ER Corner: Outcomes—Healthcare Education’s First Aim

  • Friday, December 02, 2016
  • Education

In the last ER Corner, I told you about a triple aim for healthcare education: (1) the identification of real-world, behavioral outcomes; (2) the generation of measurable, behavioral objectives that operationalize those outcomes, and (3) the creation of assessment items that directly measure the objectives. These three aims are the core principles of instructional design, and failure to attend to all three in the correct sequence can result in fundamental flaws in instruction that can lead to a corresponding failure to learn.

In this week’s ER Corner, I will discuss the first, and most critical of the triple aims: specifying/classifying learning outcomes. This will also be the subject of a workshop on this topic at noon on Wednesday, December 14. See below for a link to information about the workshop and how to register and attend in person or online.

In my last column, I provided an overview of learning outcomes, suggesting that there were two aspects of specifying outcomes that are critical to our discussion: (1) outcomes refer to real-world behaviors that demonstrate what knowledge looks like when demonstrated in the real world, and (2) outcomes are classified according to an instructional taxonomy. Classify outcomes correctly (and first!) and you can achieve perfect alignment of teaching strategies and assessment (i.e., the desired learning). Misidentify one outcome for the other, or fail to recognize that what we actually want to teach is really two different outcomes (and thus requires different teaching and assessment strategies), and no amount of teaching expertise can make up for the error.

Robert Gagné, the founder of instructional design as a field, realized in 1969 that most of the errors teachers make can be traced to two errors I’ve just described. Based on a detailed analysis of the evidence in education, psychology, and communication, he wrote the seminal volume The Conditions of Learning in 1965, which delineates a taxonomy of five different classes of learning outcome, or varieties of learning, as he called them. While these are akin to Bloom’s taxonomy, there are important differences. Whereas Bloom focused only on cognitive skills, Gagné subdivides Bloom’s cognitive skills into cognitive skills and intellectual skills, arguing that there are important differences.

Gagné’s cognitive strategies focus on internal control processes that learners select and apply to help them manage their own learning (e.g., rehearsal, elaboration), whereas his intellectual skills rely on knowing what or how to do things (much like Bloom’s taxonomy). Intellectual skills are further subdivided into a hierarchy, from most to least complex: problem solving, rule-using, defined concepts, concrete concepts, and discriminations. He also added three other domains, or varieties of learning: motor skills (the physical movements required in skills such as those involved in hitting a baseball), attitudes (beliefs or feelings such as those involved in empathy, compassion, altruism), and verbal information (facts and propositions such as drug names or names of tools).

Why do we need these five different varieties of learning in the first place? What difference do they make in our instruction?

We need them because outcomes are the tail that wags the dog in good instructional design. Each requires its own set of teaching and assessment strategies. Take using an ultrasound wand during pregnancy: there are physical movements (pressure, grip, etc.), intellectual skills (knowing where to place the wand, what pattern to use, how long to do it, recognizing what the image is showing), verbal information (the names of anatomical locations and features of the fetus), and attitudes (patient interaction, delivery of difficult news). While it is true (and desirable) that each of these can be taught and assessed separately, if we do not first consider which of these outcomes are involved and which of them we want to teach under this circumstance, we will either ignore a necessary outcome (and thus not develop any teaching or assessment for it) or conflate two or more different outcomes and select the wrong strategies and assessment.

A common example of this latter error is when we mistake rules (one of Gagné’s intellectual skills) for verbal information, and vice-versa, as when teaching “when performing an ultrasound for purpose x, the wand should be placed in position y with z pressure.” Having already classified this as a rule, I know that this is a real-world application of a skill, not verbal information, which then guides the design of my objective (e.g., “Given an ultrasound wand and a simulated or real patient, the learner will be able to demonstrate a standard ultrasound exam using the transducer on the patient to generate 2-D images of the developing fetus that meets the standards in use at _____ hospital or clinic.” And because I have my outcome and objective aligned, it is impossible for me to generate the wrong assessment. In this case, it would involve a real or simulated patient in a real or simulated environment, and the actual procedure itself: “tell the student to ‘perform a standard ultrasound on the patient to generate a 2-D image of the developing fetus for a first-trimester pregnancy.’ ”

However, if I did NOT first classify my outcomes, I might then generate an objective that could be interpreted as either verbal information or a rule, which might then lead to an assessment item appropriate for verbal information such as a true-or-false item that asks the learner to “tell me how to perform a standard ultrasound to produce a 2-D image of the developing fetus for a first trimester pregnancy,” to which the student could parrot back a memorized answer. We would have no evidence that they can actually perform the skill.

This may seem obvious, but it is not always so. Even if we develop the right objective for the end, there are still prerequisite outcomes that are necessary. If a student fails the exam, was it because he or she did not know the motor skills, the names and labels involved, or the rule for what to look for and how to classify resulting images? Likewise, each different kind of outcome requires its own teaching strategies. For example, attitudes are learned through strategies such as modeling and role play and are ultimately assessed by observation of the choices people make regarding the object or environment in which the attitude can be observed. Yet, more often than not, we try to teach and assess attitudes by using strategies that align with verbal information (e.g., telling people what specific attitude they should have and why they should have it or asking them to answer multiple-choice items).

If you want to learn more about and gain practice in specifying learning outcomes, come to the AEIS Workshop on Outcomes on December 14. For more information on attending this workshop in person, participating live from another campus, requesting a workshop on your campus, or to set up a consultation with Education Resources for teaching or education scholarship assistance, contact Shae Samuelson at (701) 777-6150. Stay tuned for the next ER Corner and its associated workshop, which will focus on how to write a good objective based on outcomes!

Richard Van Eck, PhD
Associate Dean for Teaching and Learning 
Founding Dr. David and Lola Rognlie Monson Endowed Professor in Medical Education