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I Spy With My Little Eye


There has been an increased emphasis on the role of simulation within the education of the paramedic student. Within the paramedic education offered by Eastern Kentucky University, we have a very robust suite of simulation tools that will immerse paramedic students in a multitude of scenarios.  Research shows that those who do well on simulation, will also do well in the clinical environment. However, there still remains a problem of moving those students from that role to that of active prehospital medical provider. One of the largest barriers to this is the ability to pass their National Registry exam. This blog post will not be one that blames the exam as the problem. Instead, what I want to discuss is a potential tool that has helped me personally when I was a full-time active street medic.

Let’s take a moment and look at the national registries first-time pass rates over the last five years. After that we can compare them to the first-time pass rates for nurses taking the NCLEX exam during the same time frame.   In 2012, 12,255 students made their first attempt at the NR EMT paramedic exam. Of those that attempted the exam, the first-time pass rate for the nation was 71%. Five years later in 2017, the Registry records that 7585 students have taken the exam.  There is an improvement in pass rates, but it is a very meager 75%.  If we compare this to our nursing colleagues, in 2012 150,266 nursing students attempt the NCLEX exam. Based on statistics from their website they showed a 90% first-time pass rate. Five years later about the same number of students tested, 143,408. The first-time pass rate in 2007 stayed fairly close to the one in 2012 of 88%.

I’ve got the Problem, Now Give Me a Solution

Rather than dwell on the problem, I’m much more interested in trying to find a solution. One such solution, that anecdotally, has works for me as well as others, is the use of mind’s eye or mental rehearsal. Now before you label me as a granola eating, new age thinking, meditating monk, hear me out on this. Elite athletes as well as well as top musicians use it all the time (Connolly & Williamon, 2004).  The science does seem to support the role that doing a mental rehearsal of any skill will help our students to be able to perform that better while under the stress of actual patient care, or during testing.

The practice of mental rehearsal involves imagining whatever task you wish to perform mentally instead of actually doing it.  Sometimes we think about what we have done when completing a simulation.  Mental rehearsal views the detailed mental representations of a specific real or hypothetical event (Szpunar, Spreng, & Schacter, 2014). When the paramedic student is engaged in mental rehearsal, the brain believes that the task is actually happening, although the student may be reclining in bed or sitting in her favorite restaurant.  Many of us have heard the perfect practice makes perfection mantra.  It is true that practice of any task is imperative, but having multiple practice sessions usually leads to much better results than practice filled with mistakes.  As the use of mental rehearsal is always perfect, it can stand to reason that the student is able to begin to have a greater sense of confidence in her skills.  As the saying goes, "Practice makes perfect."  Yes, practice can cause improvement, but "perfect practice" can lead to better results than practice full of failures.  According to research completed at Wright State University (2013), “Experiencing success increases confidence, even if that experience is imagined.” This line of thought was also supported by Shearer, Thomson Mellalieu & Shearer (2007).  In their study the discovered that those who took part in mental rehearsal prior to execution did better on a team obstacle course than those who did not do the visualization. 

Limitations of Mental Rehearsal

The use of mental rehearsal is not a silver bullet however.  The person doing the practice must be familiar with the steps and knowledge needed to do the activity.  A second caveat to mental rehearsal is that it is NOT a supplement to actually practicing simulations, but should instead supplement them.  Being able to get constructive and timely feedback from a paramedic instructor to better the actions taken during the simulation is invaluable and cannot be replicated with mind’s eye rehearsal.  Mental rehearsal boosts the learning process and gives the student the extra boost once they have reached the novice level of competency. 

How it’s Done

Decide on a time a place where you won’t be interrupted and then make yourself comfortable.  Eyes open or closed, it doesn’t matter.  When you are ready begin to imagine yourself completing the task.  For purposes of illustration, let’s take the skill of endotracheal intubation.  As you begin the process, imagine that you have all of the equipment that you need in front of you.  Take each step of the skill of intubation and imagine every detail of the skill.  As you are progressing through it, you will do each step perfectly with no complications.  After all…it’s your story.  Repeat the process as needed.  Remember to praise yourself for being successful.  Self-reinforcement is another key to self-motivation.


The practice of mental rehearsal is perfect for paramedic students because it allows them to practice a multitude of specific situations or psychomotor skills.  It comes with multiple benefits.  Mental rehearsal has the potential to help your students improve their skills, increase their self confidence in their ability and control emotions by purposely placing themselves in challenging scenarios.  I encourage you to try it before you discount its benefits!


Connolly C, Williamon A: In Musical Excellence: Strategies and Techniques to Enhance Performance. Edited by: Williamon A. Oxford University Press, Oxford; 2004:221–245.

Shearer, D. A., Thomson, R., Mellalieu, S. D., & Shearer, C. R. (2007). The relationship between imagery type and collective efficacy in elite and non-elite athletes. Journal of Sports Science & Medicine, 6(2), 180.

Szpunar, K. K., Spreng, R. N., & Schacter, D. L. (2014). A taxonomy of prospection: Introducing an organizational framework for future-oriented cognition. Proceedings of the National Academy of Sciences, 111(52), 18414–18421.


About the author:

Dr. Bill Young began his EMS career in 1975 with a small fire department near Williamsburg, KY. They began running first responder calls long before the phrase ever existed. In addition to Kentucky, his career has taken him to Tennessee, Colorado, Georgia, and Kansas. He has served as a street medic, training officer, supervisor, state regulator, and educator. Currently, he is an Associate Professor and the Director of the Department of Paramedicine at Eastern Kentucky University.

Published on November 27, 2017

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