structure
5. Understand the role of the unfolding scenario
of the teaching strategies used in the ATLS skill
and the role of the instructor in teaching a
stations. There are several essential stages of teaching
psychomotor skill.
a psychomotor skill.
Psychomotor objectives support those learning activities
that require discrete motor functions and physical
manipulation to perform a specific task. In ATLS, these Conceptualization
include particular skills that are learned in skill stations
and applied in the initial assessment station. The learner must understand the cognitive elements of
the skill, such as why it is done, when it is done, when it
is not done, and the precautions involved. The learner
S c en a r io - B a sed A pproac h must know the instruments and tools involved in the
performance of the various skills. In ATLS, videos on the
MyATLS mobile app and mATLS course foster this step.
ATLS skills are taught using a scenario-based approach. It is also the reason an instructor is asked to conduct
This means that participants are presented with a the interactive discussion on the topic of his or her
scenario, and they respond to questions and assess the skill station, so that they are aware of the participants’
“simulated” patient to determine which interventions knowledge of the relevant concepts.
are required. At this point in the scenario, when a
skill is determined (e.g., insert an interosseous device,
apply a pelvic binder, etc.), the participants learn that Visualization
psychomotor skill, using the five-step model described
below. Once all participants have completed that skill The learner must see the skill demonstrated in its
and received feedback, the scenario continues until entirety, thereby having a model of the performance

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­384 SECTION 3 n ATLS Instructor Training

expected. In a skill station, this may be done by the positive feedback for reinforcement of correct behaviors,
instructor or an advanced student in a non-psychomotor as well as active participation of all students.
skill, such as interpreting x-rays.

Skill Mastery
Verbalization
Skill mastery is the ability to routinely perform a
The verbalization component of learning a skill involves sequence of skills in practice situations without
two aspects. First, the learner must hear a narration of error. (This may or may not be achieved during the
the steps of the skill, along with a second demonstration ATLS course, depending on prior training. Another
by the instructor. Second, the learner is asked to narrate indirect goal of the ATLS student course is to offer the
the steps of the skill while watching the instructor first steps for the learner to achieve mastery during
perform it again. There is greater likelihood that learners further development.)
can correctly perform the skill if they see it three times, As previously stated and depending on the background
hear it described, and transfer that description to their of the students, this step may or may not be achieved
own words before undertaking the skill themselves. during the ATLS course; nevertheless, the ATLS
During the ATLS course, after the instructor has narrated instructor makes sure the performance of the skills,
and demonstrated the steps of a skill, such as helmet whether practical or surgical, is the result of high-level
removal, he or she must ensure students are able to thinking skills that lead to adequate problem-solving,
describe the process of removing a helmet in the ATLS rather than simple rote performance or parroting skills,
way, until they can verbalize the sequence correctly. and that those skills are performed using the ATLS
way. Students who are able to demonstrate a degree
of naturalization at the skill stations as a consequence
Practice of prior education and clinical experiences will need
less training practice; however, those students who
The learner, having seen the skill, heard a narration, and may not have had the opportunity to achieve precision
repeated the narration, now performs the skill. The skill practice in some or all the skills are allowed additional
may be broken down into discrete units for practice: time and assistance with the skills, and the instructor
focuses more on teaching and evaluating these
•• Subcomponent practice—practicing a small students’ performances.
portion of the skill
•• Linkage practice—practicing small portions Skill Autonomy
linked together
•• Contiguous practice—practicing the entire skill Skill autonomy is the ability to regularly and routinely
repetitively perform the skill in real-life situations without error.
(This cannot be achieved as a result of the ATLS
In an ATLS course skill station, for example, each course alone.)
student practices the skill, narrating each step as he or Considering that this step continues beyond the
she performs it or while answering questions about his ATLS course, the instructor warns students of their
or her performance, in the context of a scenario. This responsibility to practice the skills in order to achieve
leads the learner to precision practice and eventually perfection—that is, to acquire mastery level skill
to articulation. performance without cognition, ability to multitask
effectively, and perform the skill perfectly in actual
patient situations.
Correction and Reinforcement
Skill errors need immediate correction. Positive
reinforcement is used to “cement” correct performance. The Five-Step Approach to
In an ATLS course, the instructor interrupts and Te aching Psychomotor
corrects the wrong behavior to prevent learning the Skills
wrong technique. Each skill station ends on a correct
performance or demonstration of the skills taught, in
which instructors serve as role models for correctly There are many models used to teach psychomotor
performing the technique, ensuring encouragement and skills (Eason, Stratford-Martin, & Atherton, 2012). Most

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 CHAPTER 1 n Teaching ATLS 385

are based on the principles of how psychomotor skills performed only once at the beginning (to the whole
are learned (Harrow, 1972; Singer, 1972). The five-step group of students).
approach (Paulman, George, & Doto, 2001) is a simple Students who have completed the mATLS course will
and powerful way used in the ATLS skills stations: have seen the skill performed on a video. However, it
will be important for instructors to ensure that they have
1. Teaching why: Explaining why the skill indeed completed the visualization phase of learning
is important and when it is used is the a skill before continuing the learning process. The
conceptualization phase. In the ATLS provider student talk-through may be repeated for students with
course, this first step is mainly accomplished little or no experience in the skill. The instructor may
by reading the student manual and during the choose to have the more experienced students go first,
interactive discussions. A quick update at the although verbalization and practice need to be done by
beginning of the skill station is recommended. all students. The reinforcement and correction can be
2. Silent demonstration: The instructor gives shared with the other students of the group. This will
a silent demonstration of the skills performed help them be more actively involved throughout the
in real time (Eaton & Cottrell, 1999). This step station, and they will learn by critically observing how
allows for a visualization of what students need their colleagues perform a skill.
to achieve, or the target they should aim at.
3. Instructor talk-through: The instructor
performs the skill step by step, explaining
The ATL S Sk ill S tations
(verbalizing) all the important aspects (hand
position, movement, orientation of movement, Interactive skill stations are an important part of the
landmarks, etc.). This deconstructs the skill into ATLS student course. During these stations, case
its component parts and helps students discover scenarios are presented that illustrate key learning
and understand the technique. points stressed in the course. In the 10th edition, the
4. Student talk-through: The student tells the case scenarios unfold throughout the skill stations, and
instructor step by step how to perform the skill, the students learn relevant skills when they identify that
prompted by the visual cues of seeing the skill the patient needs the specific skill. In the skill stations,
again (the student does not execute the skill but students are encouraged to interact with the instructor
narrates for the instructor what should be done, to answer guided discussion questions and demonstrate
which is the second aspect of verbalization). By application of ATLS content. The skill stations provide
not performing the skill themself, the student the opportunity for the instructor to assess the cognitive
can fully concentrate on how the skill should be knowledge and psychomotor skills of the students and
performed. This step identifies for the student to work with them to incorporate their knowledge and
and instructor what part of the technique is well skills in clinically realistic scenarios.
understood and what part needs clarification. As a result of the interactive discussions held prior to
It also helps to check whether the student the interactive skill stations, students should understand
cognitively understands the skill before actually the core concepts that each of the stations illustrate. The
performing it. stations permit the student to work through clinical
scenarios using these core concepts. The instructor’s
5. Practice: Once students know what they are
role, after presenting the scenario, is to guide the
aiming at and how the different steps should be
students, ask the stimulus questions, and interact in
performed in detail, they are ready to practice
a realistic manner to reinforce the key concepts and
the skill. Students perform the skill, telling the
the related psychomotor skills. The instructor must
instructor what they are doing. The instructor
also ensure that each student at a skill station can
observes, reinforces the parts executed correctly,
demonstrate the core skills of that station in a safe
and corrects the parts that need to be adjusted.
and satisfactory manner.
The five-step model may appear time-consuming and Facilitating skill stations in ATLS courses must
unnecessarily complicated, but it has been shown reflect the sequence of psychomotor learning. In
that the time needed to correct a problem after a skill addition, the important concepts and principles of
was not performed well often takes far more time the course are reinforced during the skill stations.
and effort. Therefore, the skill stations have clinical scenarios
When applied to a group, the five steps need not associated with each, and the instructor uses the
be repeated for every student. Typically, the silent clinical scenario to promote realism, integrate
demonstration and instructor talk-through are the skills taught in the course into total patient

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­386 SECTION 3 n ATLS Instructor Training

treatment, and provide a vehicle for discussing

treatment techniques.
Instructor Responsibilities
It is the instructor’s responsibility to ensure that
all students are taught the core skills within the time Instructors must present the interactive skill stations
allocated. This requires careful planning to ensure with the utmost care and preplanning. Effective skill
learning objectives are met. The scenarios are an teaching in an ATLS course requires that the instructor
important part of the integration of the psychomotor do the following:
skills into clinical practice, rather than being learned
in isolation. Instructors need to be careful that the skill •• Understand the objectives of the station, as
stations do not become a mini-lecture or a question- identified in the ATLS Faculty Manual.
and-answer session; rather, the “doing” of the skills
•• Be familiar with the unfolding case scenarios,
should be the focus.
It is important to remember that teaching the skills stimulus questions, and skills that are required
involves the same organization of environment, set, by all students and need to be taught using the
dialogue, and closure: 5-step model vs. only demonstrated by
the instructor.
•• Environment: The instructor is responsible •• Be very familiar with all of the equipment at
for preparing the clinical scenarios and must be the station, and be sure that it is set up in such a
very familiar with all equipment (state and use). way as to facilitate effective teaching. Know the
•• Set: The instructor introduces the skill clinical scenarios.
station title and objectives, briefly reviews •• Present the station in an organized and
the related interactive discussion material (Step cohesive manner, according to the scenario (i.e.,
1 of the five-step approach), explains that each environment, set, dialogue, and closure).
student will be given primary responsibility in
•• Do not allow the station to become a discussion
one scenario, tells students that each one is
station or a lecture with little or no student
expected to interact, and presents the first
action.
clinical scenario.
•• Talk less than one-fifth of the time, facilitating
•• Dialogue: This component involves presenting
interactivity with the students about the clinical
the case scenario, asking the stimulus
scenarios and their relationship to ATLS core
questions, and teaching the skills when they are
knowledge.
identified at the relevant point in the unfolding
case scenario. Once a skill is taught, the case •• Provide adequate opportunity for the students
continues with more stimulus questions until to practice each of the skills required at the
another skill acquisition point, at which time station.
the next skill is taught. The instructor leads the •• Observe and fairly evaluate every student’s
student group through Steps 2 through 5 of the performance while giving positive feedback.
five-step approach. The instructor performs
for all students a silent demonstration of the
skills at the station, provides a talk-through of
the skill to ensure students understand how it
Instruc tor Helpers
should be performed in the ALTS way, observes
each student’s performance, provides correction In the ATLS courses, various students may already have
and reinforcement, and ensures all students mastered many of the psychomotor skills from their
actively participate. prior educational and clinical experiences. Some of
them are able to demonstrate a degree of competency
•• Closure: The instructor stimulates reflection
in some or all of the ATLS skills. Others may have had
on performance by asking each participant limited educational and clinical experiences with
to self-critique and to give feedback to each some of the ATLS skills, perhaps never having had
other. The instructor also provides feedback opportunities to achieve competency in certain areas. It
about students’ performance and summarizes is necessary, as part of the educational experience of the
the major objectives covered during ATLS course, that all students be given the opportunity
the station. to practice and demonstrate psychomotor skills in all

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 CHAPTER 1 n Teaching ATLS 387

skill stations. If some students already have achieved George JH, Doto FX. A simple five-step method for
competency prior to the ATLS course, their roles in teaching clinical skills. Fam Med 2001;33(8):577–578.
the ATLS skill stations may be as “instructor helpers,”
as long as the instructor is confident that they have
Harrow AJ. A Taxonomy of the Psychomotor Domain.
achieved an appropriate degree of skills mastery and are
able to demonstrate skills that are consistent with the New York: David McKay; 1972.
ATLS guidelines.
Educators are encouraged to read Sawyer et al (2015), Nicholls D, Sweet L, Muller A, et al. Teaching
which reinforces the importance of a structured and psychomotor skills in the twenty-first century:
deliberate approach to teaching skills. In the article on Revisiting and reviewing instructional approaches
teaching psychomotor skills in the 21st century, Nicholls through the lens of contemporary literature. Med
et al (2016) outlines an excellent framework that offers
Teach 2016;38(10):1056–1063.
useful concepts to further develop ATLS skills teaching
in the future.
Peyton J. Teaching in the theatre. In J. Peyton, ed.
Teaching and Learning in Medical Practice. Heronsgate
References Rickmansworth, Herts: Manticore Europe;
1998:171–180.

Eason G, Stratford-Martin J, Atherton H. An appraisal Sawyer T, White M, Zaveri P, et al. (2015). Learn, see,
of the literature on teaching physical examination practice, prove, do, maintain: An evidence-based
skills. Educ Prim Care 2012;23(4):246–254. pedagogical framework for procedural skill training
in medicine. Acad Med. 2015;90(8):1025–1033.
Eaton DM, Cottrell D. Structured teaching methods
enhance skill acquisition but not problem-solving Singer RN. The Psychomotor Domain: Movement
abilities: an evaluation of the “silent run through.” Behaviors. Philadelphia: Lea and Febiger;
Med Educ 1999;33(1):19–23. 1972:385–414.

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­388 SECTION 3 n ATLS Instructor Training

LESSON 8: Role of Instruc tor

Skill Station Practice during
Each participant must assume the role of the instructor
Instructor Course once. The station is preassigned prior to the course
to permit optimal preparation. The instructor is
expected to perform a complete (environment, set,
Le sson S tatement dialogue, and closure), structured run-through with
each of the students and to give them feedback on their
performance. The participant assuming the instructor
The purpose of this lesson is to provide new instructors role will be assessed for how well he or she runs the
with an opportunity to practice their role in the skill session (including the quality of feedback given to
stations of the ATLS student course. the students).

Le a r ning Objec ti v e s Feedbac k Prov ider

By the end of this session, participants will be able to: Each time, one participant will also need to give
feedback to the colleague performing as the instructor.
1. Practice teaching a psychomotor skill. The quality of the feedback (content and form) will be
assessed. In this role, participants may also assume the
role of time-keeper.
Introduc tion The participant will also play the role of a normal
student. The educator will provide the instructor with
the skill and the associated scenario points relevant
For the practical part of this lesson during the instructor to the assigned skill, which will be used to facilitate
course, participants will be divided into small groups. skill teaching.
Each group has its own rotation schedule (available
during the course). For each rotation, participants will
play a different role: instructor, feedback provider,
and student.

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 CHAPTER 1 n Teaching ATLS 389

LESSON 9: level. During the practice sessions, more interactive

dialogue and teaching/learning opportunities occur
Initial Assessment than do during the teaching session.
The initial assessment testing station (Note:
nomenclature may vary between countries, with some
Le sson S tatement referring to this as the IA assessment station or IA
testing station) presents students with the opportunity
to demonstrate, uncoached, their knowledge and skills
Effective learning in the Initial Assessment Skill Station in advanced trauma life support management. In this
requires the students’ engagement and integration of station, the instructor is saying to the student, “Show
all learning domains. me and tell me what you have learned.”
The Initial Assessment Skill Station requires the The Initial Assessment Practice Station requires
students to apply ATLS principles to the management planning, knowledge, and participation. The planning
of simulated trauma cases. The success of this station is done according to the environment, set, dialogue,
requires instructors with effective facilitation and and closure components. The rest of this lesson refers to
feedback skills. the practice station.

Le a r ning Objec ti v e s Environment

•• Become familiar with the clinical scenarios. The
By the end of this session, participants will be able to: instructor needs to master the patient scenario,
including all critical treatment decisions (CTDs)
1. Understand the instructor’s roles and responsi- found in the scenario and potentials for adverse
bilities in the initial assessment practice station. outcome (PAO) found on the assessment form.
2. Explain how to promote learning in the Initial •• Become very familiar with all equipment (how
Assessment Practice Station.
to use it and make sure it is present and in a
3. Identify the essential elements (i.e., usable state for the simulation).
environment, set, dialogue, and closure) of the
Initial Assessment Practice Station. •• Brief the patient and nurse, who need to know
how the instructor will run the scenario.
•• Assign tasks to the nurse and fellow instructor
Initi a l Asse ssment (who will guide the student during the scenario
and who will observe students and group).

The initial Assessment Practice Station is the culminating

experience in the ATLS student course, and for good Set
reason. It is in this station that students must demonstrate
command of the ATLS approach to the first hour of trauma Set begins outside the room in order to have the full
management. This is evaluating (according to Krathwohl’s attention of the students. The instructor will take no
taxonomy) in the grandest sense because students must more than 5 minutes to:
appropriately manage a simulated patient with multiple
injuries by using what is learned from reading the student •• Explain briefly the different roles of students:
manual and participating in interactive discussions, skill
-- The performing student evaluates the
stations, triage discussions, and all other aspects of the
ATLS student course. This is where the entire course patient and then prioritizes and delivers the
comes together. treatments/interventions.
The Initial Assessment Practice Station is organized in a -- The critiquing student offers comments
way that facilitates learning and evaluation. The practice about the assessment, prioritization, and the
stations must be viewed as teaching stations because treatments/interventions provided by the
they present the last good opportunity for instructors to student performer.
assess students’ strengths and weaknesses in applying
the ATLS model of trauma management and to provide •• Identify the situation and the resources
feedback and instruction to bring students to a higher (hospital and surgical) that are at the students’

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­390 SECTION 3 n ATLS Instructor Training

disposal. This is usually identified in the scenario, the instructor should allow the
scenario. If not, it is often helpful to place the patient’s condition to improve. Conversely,
student in a small community hospital with if the student makes one or more assessment
limited resources that require transfer of the and management errors, the patient should
patient to a trauma center. respond in direct relationship to the severity
•• Read the case scenario. of the mistake.

•• Ask the student to repeat the information just -- The instructor should cue the patient and
given to ascertain what he or she understands nurse to change the patient’s signs and
about the scenario. symptoms as closely as possible to those that
would occur in a real-life situation.
•• Answer questions about the scenario.
-- The patient’s physiological responses to
•• When the briefing is complete, the instructor procedures performed by the student are
and students enter the room. The instructor: not given until the student simulates and/
•• Invites the student to engage immediately with or relates what is being done to assess and
the patient. treat the patient. For example, the instructor
should not answer a student question such as,
•• Asks the student to “think out loud.”
“What are the breath sounds like?” unless the
•• Asks the student to verbalize and perform student has used a stethoscope to listen for
a procedure within the limitation of the breath sounds. During the practice sessions,
simulation (e.g., no real insertion of a chest tube the instructor may make efforts to guide the
or intubation). student with leading questions, such as, “Are
•• Asks the student to put his or her hands on the you finished with your airway management?”
patient. Example: If a student asks about breath “Why did you do that?” or “What other
sounds, the instructor directs the student to approach might you use here?”
listen with a stethoscope and then describes the •• The instructor needs to ensure appropriate time
breath sounds. management. During the practice session, the
student should progress through the primary
survey, the secondary survey, and transfer
Dialogue arrangements.
•• Tell the student to begin managing the case. •• If clarification or remediation is needed, pause
the case as necessary to bring the student back
•• The instructor must provide immediate and
to an earlier event in the case. This technique is
appropriate physiological feedback as the
appropriate only during the practice sessions.
case progresses and as is appropriate, such
as vital signs and/or the result of urinary •• Dialogue is also the time when the instructor
catheterization. prepares his or her feedback by observing the
student’s performance.
-- This may be done by the nurse assistant, as
long as the information is consistent with how
the case is unfolding, or by the instructor. It is important that the instructor keep the students
on track. He or she should not mislead or misdirect
-- The instructor is also responsible for students, as this does not lead to effective learning.
providing other information and findings One important pitfall to avoid is to allow the initial
to the student, such as the results of a rectal assessment station to become a discussion station.
examination and/or bowel sounds. Instead, encourage the student to manage the case
hands-on and not talk about the case.
-- Because the patient’s responses must
It is important that the instructor stands back from
change to reflect the student’s actions, the the patient's bed in an unobtrusive position that allows
instructor must be continually cognizant him or her to observe the student's performance but not
of the student’s activities. If the student is be part of the scenario. Standing too close to the bed
performing satisfactorily and in accordance can lead to a one-on-one discussion with the student
with the sequence described in the patient rather than facilitating the scenario to run its course.

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 CHAPTER 1 n Teaching ATLS 391

Transition from Dialogue to Closure

Instructor Responsibilities
Dialogue ends either when the student manages
the patient up to transfer or when time is up. The •• Follow the environment, set, dialogue, and
transition from dialogue to closure may be confusing closure structure.
at the beginning. In the dialogue, it is expected that
•• Monitor student performance closely.
the performing student make a (medical) summary of
how he or she managed the case (along the ABCDEs). •• Provide additional information about the case
This can be incorporated into the scenario by asking to the student as appropriate without leading
the student to give his or her transfer report to the too much.
receiving doctor. It is in the closure that the instructor
•• Recognize when to adapt the scenario and
invites the performing student to reflect on his or her
performance (how he or she felt, what went wrong or patient’s condition/response to the student’s
well, etc.). performance.
•• Facilitate effective feedback.

Closure
The closure of the initial assessment station is the
Instruc tor Hints for
time when the instructor and students reflect on the Improv ed Consistenc y
performance. The feedback is delivered using the
principles presented in Lesson 5. The student is initially
asked for a self-critique. Then the instructor encourages 1. Present a case scenario to the student outside
the feedback provider to join in the discussion of the the room.
management of the case scenario and the student’s
•• Hand the student a stethoscope.
performance by asking for examples of things done
well. At the end, the instructor comments on the self- •• After presenting the scenario, ask the student
assessment and feedback and provides information what he or she expects to find when entering
to the student based on his or her performance. A the room (he or she may not have heard you if
method that usually is effective is to call the student’s nervous).
attention to the missed or underappreciated injury, •• Ensure the scenario is gender and age
improperly sequenced care, or inappropriate care by appropriate for your moulage patient. For
asking him or her why the patient exhibited certain example, if the moulage patient is a 20-year-old
signs and symptoms, rather than to call direct attention female, don’t use the scenario of a 50-year-old
to the student’s shortcomings. For example, a patient male. Help the student suspend disbelief (i.e.,
with a simple pneumothorax develops a tension pretend it is real).
pneumothorax as the result of missing the initial injury.
The instructor might ask the student why the patient’s 2. Make gloves visible for the student to put on to
oxygen saturation levels did not improve or why the simulate universal precautions. This step should
patient’s ventilatory effort became more difficult, also help him or her touch the patient.
rather than asking directly why the student missed the 3. Stand either to the patient’s left or far
pneumothorax when the patient exhibited decreased enough away so the student can get to the
breath sounds. patient’s right side, as most people feel most
The instructor summarizes the results by briefly comfortable examining from the right. Standing
reviewing what was positive about the student’s demonstrates your interest in the student
performance, what the areas of weakness were, and more than just sitting and also allows for better
how the student can perform differently the next time interaction with the student and patient.
to avoid making the same mistakes.
4. Have the student touch, listen to, talk to, use
Finally, the instructor concludes the session by
the stethoscope on, and examine the moulage
providing a summary of the important points that the
patient (hands on)—that’s why we use real
case illustrated. This summary should be organized with
people, not mannequins. THIS IS A KEY POINT!
assessment, treatment, and transfer issues.
5. You can coach the patient ahead of time to
simulate a pneumothorax. For example, “Move
your chest up and down on one side without

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­392 SECTION 3 n ATLS Instructor Training

breathing, but breathe normally when the in the chest, etc.). Take the time to do this as
student is listening to the normal side,” “Moan you see fit based on the scenario and student.
when the student pushes the right upper part of Alternatively, if time is a concern, you may ask to
your abdomen,” or “Stop breathing,” and so on, verbalize the procedure.
based on a cue from you. You should also coach 8. Sometimes students may think they have said
the patient based on the scenario. For example, something that they didn’t, and you are waiting
“If I touch your toe or if I mention the weather, for them to say it (or they did and you didn’t hear
stop breathing, gasp, etc.” These instructions it). A nice way to check for this is to have them
may not apply to all the scenarios, but they can talk to the surgeon they are calling (you play
assist in providing realism when appropriate. the surgeon on the other end of the line). This
6. You can also coach the nurse to actively technique can also serve to jog their memory to
participate. Some nurses understand the do something they forgot, which helps them.
scenario like you do and can give the vital signs 9. During the practice scenarios, show them the
for you (at least the first and second set). Later grading sheet so that they can see how the
on, you may want to control the scenario yourself scenarios are graded (they will learn from
through vital signs, depending on how well the this too).
student does and how well you and the nurse
work together. 10. Watch for students who may make good
instructors and mark them as instructor
7. Have the student show you how to perform potential.
procedures (e.g., intubate while protecting the
cervical spine, place a chest tube, stick a needle

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 CHAPTER 1 n Teaching ATLS 393

LESSON 10: Fac ilitator

Initial Assessment Station Each participant will have the opportunity to play
the role of the instructor once. The patient scenario
Practice during Instructor Course is assigned prior to the course to permit optimal
preparation. The instructor is expected to perform a
complete, structured (i.e., environment, set, dialogue,
Le sson S tatement and closure) run-through with one student (either
played by another participant or a faculty member) and
to give that student feedback on his or her performance.
The purpose of this lesson is to prepare new instructors The participant will be assessed for how he or she runs
for their role in guiding the initial assessment stations the session as an instructor (including how feedback is
in the ATLS student course. given to the student).

Le a r ning Objec ti v e Feedbac k Prov ider

By the end of this session, participants will be able to: Each participant will also need to give feedback to a
colleague performing as an instructor.
1. Practice facilitating an initial assessment station.

S tudent
Introduc tion
When not assigned the role of instructor or feedback
For the practical part of this lesson on initial assessment, provider, the participant will play the role of a student
a practice station is assumed (not an assessment station). with a certain behavior (role-play).
Participants will be divided into small groups. Each
group has its own rotation schedule (available during
the course). For each rotation, participants will play a
different role.

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­394 SECTION 3 n ATLS Instructor Training

LESSON 11: chef tastes the soup while cooking, it is a formative

assessment. When the customer tastes the soup on the
Summative Student Assessment table, it is a summative assessment.
In ATLS, both forms of assessment are built in
throughout the course, especially in the practice versus
Le sson S tatement teaching stations. Another aspect of testing is that
it enhances learning. Learning in combination with
testing leads to more lasting retention than any other
In assessing a student’s performance, a variety of learning condition without testing (Larsen et al., 2008).
tools are necessary to ensure a valid, fair, and reliable The differences between assessment and feedback are
assessment and offer faculty members an opportunity shown in n TABLE 1-2.
to reflect on the effectiveness of their teaching.
table 1-2 differences between
assessment and feedback
Le a r ning Objec ti v e s
FEEDBACK ASSESSMENT
By the end of this session, participants will be able to:
SHARED PRINCIPLES
1. Describe the basic concepts of summative and
formative assessment. Basis Observation (subjective)

2. Explain the change in role from instructor-coach

Content Objective, criteria
to instructor-assessor.
3. Explain how to plan the summative initial DIFFERENT PRINCIPLES
assessment session according to the
environment, set, dialogue, and closure. Timing Timely, as soon Scheduled
4. Identify the assessment forms used in the as possible after
instructor course. performance
5. Describe the importance of and the selection
principles for instructor potentials. Setting Informal Formal

Scope Specific behavior Overall performance

Definition of Asse ssment
Reference Self Peer-, norm-referenced

Globally, the terms “assessment” and “evaluation” are Purpose Improvement of Certify competence,
often used interchangeably. For the purpose of the learning grading, measuring
ATLS course, “assessment” relates to the learner and performance
“evaluation” relates to the course/program.
As there are multiple definitions of “summative assess-
ment” in the literature, the adopted definition in the
ATLS concept is “the process of observing a student’s Asse ssment Conc ep ts
performance and comparing it with an expected standard
or template in order to score or rate the performance.”
This entails that we have to objectify subjective observ- Validity and reliability are key assessment concepts.
ation in order to offer fair and valid assessment. This
assessment should encompass all the learning domains
of the ATLS course: cognitive, psychomotor, and affective. Validity
Generally there are two types of assessment:
summative and formative. Formative assessment is Validity pertains to the extent to which the test actually
aimed at further development and improvement, and measures what it purports to measure. It is the most
summative assessment is aimed at deciding whether a important aspect to consider in a test, because without a
student has reached the expected minimum level of valid test, the results have no educational meaning to the
competence to pass the course. For example, when a student or instructor. There are several types of validity,

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 CHAPTER 1 n Teaching ATLS 395

but the one that most pertains to ATLS is content validity, creates a supportive assessment environment by being
meaning that the test questions cover all aspects of the clear about goals, roles, and procedures. This clarity
content delivered in the course in any domain. Content should be shared with the students, and they should be
validity is ensured by the careful selection of the multiple- given opportunities to answer their questions regarding
choice questions and by ensuring the assessment the evaluation process.
objectives are the same as the learning objectives. One of the strengths of the ATLS course is that it relates
to the students’ day-to-day work life, thus encouraging
the instructor to be as realistic as possible. Realism is
Reliability a very important principle that enhances the learning
environment throughout the course. For example,
In general, reliability of a test indicates the extent to moulage patients in real-time initial assessment stations
which the scores on a test are reproducible; that is, should mimic real-life patient situations. However, care
whether the results a candidate obtains on a given test should be taken not to overdo the realism, as that will
would be the same if she or he were presented with adversely affect the learning environment.
another test/instructor or all the possible tests of the The instructor needs to be familiar with assessment
domain. The type of reliability that most pertains to forms and what they assess. This information is covered
ATLS is inter-rater reliability, which entails that measures later in the lesson.
are consistent over time and between different assessors
or instructors. This is important because we have
different instructors assessing the students in each and Assessment in the ATLS Course
every aspect of the course. The instructor course helps
to ensure that all instructors use a common reference.
In the ATLS course, all three domains of learning are
covered: cognitive, psychomotor, and affective. This
requires multiple tools and methods of assessment.
Asse ssor Influenc e on Formative assessment encourages learning and
Asse ssment promotes student progress throughout the course with
the following:

The assessor (instructor) is an important pillar in the •• Pretest multiple-choice questions

assessment process, as he or she observes and documents
•• Interactive discussions
the student’s performance and makes judgments.
In addition to student performance, the instructor’s •• Skill stations
personal bias is an important factor in assessment.
•• Triage scenarios
This bias is human and natural, because there is an
undeniable element of subjectivity in assessment. The •• Initial assessment (practice station)
first and most crucial step to minimize this bias is to
be aware of it and its consequences. Although that is Summative assessment is needed to determine if the
easier said than done (and some instructors have more student has reached a minimal level of knowledge and
difficulty with it than others), it is important to overcome competence to be certified as an ATLS provider. This
bias by adhering to the objectives of the test or session is done in the following parts of the student course:
and being familiar with the evaluation forms.
By adhering to the objectives that are outlined in the •• Final multiple-choice test
evaluation forms and the evaluation schemes in ATLS,
•• Skill stations
instructors can ensure a reliable and fair assessment of
students, thus adding to the value of the ATLS course. •• Initial assessment (testing station)

Principles of Good Assessment Initi a l Asse ssment

Te sting S tation
In addition to using reliable assessment forms and
minimizing instructor’s bias, creating an effective
assessment environment and educating the students The initial assessment testing station is the final
about the process are also important. The instructor summative component of the course. It presents

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­396 SECTION 3 n ATLS Instructor Training

students with the opportunity to demonstrate the •• Asks the student to put his or her hands on the
knowledge and skills of advanced trauma life support patient. For example, if a student asks about
management that they have learned during the course. breath sounds, direct him or her to listen with
The initial assessment testing station requires careful a stethoscope and then the instructor describes
planning, which is applied to the environment, set, the breath sounds.
dialogue, and closure components.

Environment Dialogue
The instructor uses the same clinical scenario as the Tell the student to begin managing the case. The
practice scenario earlier in the course. The instructor instructor must provide immediate and appropriate
briefs the patient and nurse and reminds them that this physiological feedback as the case progresses and as
is now a testing scenario. is appropriate, such as vital signs and/or the results of
interventions. This may be done by the nurse assistant
as long as the information is consistent with how the
Set case is unfolding.
The instructor is also responsible for providing other
Set again begins outside the room in order to have the information and findings to the student as requested.
student’s full attention. The instructor will take no more Because the patient’s responses must change to
than 5 minutes to: reflect the student’s actions, the instructor must be
continually cognizant of the student’s activities. If the
•• Briefly explain that this is a testing station and student is performing satisfactorily and in accordance
not a practice station. with the sequence described in the patient scenario,
the instructor should allow the patient’s condition
•• Explain that the student (only one) will
to improve.
assess the patient, prioritize and deliver the Conversely, if the student makes one or more
treatments/interventions, and determine if and assessment and management errors, the patient should
when the patient is ready for transfer to a higher respond in direct relationship to the severity of the
level of care. mistake. The instructor should cue the patient and
•• Identify the situation and the resources nurse to change the patient’s signs and symptoms as
(hospital and surgical) that are at the student’s closely as possible to those that would occur in a real-
disposal. This is usually identified in the life situation.
The patient’s physiological responses to procedures
scenario. If not, it is often helpful to place the
performed by the student are not given until the student
student in a small community hospital with
simulates and/or relates what is being done to assess
limited resources that require transfer of the
and treat the patient (e.g., the instructor should not
patient to a trauma center. answer a student question such as “What are the breath
•• Read the case scenario. sounds like?” unless the student has used a stethoscope
to listen for breath sounds). The instructor may ask
•• Ask the student to repeat the information just
questions to determine the student’s reasoning and
given to ascertain that he or she understands
care progression as appropriate.
the scenario and that this is a test.
The instructor also needs to ensure appropriate time
•• Answer questions about the scenario. management. During the testing session, the student
should progress through the primary survey, the
•• When the briefing is complete, the instructor
secondary survey, and transfer report.
and students enter the room. The instructor:
•• Invites the student to engage immediately with
the patient. Closure
•• Asks the student to “think out loud.”
Because this is a testing station, there is no feedback
•• Asks the student to verbalize and perform provided to the student. However, some course directors
a procedure within the limitations of the may allow feedback; the instructor should check with
simulation (e.g., no real insertion of a chest tube the course director. Closure involves thanking the
or intubation). student for participating in this activity and concluding

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 CHAPTER 1 n Teaching ATLS 397

the scenario. The instructor should then complete the is an opportunity to learn. If a student’s suboptimal
assessment form based on the specific patient criteria. performance is due to anxiety, it is the instructor’s role
Look out for students who may make good instructors to help that individual calm down so he or she will be
and indicate their instructor potential on the form. able to demonstrate his or her true performance.
Note that a summative assessment can also have a The key to navigating those issues is to make sure
formative component if feedback is provided to the that the judgment is as objective and fair as possible
student after the test. through the use of the forms and to limit evaluation
As an instructor, you play multiple roles during the to the expected objectives.
course, most importantly during the Initial Assessment For a student who has obviously failed, inform the
Skill Station, which is the most crucial session in the course director as soon as possible after completion
ATLS course. In that session there is one practice station of the test session or during the faculty meeting. If
(formative, with the instructor playing the role of coach) you have any doubts, the instructor should discuss the
and one test station (summative, with the instructor situation with the course director right away.
being an assessor) (n TABLE 1-3).

table 1-3 practice vs. teaching S tudent Course

initial assessment Comple tion C r iter i a
PRACTICE TEACHING
In order for the student to complete the course, he or
Role of Coach and Assessor
she needs to fulfill three criteria:
faculty feedback provider

1. Attend the entire course.

Set Explain teaching Explain assessment
aspects aspects
2. Demonstrate knowledge and proficiency in core
content (achieve at least 70% on the written test).
Dialogue Provide infor- Provide information 3. Satisfy minimum skills requirements in the skill
mation; prompt; only as needed or stations and the initial assessment test station.
correct mistakes requested

Closure Feedback by stu- Almost no feed- Do cumentation

dents and faculty; back; may need to
review all CTDs forewarn under-
performing student Every initial assessment scenario has its own form
where the instructor finds the assessment criteria, such
as the CTD and the PAO. On those forms, the instructor
can mark:
Managing Poor Performance
•• Performance status: S (successful), IRM
(incomplete/remedial), IRC (incomplete/repeat
Students are unique in the way they grasp knowledge and course)
skills, the way they handle the test situation emotionally,
and their ability to perform during assessment. There •• Instructor potential
are students who will clearly perform below the level •• Written comments about the observed
of expected performance and will need to be failed performance
without hesitation. Other students will perform just
under the requirements (for many reasons, such as
anxiety, peer pressure, and insufficient preparation).
They are considered for remediation. It is important
Selec ting Instruc tor
to realize the need and value for remediation for the P otenti a l
troubled students to provide a fair second chance. This
makes sense only if the student has the opportunity to
improve (learn) prior to retesting and has been given The high-quality standard of ATLS courses can be
thorough feedback on his or her performance. This maintained only if instructors perform up to the expected

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­398 SECTION 3 n ATLS Instructor Training

standard. The recruitment process for instructors takes application of the ATLS principles of trauma
place during the ATLS student course and the ATLS patient care in the first hour.
refresher course. It is a complex task to adequately assess
•• Use environment, set, dialogue, and closure to
instructor potential. The instructor should:
teach and test.
•• Make ongoing observations throughout the •• Conduct formative and summative assessment
course and faculty meeting discussions. throughout the course for every student.
•• Use criteria based on the mission of the ATLS •• Understand the differences between the practice
instructor to estimate if the student has the station and the testing station.
potential to:
-- Stand behind the ATLS concept (content and
educational format).
References
-- Walk with the learner.
-- Support the team teaching process. Larsen D, et al. Test-enhanced learning in medical
education. Med Educ 2008;42:959–966.

Summ a ry

•• Effective assessment enhances students’

internalization and the correct and timely

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 CHAPTER 1 n Teaching ATLS 399

LESSON 12: despite the passage of time, are remembered fondly

because they have left indelible footprints and touched
Looking Back, Looking Forward the participants’ lives. If participants were to seek the
advice of these teachers, how would they answer these
questions now?

Le sson S tatement •• What are one to two ideas that guided their
teaching?

As the instructor course draws to a close, it is timely •• What tips will they give you for your first
to pause and reflect on what the new facilitators have student course?
learned and to look forward to continual development
as an ATLS facilitator. This will enable the transfer of
learning from this instructor course to the first ATLS Personal Learning Points
student courses that they will teach.
The preceding questions should prompt instructor
course participants to link them with their personal
Le a r ning Objec ti v e s learning points from this course:

•• What are two to three key learning points

By the end of this session, participants will be able to: during this course?

1. Recall the key characteristics of the best teachers •• What is the link between your personal key
that were discussed at the start of the Facilitator learning points with the best teachers and their
Course. characteristics?
2. Articulate the ways in which they will personalize
the ATLS instructor mission.
Look ing forwa r d
3. Reflect on the key learning points of the Instructor
Course.
4. Identify specific things learned in the Instructor Mission Alignment: Spending time to reflect on
Course that they will apply in their first Student the best teachers, their characteristics, and personal
Course as an instructor-candidate. learning points brings the participant to a good
baseline for the next stage of development. As the
5. Discuss the role of evaluation in the ongoing
instructor course participant starts as an ATLS
development of facilitation/teaching skills.
facilitator, it is important to align with the mission of an
ATLS facilitator:

Look ing B ac k •• Stand behind the ATLS concepts

•• Walk with the learners
Some instructor course participants might have •• Support the team teaching process
found this instructor course to be an unexpected
experience, at times leaving them grappling with The mission statement starts with the action words
concepts that are new and hopefully exciting. “stand,” “walk,” and “support.” New facilitators should
Therefore, this course should not be the end of the pause and write a statement on what actions—whether
instructor course participant’s journey but a new it is thinking, behaving, or doing—they will adopt to
beginning to teaching and learning that is more effective personalize the mission statement.
and fun. Writing the above statement helps participants to
crystalize their thoughts and make a commitment
to start right. When new facilitators start teaching,
Best Teachers it is the courage to translate personal learning points
into action that will transform them into effective
This course started with a discussion on the best teachers teachers: the three Cs of crystallization, commitment,
the instructor course participants have ever had and and courage-in-action.

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­400 SECTION 3 n ATLS Instructor Training

Once instructor course participants receive notification 2 days after teaching in a student course. If appropriate,
of the first student course they will teach, they should the new instructor may want to contact the course
recall the personalized mission statement and list two director or a senior facilitator from the student course,
to three specific action points to apply in this student to provide feedback.
course. The new facilitator may consider sharing these During the student course, the new instructor may
points with the course director so that he/she can also have observed other instructors whose facilitation
guide the new facilitator in this major milestone. and teaching are exemplary. New instructors are
encouraged to surprise them with a congratulatory
e-mail and ask them to share some tips—SEAB are
instruc tor C a ndidatur e quite certain that many are very generous with
such advice.
The model of reflection developed by Rolfe et al is a
Once instructor course participants have completed useful guide:
the instructor course successfully, they will be invited
to teach in student courses as an instructor candidate
under the supervision of senior facilitators. As much
as possible during the same student course, the new
instructor should deliver an interactive discussion and
teach the related skill station and the initial assessment
station. The course director and senior facilitators will
evaluate the performance of the instructor candidate.
Upon course director’s and senior facilitator’s
recommendation that the instructor candidate has
performed satisfactorily, he/she will qualify as a
facilitator and be welcomed into the international family
of ATLS facilitators.
Adaptation of the Rolfe reflective model. (Rolfe G, Freshwater D,
Jasper M. Critical Reflection for Nursing and the Helping Professions.
be yond atl s Basingstoke, UK: Palgrave; 2001:26, 35.)

Briefly, this is how the model may work:

Many of the lessons during the instructor course can be
applied to teaching in other clinical and professional •• What: Start by recalling and describing one to
situations (e.g. teaching medical students and teaching two specific incidents/moments that happened
junior doctors in the department). The ATLS Senior during the teaching in the student course.
Educator Advisory Board (SEAB) hope that the new
facilitators will apply the lessons learned during this •• So What: Recall and describe the consequences
course in the myriad of teaching opportunities that as a result of these incidents/moments.
they encounter during clinical work. •• What Next: Think about what needs to be done
differently/changed the next time the facilitator
teaches, make the commitment to change, and
The Reflective Facilitator when the time comes, call up the courage to
change. After that, start with “What” again and
Review and Reflect: On the day before the new complete the reflection.
facilitator teaches in a student course, he or she
should review the personalized mission statement and
remember the commitment to: A Leg ac y of Te ac hing
•• Stand behind the ATLS concepts.
•• Walk with the learners. Many doctors realized that medicine is not just
a career but a calling. Likewise, completing the
•• Support the team teaching process. instructor course is not just a first step in the journey
New facilitators should reflect on how they have of teaching but an initiation to build a legacy
performed and actualized this commitment within 1 to of teaching.

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 CHAPTER 1 n Teaching ATLS 401

The kind of legacy to be built is determined largely work and life. Therefore, taking time out regularly
by the facilitator. It starts with his or her broad to review and reflect so that he or she can crystalize,
understanding and alignment to the mission of the recommit, and have the courage to change and improve
course or program. It is made up of the hundreds and is important.
thousands of teaching moments experienced with
students and learners, and also the many interactions “A teacher takes a hand, opens a mind, and touches a
with peers, seniors, and support staff. This legacy heart.”
is built during the ordinariness of his or her daily Author Unknown

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Chapter 2

TEACHING THE ATLS INSTRUCTOR COURSE

Introduc tion C h a ng e s in This Edition

This chapter is written for educators, course directors, The SEAB concentrated its efforts on incorporating
instructors, and coordinators. It includes a rationale the most important changes without losing the high
for the ATLS instructor course, annotated course quality of the previous course structure. The 10th edition
schedules, and detailed information about each segment includes the SEAB's new Educator Role Definitions for
of the instructor course. This chapter complements a clearer description of all educator types.
Chapter 1: Teaching ATLS, with the required
background information to run this course in the best
possible conditions. Content Revision
The main goal of the instructor course is to prepare
instructors to teach the ATLS student course, either the Lesson 2: Adult Teaching and Learning has been updated
standard course or the hybrid course with mATLS. Over to reflect contemporary theories and maintain the key
the years, the methods for teaching the ATLS course have elements relevant to ATLS.
evolved to include greater emphasis on interactivity Lesson 3: Interactive Teaching in ATLS was developed
and small group learning. The 10th edition instructor as a result of the shift to interactive discussions and away
course extends these concepts, with more emphasis on from lectures. The important structure of environment,
scenario-based learning for contextualization. set, dialogue, and closure (ESDC) has been maintained.
The development of the 10th edition of the ATLS The relevant information from the previous Chapter 5,
instructor course has been the work of the Senior “Group Dynamics,” was incorporated into this chapter.
Educator Advisory Board (SEAB), in the name of the chair Additional information on scenario-based teaching
of the ATLS subcommittee of the Committee on Trauma. has been incorporated to reflect the changes to the
The nine members of the SEAB are representatives from teaching of the 10th edition. The term “facilitator” has
each international region. For this revision, the aim of been used to replace “instructor” in many instances
the SEAB was to build on the very strong foundation of to emphasize the nature of the engagement with the
the previous editions, embrace current best educational student. ATLS instructors need to facilitate student
principles, and incorporate the experience and expertise participation in the learning process.
in teaching ATLS and the instructor course from all
around the world. There has also been a need to align the
instructor materials with the changes in the pedagogy Feedback
used in the 10th edition.
The SEAB would like to acknowledge the assistance With the interactive and experiential nature of the
provided by both the UK and Swiss National Educators student course, the function of giving feedback is
in reviewing materials and welcomes feedback on the essential. As such, the revised instructor course
updated instructor course structure and content. The continues to dedicate a full lesson to this subject. Course
board is committed to ongoing review, to include participants are expected to practice and give feedback
comments and suggestions from educators who throughout the instructor course so that that educator
implement the instructor course so that future editions and course faculty can observe and comment on their
will continue to improve. This feedback can be provided feedback skills. Role-modeling from the faculty plays
through the ATLS office via e-mail to atls@[Link], or a very important part in reinforcing effective feedback
through your regional educator. principles. The learning conversation has been renamed

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­404 SECTION 3 n ATLS Instructor Training

“dialogic feedback” in line with more recent literature Each schedule aims to achieve the same objectives and
in this area. cover the same components of the instructor course. A
detailed description of each schedule follows.
The ATLS instructor course is organized around
12 lessons (excluding precourse and postcourse
AC S-ATL S Administr ati v e faculty meetings).
P olic ie s

The ATLS Instructor Course

Roles and Responsibilities Lesson
The last lesson of the ninth edition instructor course on The course is highly dependent on the educators and
roles and responsibilities of the ATLS instructor (given their ability to act as role models and motivate the
by the course director) was taken out of the slides and participants. Because the instructor course focuses
the course schedule. The value of this presentation at on how to teach the ATLS student course, educators
the end of the course, when participants are tired, was should be familiar with the organization, content, and
considered questionable, and all of the information is teaching methods of the student course—in particular
available in the book. The course director may direct the changes to the 10th edition content and pedagogy.
the participants to the part in Chapter 1 of Section 3. This will allow the educator to help the participants to
contextualize the educational concepts and instructional
strategies in the student course. The instructor course
Schedules is also highly dependent on the faculty to bring in their
field experience and to demonstrate their support of
The 10th edition offers three types of schedules to the interactive education principles.
provide sufficient opportunities to practice throughout This section describes each of the instructor course
the instructor course: lessons and includes suggestions on how to optimally
deliver each component of the course. Educators, course
1. The standard 1.5-day course has a slightly directors, and course faculty should use the information
revised structure. presented hereafter and in Section 3, Chapter 1 to focus
the presentation and discussion of each component of
2. The 2-day course is based on the experience and
the instructor course.
practice of different regions (Europe, Australia).
Note: Throughout this chapter, future instructor
The aim of this schedule is to facilitate active
candidates who participate in the instructor course
practice of concepts and skills presented in the
are identified as participants, whereas the designation
instructor course. As advocated in the instructor of student refers to the students taking an ATLS
course, students require an opportunity to practice student course.
and receive feedback and then to practice again.
The 2-day schedule allows instructor candidates
to practice each element twice and therefore to Lesson 1: Introduction and Course
have an opportunity to implement the feedback Overview
they have received. It is strongly believed that this
additional practice will enhance learning and self- Delivered by the course director [20 minutes]
confidence from the instructor course. The SEAB As course director, you will:
strongly recommends the 2-day course.
3. A third schedule for sites in the United States 1. Welcome the participants to the instructor
is available as a 1-day instructor class. This course.
schedule is to be used only when the class size 2. Introduce yourself as the course director.
is six or fewer students. The schedule follows 3. Introduce the course educator and other faculty
the same rotation and presentation times but (or explain that they will meet the remaining
includes less microteaching time because fewer course faculty later in the course).
students deliver microteaching presentations.
This option, if chosen, may be used only in the 4. Ask the participants to introduce themselves
United States. SEAB does not equate the 1-day and state what they are hoping to get out of the
course with the recommended 2-day course. course. This is an important part of establishing
a supportive team environment and also allows

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 CHAPTER 2 n Teaching the ATLS Instructor Course 405

you to draw on this information throughout As educator, you will:

the course and adjust teaching to meet
these expectations. 1. Model the interactive approach to teaching
5. Explain that the course will be taught by a team throughout the instructor course, particularly
composed of the course director, the educator, in this lesson. The lesson is structured with
and the other faculty. regular questions to encourage this interaction.
It is important to model the appropriate use of
6. Briefly outline for the students your involvement questions and avoid answering the questions for
with ATLS. the participants.
7. Explain that your role as course director is to 2. Introduce the generic structure of all interactive
help ensure a well-structured and evenly paced approaches—environment, set, dialogue, and
instructor course that will prepare them to teach closure—which will be applied to every aspect of
an ATLS student course, offering educational teaching (interactive discussions, skill stations,
principles that also can be applied to other and initial assessment), as well as the basic
clinical teaching contexts. principles of scenario-based teaching. You will
8. Inform the participants that, after successful need to use your familiarity with the 10th edition
completion of the instructor course, they will to highlight the importance of interaction in all
be considered ATLS instructor candidates; after components of the ATLS student course.
successfully teaching one ATLS student course
under supervision, they can become
full instructors.
Lesson 4: Questioning Techniques
9. Explain that the ATLS instructor course is one
of the few continuing medical education (CME) Delivered by the educator [25 minutes]
activities that uses this format to ensure good, As educator, you will:
uniform, quality teaching and instruction.
1. Explore different types of questions based on
Emphasis on the mission of the instructor is central the participants’ own questions, using the
(see slide presentation). The course director and the activity proposed in the slide presentation.
educator should take time to understand the three The participant will be asked to write down the
facets of the instructor’s mission and should have some question and then try to transform it.
detailed examples in mind to illustrate the mission 2. Explain the usefulness of this process while
during discussion with the participants. preparing to teach the student course.
3. Elicit at least one answer from each participant.
Lesson 2: Adult Teaching and 4. Demonstrate the strategies for managing
Learning responses to questions to ensure ongoing student
participation in discussions.
Delivered by the educator [30 minutes]
As educator, you will:
Lesson 5: Feedback
1. Explain that the aim of this lesson is to provide
participants with basic knowledge regarding Delivered by the educator [30 minutes]
essential educational concepts and principles. As educator, you will:
2. Communicate the relevance of the material and
illustrate it with examples from the ATLS course 1. Explain the power of feedback as a key feature to
whenever possible. foster learning in a safe and supportive learning
environment.
3. Refer back to these educational principles in later
lessons to provide reinforcement. 2. Invite participants to elaborate on experiences
with effective and ineffective feedback,
describing what makes the difference.
Lesson 3: Interactive Teaching in ATLS 3. Explain the importance of understanding and
applying principles for effective feedback and
Delivered by the educator [20 minutes] using a structured approach, using personal

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­406 SECTION 3 n ATLS Instructor Training

examples, soliciting examples from the strengths and weaknesses and to offer some
participants, and inviting faculty to share their constructive feedback.
experiences with giving feedback and what works.
•• Video recording of the performance is a valuable
but optional part of the micro scenario-based
Depending on the local culture and the experience of
teaching, as it allows the participants to see
the group, you may concentrate on one or the other of
the feedback models and you will encourage them to their own strengths and areas of improvement.
practice giving feedback during the instructor course. Viewing the video sequence directly at the end of
the feedback (usually focusing on key moments
of the performance) is optimal for learning.
Lesson 6: Preparing to Facilitate However, this may be difficult when there is
a Micro Scenario-Based Teaching time pressure or when handling of the video is
Session cumbersome.
•• It is important to ensure participants that the video
Preparation for Micro Scenario-Based Teaching
recording (if used) will be handled confidentially.
Delivered by the educator [10 minutes] •• It is helpful to give a clear signal (e.g., hand sign,
As educator, you will: card, bell, verbally) to the presenter 1 minute
prior to the end (i.e., after 7 minutes) so he or she
1. Prepare participants to deliver the interactive can anticipate the closure of the presentation.
discussions during the ATLS student course. The timing can also be delegated to a participant.

Each participant needs to be assigned an interactive •• Let the student first give his or her feedback,
discussion topic to be used prior to the course (use the followed by the other participants’ feedback (as
ATLS participant manual to identify these resources). positive and constructive form), and then give
You should assign one topic area and ask the participants your feedback as educator. This models the
to develop an interactive discussion with an unfolding feedback sequence of Lesson 5.
case scenario that fits in the allocated time. •• The educator should make sure participants
In keeping with the emphasis on interactivity and
providing feedback are aware of their function
focused discussion, participants will implement an
before the presentation starts. The educator
8-minute micro scenario that is case-based, with at least
should also make sure the feedback is given
two unfolding progressions. Their interactive discussion
should clearly demonstrate the structure of environment, according to the principles of Lesson 5 and if
set, dialogue, and closure. The highlight of this segment of necessary may role-model it.
the course is the detailed feedback provided by the course •• The use of the Micro Scenario-Based Teaching
educator, the course director, the course instructors, Assessment Form for Participants helps to
and other participants following each teaching episode. structure the observation and the feedback and
Depending on the schedule of the instructor course, fosters learning from the others. Each participant
time may be arranged for participants to make last-
should fill out the form (when they are the
minute modifications to their presentations. During
feedback provider) during the presentation and
this preparation, it is useful if the educator and the
hand it to the presenter after the feedback is given.
course director are available to answer questions from
the participants. •• An alternative approach is to hand the video
recording to the participants so they can review
it after the course and reflect on it. In this
Micro Scenario-Based Teaching case it is important that during the feedback
sequence the educator points to specific
All [135 minutes in total; for each participant: 8 minutes positive behaviors and behaviors that need to
for interactive discussion, 9 minutes for feedback and be improved to ensure participants will benefit
evaluation, 1-minute rotation]
from the microteaching experience.
Information for educators who may be unfamiliar
with micro scenario-based teaching: •• In the 2-day instructor course, a second micro
scenario-based teaching session is scheduled.
•• The 8-minute interactive discussion is sufficient This session is arranged shortly after the first
to provide insight into the participants’ to encourage participants to put into practice

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 CHAPTER 2 n Teaching the ATLS Instructor Course 407

the feedback they just received. This format 1. Prepare participants to deliver their assigned
maximizes the learning effect of this approach. skill station. They must to be provided with
the part of the scenario that is relevant to their
skill—a summary slide of the case up to this
Lesson 7: Principles of Teaching a point may need to be provided if the skill they are
Psychomotor Skill Station assigned comes in the middle of a scenario in the
student course, and the educator should arrange
Principles this material for them.

Delivered by the educator [45 minutes] The organization of the upcoming practice session
This lesson provides the participant with the principles needs to be well understood by the participants. The
of teaching psychomotor skills, tools for handling participants are dispatched into three groups; there
problematic students and situations in the ATLS course, are three rotations, so each participant in a group will
and useful methods of alleviating the problem areas to play each of the following roles once:
improve performance and skill retention.
As educator, you will: •• The instructor of the station, who will teach the
skill to the other students. Participants will be
1. Explain the importance of psychomotor skills to assigned a station, and they have to prepare
the aims of the ATLS course. prior to the course. It is important that they
2. Facilitate the understanding of the crucial get the experience of teaching the entire group
components of teaching skills (the five-step and making sure that they manage their time
model). Some courses use faculty to demonstrate appropriately. Therefore, the educator needs
the 5-step model. The SEAB has also developed a to carefully consider the skills and relevant
video that you may use (optional). scenario information appropriate for the
3. Ask participants to reflect on the learning time available.
process of similar skills with the planned activity
•• The feedback provider, who will observe the
in the slide presentation.
teaching of the station and provide feedback
4. Record participant responses on a whiteboard afterward to the performing instructor.
and refer back to this information when
reviewing the slide content concerning the •• The role of a student of the group participating
principles of teaching psychomotor skills. at the station.
5. Emphasize the environment, set, dialogue, and
Additional time (15 minutes) is scheduled for
closure structure in the setting of a skill station.
participants to prepare their stations. This reinforces
6. Promote a clear understanding of where the the environment component of teaching a skill
components of teaching the skill stations fit station. It is expected that they will review briefly the
within the environment, set, dialogue, and scenario of their station and go to the room to check
closure structure and why this structure is their equipment.
important for establishing relevance and During this preparation time, it is useful if the
rationale for the skill teaching. educator and the course director are available to answer
7. Address how to walk students through the 5-step participants’ questions.
model when they are acting as the instructor
on a skill station (e.g., student 1 performs the
skill while student 2 talks through the steps, and Lesson 8: Skill Station Practice
then student 2 performs the skill while student during Instructor Course
3 talks through the steps, etc.). This is necessary
to ensure all students have the opportunity to All [60 minutes; for each participant: 1 minute to check
visualize, verbalize, and practice with feedback. station, 9 minutes to role-play, 8 minutes for feedback,
2-minute rotation]
The focus is on the participants’ ability to facilitate
Preparation hands-on learning at the skill station, applying a
structured, stepwise approach. Therefore, feedback
Delivered by the educator [10 + 15 minutes] and suggestions for students from instructors and peers
As educator, you will: focus on how the participant taught the skills, not on

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­408 SECTION 3 n ATLS Instructor Training

medical content. Participants should come away from 3. Focus the attention of participants on the per-
this station with a better understanding of how they formance of the instructor during all the com-
can effectively teach the station. ponents (environment, set, dialogue, and closure).
4. Direct the participant to observe and discuss how
the instructor performed, including which beha-
Faculty Role viors and actions contributed to the learning pro-
cess and which did not. The discussion can be struc-
The faculty’s role in this station is to: tured along the environment, set, dialogue, and
closure moments. After the role-play, summarize
1. Briefly introduce the station and its purpose in the discussions and formulate key messages.
the instructor course.
5. Ask the participants to comment on what they
2. Eventually brief the participant who has to role- observed.
play the student or (if faculty plays the student)
clearly announce that he or she will be the role- 6. Discuss the fact that there is no perfect instruct-
playing student. or; however, reflecting and learning from every
practice situation creates a better instructor.
3. Ensure the designated feedback provider is aware of
his or her role. The feedback should be focused on
the teaching skill rather than on the ATLS content. Preparation
4. Invite the instructor student to start the role-play
by taking care of the group of students. Delivered by the educator [10 + 20 minutes]
The organization of the upcoming practice session
5. Observe the “instructor” participant teaching
needs to be well understood by the participants. It is
the station (how he or she handles the teaching
organized the same way as the skill station practice.
of the designated student and how he or she
The participants are dispatched into three groups;
handles the rest of the group).
there are three rotations, so that each participant
6. Conclude the role-play when time is over. in a group will play each of the following roles
7. Initiate the feedback session following the one time:
principles of the chosen model for providing
feedback (see Lesson 5). •• The instructor of the station, who will teach it to one
student. The participant has been assigned a station
he or she had to prepare prior to the course.

Educator Role •• The feedback provider, who will observe the

teaching of the station and then provide
The educator’s role is to rotate among all groups, observe, feedback to the performing instructor.
and help the faculty give feedback as appropriate. •• The role of a student of the group participating
at the station.
Lesson 9: Initial Assessment Additional time (10 minutes) is scheduled for
participants to prepare their stations. This reinforces
Principles the environment component of the initial assessment
station. It is expected they quickly review the scenario
Delivered by the educator [30 minutes] of their station and go to the room to brief the patient
As educator, you will: and the nurse.

1. Collaborate with your faculty and course director

to determine how to conduct the demonstration Lesson 10: Initial Assessment Station
of the initial assessment teaching station. Some Practice during Instructor Course
courses use faculty to demonstrate. The SEAB
has also developed a video that you may choose Practice
to use (optional).
All [60 minutes; for each participant: 1 minute to check
2. Direct the faculty to play the role of the instructor station, 9 minutes to role-play, 8 minutes for feedback,
well with a “middle-of-the-road” participant. 2-minute rotation]

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 CHAPTER 2 n Teaching the ATLS Instructor Course 409

During an instructor course, it is important to conduct As educator, you will:

the station as a practice station during a student course.
The focus is on the participants’ ability to facilitate 1. Explain the basic concepts of summative
learning the initial assessment and management compared to formative assessment.
skill station. Therefore, feedback and suggestions 2. Describe the change in role from instructor-
for participants from instructors and peers focus on coach to instructor-assessor.
facilitation skills, not on medical content. Participants
should come away from this station with a better 3. Explain how to plan the summative initial
understanding of how they can effectively facilitate assessment session according to the ESDC.
the station. 4. Identify the assessment forms used in the
provider course.
5. Explain the importance and the selection
Faculty Role
principles for instructor potentials.
The instructor course instructor’s role in this station The topic requires a combination of lecturing on the
is to: basic concepts of assessment, as described in the slides,
and demonstrating how to “run” an assessment station
•• Briefly introduce the station and its purpose in using all these principles when assessing different
the instructor course. types of students. This will give students a good picture
of the desired performance of an instructor in an
•• Eventually brief the participant who has to role-
assessment station.
play the student, or if faculty plays the student,
The role-play of an assessment station involves two
to clearly announce that he or she will be the
instructors and one student, as in an actual assessment
role-playing student.
station (all roles played by faculty members). The role-play
•• Make the designated feedback provider aware of should illustrate how helpful sticking to the principles
his or her role. can be to adequately and fairly assess all students.
•• Invite the instructor student to start the role- Instructions for the role-play:
play by taking care of the student.
•• Instructor: Should play the role of an instructor
•• Observe the “instructor” participant teaching
who makes some small errors but not obvious
the station (how he or she handles the teaching
ones (e.g., forget some aspects of the set, miss
of the designated student and how he or she
a subtle critical treatment decision [CTD], etc.).
handles the rest of the group).
The participants should get the impression that
•• Conclude the role-play when time is over. he or she is good, but the errors can be pointed
•• Initiate the feedback session according to the prin- out during debriefing.
ciples of the chosen feedback model (Lesson 5). •• The student: If time permits, different types of
•• Summarize the instructor’s performance, students could be played to illustrate the various
clearly identifying positive elements and areas difficulties in assessing a student performance.
for improvement, if any. Examples of student types include:
•• Comment on the feedback given by the feedback -- The average student, who will pass.
provider, clearly identifying positive elements
and areas for improvement, if any. -- The hesitant or insecure but overall well-
performing student who “only gets to the B”
and misses one of the other CTDs and should
Educator Role be failed.
-- The overwhelming/arrogant/nonverbalizing
The educator’s role is to rotate among all groups, observe, student doing everything right and has to be
and help the faculty give feedback as appropriate. passed (despite his or her attitude) but who
would not be instructor potential (IP).
Lesson 11: Summative Student •• The participant: Before the role-play starts, the
Assessment educator may state, “Imagine we are looking at a
movie on student assessment, which I will stop at
Delivered by the educator [40 minutes] certain points for questions and discussion. The

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­410 SECTION 3 n ATLS Instructor Training

main focus is on the instructor (played by one of to the motivation and development of professional skills
the faculty members): What does he or she do of beginning teachers. Within ATLS, we also strongly
to adequately assess his or her student? Keep in recommend that instructor course participants have an
mind the principles we just discussed and look at experienced ATLS instructor, being a member of the
similarities and differences compared to what the instructor course faculty, as mentor. Mentor-student
instructor does in an initial assessment station, combinations can be incorporated in the precourse
information for the faculty.
aimed at supporting student learning.”
The first mentor-participant contact should preferably
take place 2 to 3 weeks before the course. Mutual
During the role-play, call for time-outs after some critical expectations, concerns, or questions can be clarified,
moment (e.g., after an incomplete set). which is especially important when the participant’s
preparation is required and essential for the practice
stations. The best approach is to have a face-to-face
Lesson 12: Looking Back, Looking meeting (if in the same institution) or a phone call to
Forward make this contact more personal. In practice, it appears
that just a 5- to 10-minute phone call can clarify a lot and
Delivered by the educator [20 minutes] prevents misunderstandings from hindering the flow
Using the slides on this topic, the main goal is to and individual learning of the course. This contact is also
stimulate reflection on what was learned and the first a signal to the participants that the course organization
steps to stimulate the transfer of what was learned to cares about them and that they will have to show
the first course as instructor candidate. up prepared.
As an educator, you will: During the course, the mentor is available for questions
and monitors the well-being and progress of his or her
1. Stimulate students to document personal points assigned participants (one or two in general). In the
to remember, valuable newly discovered personal short mentor-mentee meetings, student and mentor
qualities, important take-home messages, and reflect on the learning process and performance. If
so on. (For example, “The more specific you get necessary, the mentor is also the one who discusses with
now, the easier it will be to actually apply these to the participant if the faculty has perceived problems
your next teaching experiences.”) in the performance and/or attitude of the participant.
In all cases, the mentor serves as an example of how a
2. Determine how to reinforce this transfer in a good instructor “walks with the learner.”
creative way. For example, let students note their
most important points on a postcard and send
this back to them after 2 to 3 months. Follow-up Precourse Activities
reminders such as this, especially when reflecting
on points identified by themselves, actually work! 1 to 6 Months Before the Instructor Course
3. Invite all students to share their intentions/
learning points within the group or in pairs. The course coordinator should ensure that all students
are qualified to attend the instructor course by making
sure each participant fulfills all requirements to attend
Terminate the session by getting back to the mission of this course.
the instructor course and the importance of this course
as a step in their further development as an instructor
and faculty team member. 2 to 3 Weeks Before the Instructor Course

The course director, educator, and/or coordinator are

responsible for writing a letter to the students who
running the Instruc tor are registered for the instructor course. Often, it is the
Course educator who writes to the students and sends pertinent
precourse material to the coordinator for mailing to the
students with other precourse materials.
Mentor-Mentee This is also the time when the mentor-mentee
approach needs to be considered. The director, educator,
In teacher education, research has shown that good- or coordinator assigns a mentor (member of the faculty,
quality mentoring can make an important contribution including director and educator) to every participant.

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 CHAPTER 2 n Teaching the ATLS Instructor Course 411

An invitation is sent to the mentors to contact their •• Qualified educator

designated mentee. •• Three qualified instructors
•• Qualified course coordinator
The Precourse Letter The precourse faculty meeting is designed to:

The precourse letter is designed to achieve two •• Review background information about each
objectives. The first is to orient students to the instructor qualified student.
course and clearly outline expectations. The second is
to encourage precourse preparation. All students are •• Review each participant’s student course
expected to teach in several segments of the course— information and outcome.
micro scenario-based teaching episode, skill stations, •• Review the course agenda.
and initial assessment—and precourse preparation
includes planning for these responsibilities. •• Discuss teaching assignments and strategies
The precourse letter should include the following used in practice teaching sessions.
items and attachments: •• Discuss expectations of faculty throughout
the course.
1. A welcoming statement
•• Provide educator’s directions and comments.
2. A brief description of the instructor course
•• Review the requirements for evaluation
3. Precourse assignments:
and documentation.
•• Reading the faculty manual, Section 3, Chapter
1: “Teaching ATLS” A precourse faculty meeting generally lasts 60 minutes.
•• Studying the explanation of micro scenario-
based teaching Instructor Course Schedules
•• Preparing for the assigned teaching episode
(assignments must be clearly delineated on the The schedules for the 10th edition of the ATLS instructor
course schedule) course were prepared by the Senior Educator Advisory
•• Using the micro scenario-based teaching Board to the chair of the ATLS subcommittee. Three
planning form to prepare the one micro main regular schedules are proposed—the standard
scenario-based teaching assignment 1.5-day course, the 1-day course, and the 2-day course.

•• Reviewing the micro scenario-based teaching 1. Standard 1.5 Day Schedule

evaluation form
•• Version 1 starts with a full day followed by a
•• Studying the skill stations to which the
half day.
student is assigned and in which the student
serves in the instructor role (assignments must •• Version 2 starts with a half day and finishes
be identified on the course schedule) with a full day.
•• Studying the initial assessment patient scenario 2. The 2-day ATLS instructor course is a modifi-
to which the student is assigned and in which the cation of the minimum ATLS instructor course
student serves in the instructor role (assign- requirements as listed in the previous course
ments must be identified on the course schedule) calendars. ATLS regional chiefs and their
associated ATLS educators may modify this by
A sample precourse letter can be found in Section 4: extending the ATLS instructor course to a 2- or 2.5-
Educator Course Packet. day course, which ensures that all subject matter as
well as group and individual course exercises are
completed beyond the minimum requirements.
Precourse Faculty Meeting
The 2-day schedule allows twice the practice time. A
The course director should ensure that a precourse third schedule for a 1-day course is also presented and
meeting is held. The required participants are: considered acceptable under certain conditions as
approved by the ATLS office (available in the United
•• Qualified course director States only and limited to 6 participants).

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­412 SECTION 3 n ATLS Instructor Training

All schedules pursue the same objectives and deliver all of our ATLS family. Members of the international
the same content. They differ in their duration and the community, the ATLS subcommittee, the ACS Committee
amount of exposure to practice provided to participants. on Trauma, and other educational sources have been
It is expected that all ATLS instructor courses be encouraged to submit their reviews to the project
conducted as outlined in one of these schedules. team. The SEAB believes that the instructor course
The time frames outlined herein are considered the is a fundamental step in ATLS faculty development,
minimum amount of time needed for the director, being one of the pillars contributing to the future of
educator, and/or instructors to present the information ATLS and its quality. We encourage all educators and
or conduct a specific session. instructors to provide the SEAB with any feedback that
In preparing this material, the SEAB has been sensitive might improve the quality of the instructor course and
to and considerate of requests and suggestions from the manual.

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