Teaching by Doing: A Novel Approach to Instilling Good Body Mechanics

Grace Choi, September 2023

To distill decades of caregiving knowledge into a short interactive lesson, Larabee worked in lockstep with Homewatch Caregivers of Loudoun, Virginia.

Two years into his diagnosis of amyotrophic lateral sclerosis (ALS), Dhaval Patel, a cardiologist at Reston Hospital in Northern Virginia and father of two small boys, was being moved from his stair lift to a wheelchair when his caregiver buckled under his weight and stumbled backwards. By that point, ALS had immobilized Dr. Patel’s major muscle groups and stripped him down from 140 to 110 lbs. – the totality of which now blanketed his injured caregiver on the floor.

 “It was a terrifying ordeal for both of us,” Dr. Patel, 44, says. “We didn’t know it at the time, but the aide had blown out her knee and was in tremendous pain. I was lying on top of her. Neither of us could move.” Fortunately, Dr. Patel’s wife Kathryn was working from home that day and could hear their faint cries for help from the distance. She promptly called 9-1-1. The aide went into surgery and did not return to caregiving, while Dr. Patel was assisted back to his bed by a firefighter. His life was and continues to be one in which the emotional tax of such a disease competes on the daily with the stress of securing consistent and good caregiving.

Dr. Patel’s experience points to two commonly known problems in homecare: 1) A staggering percentage of caregivers, both professional and informal, injure themselves on the job; and 2) With a rapidly aging population combined with the high cost of nursing care facilities, the labor shortages and staffing issues already plaguing the home caregiving industry will worsen quickly and dramatically, which will ultimately result in more untrained family members serving as primary caregivers for ailing loved ones. In all likelihood, you or someone you know already serves as a caregiver for a parent or relative, while holding a full-time job and maintaining any number of obligations and responsibilities.

While the obvious solution is more effective training, implementation is the greater challenge – especially at the scale that’s required.

Larabee began with a simple premise: Can we teach the physical and mental knowledge of an activity or skill through a digital platform as precisely and effectively as an in-person expert can, at scale? We had developed a unique methodology for capturing expert knowledge, as well as a dynamic display that surpassed linear videos in terms of interactivity and clarity. Our hypothesis was that many, many organizations whose business operations centered on physical tasks and skills had to choose between learning solutions that were highly effective but costly to scale (e.g., in-person teaching), and static resources like manuals and linear videos that were less clear, less effective, passively consumed, and easily forgettable.

When we first began working with Tim Bodor and Rebecca Bodor, the owners of Homewatch CareGivers Of Loudoun (one in a global franchise), our goal was to create a single proof point in the healthcare industry on which to test our hypothesis. Depending on their employer and level of training, caregivers engage in a number of tasks, from light domestic aid to more intensive medical assistance. Given that the most strenuous activities involve lifting and transfers (for toileting, bathing, navigating stairs, and so on), we narrowed our focus on a standard gait belt transfer: using a belt with handles that wrapped around the midsection of the patient to assist with the lift.

Once we defined the lesson, we needed to identify the expert instructor. Tim recommended an occupational therapist of 40 years named Mary (under a pseudonym per her request) who had taught a training session to Homewatch employees pre-pandemic that had left a lasting impression. With deep tenure in her field, Mary proved to be a wellspring of knowledge.

“The problem is that there are so many variables you can’t put into one lesson,” she says to me as we sit at her dining room table, her very large dog Juno attempting in vain to lick my recently injured toe back to health. (Caregiving abounds in this household; Mary’s husband specializes in home modifications for accessibility and safety). “What if the patient is 6 foot 3 and 300 pounds, and you’re a third his size? What if you’re transferring to a chair with one armrest instead of two, or a toilet, or from a bed? What if the patient has Parkinson’s? Or Alzheimers? There are so many factors and considerations that go into doing a safe transfer.”

“Here,” Mary abruptly stands up in front of me and wedges one of her feet between mine. “I have to just show you. Move to the edge of your seat and put your arms around my waist.” She then proceeds to wrap her arms around my midsection, lift me from my seat, and shuffle me over to the seat she had just vacated. It was a secure and confident dance. “Did you see what I did with my legs as I lifted you from your center of gravity, while you held on to my center of gravity? Too many people lift with their backs. Too many patients try and grab my neck or shoulders. Good body mechanics should be taught in school!” 

There is an exquisite saying attributed to the Asaro tribe of Papua New Guinea that goes, “Knowledge is only rumor until it lives in the bones.” For people like Mary, this rings quite true. Subject matter experts hold copious volumes of information amassed over careers, such that the more specific you get their field, the deeper the rabbit hole you both tumble into. For experts of physical skills like Mary, knowledge is written on the body, embedded in the muscle. You recognize it in the way she speaks extemporaneously and extensively on the subject matter, and in how she deftly she positions her arms, legs, and feet. And the proof is in the pudding: Mary is still lifting and transferring patients.

When it comes to teaching and training, the question should not be: “How do you capture this knowledge and share it with a wider audience?” This is a generic question for which the default answer is: film and publish a video. No, the real question should be, “How do you most successfully get what’s in the expert’s brain into the learner’s brain?” To answer that question, you have to be able to understand and deconstruct the pattern of interactions and intersubjectivities that occur dynamically between experts and learners.

Let’s think about what the most effective teachers do best. At its core, a good teacher meets learners where they are and give them the tools they need to practice, refine, revisit, and improve. For hands-on tasks, this process is clearly observed in a cycle of demonstration-deconstruction-reconstruction-improvement. I demonstrate for you how I julienne a bell pepper, then deconstruct it slowly for clarity and emphasis. You attempt to reconstruct this action by replicating the movements. I assess your actions, adjust the way you grasp your knife or where you incise the body of the pepper, and answer any questions you have. Repeat.

This, then, should also be the template for a learning solution that’s built for efficacy and scale. This level of interactivity, visual repetition, adaptiveness to learning styles and needs, and anticipatory help is necessary and possible, but it cannot be found through conventional textbooks and videos, and it certainly doesn’t occur by talking at someone.

For Mary, the challenge of distilling decades worth of knowledge was a daunting one. This is normal, and also the thing I love best about working with experts. From their mouths come a tumble of information, branches of thought, tangents of ideas. This is what my team listens for, queries, mines, and organizes. Collaboratively with the expert, as though we are sketching the blueprint for a new home, we lay the foundation for a lesson or series of lessons on which we can build and iterate. From there, we do multiple passes of these lessons from diverse perspectives and learning styles (what we refer to as empathetic design) to understand every potential roadblock, uncertainty, or opening for deeper knowledge.

After content production, editing, and coding have been successfully completed, the end result experiential step-by-step lessons for the learner of utmost clarity to engage with in the moment. Our immediate goal is for the learner to be set up for success and experience the positive reinforcement of a task completed successfully and capably.

An added benefit, we’re delighted to discover, is the powerful clarity and relief experienced by the expert. The methodology we use and journey on enables them to articulate their philosophy, approach, and practice in ways they may not have had the opportunity to do before. What’s more, being able to document and preserve their knowledge ensures their work will live on in perpetuity.

“Now ma’am,” one of Homewatch’s caregivers play-acts with me, “I am now going to wrap this belt around your waist, is that alright with you? Please tell me if it’s too tight.” We are at Homewatch Caregivers’ Loudoun office where Tim, Rebecca, and Linda have set the stage for a pilot test. On by one, their employees enter a room where I am the test subject seated in a wheelchair and they are tasked with following the lesson while performing the transfer on me. As the silent observer, I watch them interact with the screen. I comply with any instructions they give me, grasp their midsections as they do mine, and slow-dance with them until they position me into a chair. At the end of our time together, they stick around to answer questions and give feedback. Having experienced gait belt transfers directly from the expert herself, I took mental note of successful executions as well as missteps and incorrect techniques

Which leads us back to our original question of whether or not Larabee can teach actions and skills with the same precision and efficacy as in-person learning. In the case of gait belt transfers specifically, I believe the answer is no. Learning directly from an expert, side by side, shoulder to shoulder, is an indelible, irreplaceable experience. Any interaction between two individuals is a psychological encounter: a multisensory, contextually rich, layered exchange between two dynamic human beings.

However, in a very short period of time (less than 15 minutes a person), Larabee was able to teach a group of individuals with diverse learning styles an extraordinarily important skill and get them to 90% or more of where they needed to be. From what I observed firsthand, each caregiver demonstrated the core fundamentals and walked away with a confident belief in their ability to do gait belt transfers. What lacked could have been fixed easily with a tweak here, an adjustment there.

Implementing Larabee successfully in caregiving may require an inversion of current practices. Depending on the agency, aides today are often sent to expensive training seminars that vary wildly in quality and are then left to “remember” what they learned. In lieu of this, Larabee can be used as a tool to jumpstart their learning in dynamic fashion. Working with a more informed audience, experts can then perform in-person modifications and improvements in large or small groups.

For other precision-based tasks and skills, I do believe Larabee can achieve the same precision and efficacy as in-person learning if we remain vigilant in our approach to quality, clarity, and the power of good storytelling. Larabee lessons go at the learner’s pace, adapt to diverse learning styles, can be revisited again and again, and includes a communication portal for discursive engagement. In a recent conversation with the founder of Area 1 Security (and now Area 2 Farms), Oren Falkowitz referred to Larabee as an “interactive 10,000 hours.”

Dr. Patel is one of millions of Americans in need of consistent, dependable, and compassionate caregiving. The high turnover of aides, their unfamiliarity with his specific and changing needs, and nurses who “vastly differ in their knowledge or experience with safe practices” occupy so much real estate in his brain that he often wonders how much improved his life would be were these stressors to go away. His recommendation for “adequate training and continued education on best practices” – requirements he appreciated as a cardiologist – would benefit even the “more experienced caregivers who were often too confident and very reluctant to change their habits, leading to many conflicts, falls, and injuries,”

“They may benefit greatly from training with a PT,” he writes to me, though his last sentence is more dismal. “But who has the time for all of that?”

A vastly improved approach to caregiver training benefits Dr. Patel as well as the caregivers themselves who frequently experience musculoskeletal injury and strain while doing unquestionably physical, undeniably demanding work. What is required is not vast quantities of time or a complete overall to the system, but a novel approach to different forms knowledge, and an appetite for experimentation and innovation. Homewatch is one such example of an organization that recognizes the opportunity for not only improvement but a kind of transformation that has ripple effects.

When it comes to physical actions and skills, there is not a single person who has been spared the sheer exasperation of following step-by-step instructions. Whether it is assembling out-of-the-box furniture or using a complex piece of medical equipment for the first time, confusion beats out clarity far too much of the time. Larabee’s approach to learning gold standard steps and procedures is one that eradicates frustration. But why stop there? By weaving together good design, technology, content, and human behavior, we can scale a learning solution that enlivens as it guides, invites deepening knowledge, and boosts confidence as it helps turn skillful movements into muscle memory.