How to develop targeted simulation learning objectives – Part 2: The Practice

In part 1 of this two part series (https://emsimcases.com/2015/04/21/how-to-develop-targeted-simulation-learning-objectives-part-1-the-theory/), we used the revised Bloom’s taxonomy to describe an approach to developing simulation-based learning objectives by targeting a specific, complex knowledge domain and a higher level cognitive process.

Now that we know the theory behind making targeted simulation learning objectives, what kind of learning objectives should be included in a team-based resuscitation simulation scenario?

Team based simulation can be used to learn and assess a variety of different components of resuscitation skills. These simulated events display the knowledge, skills and attitudes of learners in a controlled setting. What makes simulation different from other traditional models of learning is that it combines components of crisis resource management (CRM) with medical knowledge and skills into a complex educational event. Keeping this in mind, while developing objectives for a simulated scenario, it helps to separate the CRM and medical knowledge objectives. A separation of these two key components allows for targeted feedback directed at specific areas of the learners’ performance and aids in their assessment.

A common pitfall in the development of objectives for a simulated case is including too many of them! While there are a multitude of soft skills as well as medical decisions being made during the simulated event, both the learners and assessors benefit from having a limited amount of clear objectives. Debriefing after a simulation is critical for the learning experience and having too many objectives may dilute the main teaching points of the case. As an example, at the McGill University Emergency Medicine residency program, we aim for 2 CRM based objectives and 3 medical knowledge objectives. While this is in no way the rule, we have found that tailoring the case to a smaller number of clear and well-developed objectives allows for productive and high yield debriefing sessions.

Learning Objectives for a Tricyclic Antidepressant Overdose Case

Learning Objectives for a Tricyclic Antidepressant Overdose Case

As discussed in a previous post (https://emsimcases.com/2015/04/07/crisis-resource-management/), the main components of CRM include communication, leadership, resource utilization, situational awareness and problem solving.1 A case can be specifically tailored toward a CRM objective or vice versa. For example, an objective focusing on resource utilization and triage can guide the development of a simulated case with two patients in a resource-limited setting. Conversely, a simulated STEMI case can include an objective focusing on leadership and the team leader maintaining a global perspective of the case. There are no guidelines on which CRM based objectives to include, but ensuring that your cases utilize different CRM components allows your learners to focus on a few important skills at a time and ensures that your learners are exposed to each component of CRM in a simulated setting.

Medical objectives encompass the core medical content that the simulated case was designed to address. When developing the medical objective, remember to focus on a higher cognitive process, such as “applying” over “remembering”, and a higher-level knowledge domain, such as “procedural knowledge” that includes skills and algorithms. Again, there is no limit to what medical objectives you can include, as long as they are well developed and specific. When developing the medical objective for the case, it may help to take a step back and ask yourself “what do I want my learners to take away from this case?” It also helps to consider the training level of the learners, where simulation fits within your full educational curriculum as well as your setting and to develop the objectives accordingly. As an example, an airway case may contain an objective on the choice of an induction and paralytic agent for intubation for junior learners, whereas an objective on a “can’t intubate, can’t ventilate” situation may be more suitable for senior learners.

Defining learning objectives for your simulated scenarios is key for case development, debriefing and, ultimately, learning. Using theory, we can create targeted objectives that optimize the learning time spent in the simulated setting. Breaking up the objectives into CRM and medical knowledge while limiting the total number of objectives can help focus both the learner and educator on the teaching points from the case. Through careful consideration of learning objective development, simulation can be used to both fill potential gaps in you educational curriculum and to enhance the resuscitation skills, CRM skills and medical knowledge of your learners.

Take Home Points

1) Divide simulation objectives into CRM or medical objectives

2) Limit the number of objectives for each case

3) Apply theory to develop targeted and specific objectives to align them with the teaching strategy of simulation

4) Diversify your CRM objectives throughout your simulation curriculum

5) For medical objectives, ask yourself “what do I want my learners to take away from this case?”

6) Consider the training level, full training curriculum and setting when developing medical objectives.

  1. 1) Hicks CM, Kiss A, Bandiera GW, Denny CJ. Crisis Resources for Emergency Workers (CREW II): Results of a pilot study and simulation-based crisis resource management course for emergency medicine residents. Can J Emerg Med. 2012;14(Crew Ii):354-362. doi:10.2310/8000.2012.120580.

How to develop targeted simulation learning objectives – Part 1: The Theory

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Miller’s Triangle (adapted from “The assessment of clinical skills/competence/performance.”) 

Simulation has filled a void that was once present in medical education. Written and oral examinations continue to be used to assess Miller’s “knows” and “knows how” levels of performance while clinical rotation evaluations rest at the top of the triangle: “Does”. Simulation completes Miller’s triangle by allowing learners to “show how” their knowledge and skills can be applied in a risk-free, simulated clinical environment. 1-2

As simulation educators, our roles not only include creating, programming, running realistic scenarios and facilitating debriefing, but also developing appropriate learning objectives that align with our instructional strategy of simulated team-based resuscitation.

Learning objectives are statements of what we intend or expect students to learn as a result of our instruction. In order to create these objectives, we need to determine what kind of knowledge and cognitive processes we are trying to address in our learners through the use of simulation. This is where learning theories can help.


Learning Objective Taxonomy

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Krathwohl’s Knowledge Domain and its categories (adapted from “A Revision of Bloom’s Taxonomy: An Overview”)

Bloom originally described a hierarchical taxonomy of educational objectives based on 6 categories of the cognitive domain from simple to more complex: Knowledge, Comprehension, Application, Analysis, Synthesis and Evaluation.In 2002, Krathwohl presented a revision of Bloom’s Taxonomy that expanded and described the different categories of knowledge in increasing complexity from factual to metacognitive knowledge. He also described a novel approach to educational objectives involving two dimensions: a combination of the type of knowledge and the cognitive process involved in obtaining that knowledge.

This combination represents the way learning objectives are usually developed and written; there is a component of subject content as the noun (the knowledge domain) and a description of what is to be done with that content as the learning verb (the cognitive process dimension).

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Krathwohl’s Cognitive Process Dimensions are presented from the least to the most complex cognitive process (adapted from “A Revision of Bloom’s Taxonomy: An Overview”) 

An instructor can develop learning objectives for simulation that fall under any knowledge domain and cognitive process dimension but being a learning modality that can be limited by resources, cost, space and time, I believe that these learning objectives should be optimized to the most appropriate cognitive process dimension and should specifically target subject content from a complex knowledge domain so that learners get the most out of the simulated experience. Compare these 3 examples of learning objectives for a simulated scenario of unstable bradycardia.

Ex 1: Understand the treatment of a patient with unstable bradycardia.
Ex 2: Recall the appropriate dose of atropine in the setting of unstable bradycardia.
Ex 3: Appropriately employ the ACLS bradycardia algorithm to a patient in 3rd degree AV-block.

In example 1, the learning verb, to understand, is ill defined. A non-specific learning verb makes it more difficult to assess the learner’s performance. Also, while treatment as the noun may be classified as conceptual knowledge, it is too vague to tailor specific debriefing comments towards.

In example 2, the learning verb recall uses the lowest level of cognitive processes: remembering. Also, the dose of atropine represents factual knowledge, the lowest level of the knowledge domain. While this could be an objective for a simulated scenario, the objective could also be adequately (or even more appropriately) met using less complex instructional strategies (textbooks, blogs or lectures) or assessment tools (paper tests or oral exams).

In example 3, the learning verb employ targets the highest cognitive process dimension of the three examples: to apply. The ACLS bradycardia algorithm represents procedural knowledge that is well defined which helps both the learners and educators understand their expectations. The learning objective is specific and tailored to the case.

Which levels of knowledge and cognitive process dimensions should we target?

While learners in simulated scenarios do employ factual and conceptual knowledge in the evaluation, diagnosis and treatment of the simulated patient, I think the facets of procedural knowledge (remember, this is the educational theory “procedural”, not cricothyroidotomy “procedural”) best represent the kind of knowledge simulation can afford to learners. These facets include subject-specific skills, algorithms, techniques, methods and criteria for determining when to use appropriate procedures. Debriefing scenarios can also incorporate the metacognitive domain as learners can reflect on their performance and gaps in their knowledge. The apply dimension, which includes executing and implementing procedures in a given situation, most adequately describes the cognitive process used by learners during simulated scenarios while debriefing may involve evaluating certain processes.

Each cognitive domain process has useful learning verbs associated with them to help us create targeted learning objectives.

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Adapted from “A Revision of Bloom’s Taxonomy: An Overview”

Final Tips

So, when developing your learning objectives for a simulated scenario, targeting a specific knowledge domain and cognitive process as the learning noun and verb, respectively, will help guide the process. To optimize the learning objective and align it with the instructional strategy of simulated resuscitation scenarios, try and aim for a more complex knowledge domain (such as procedural knowledge) and a higher cognitive process.

Now that we know some of the theory, what kind of objectives should we make? Should we focus on medical management? What about crisis-resource management? In part 2, we will tackle what kind of learning objectives should be included in a team-based resuscitation simulated scenario.


References

1) Miller, G. (1990). The assessment of clinical skills/competence/performance. Academic Medicine,65(9), S63-7.

2) Kyle, R. (2008). 7.5 Which of these Curriculum Components are Best Suited to Simulation? In Clinical simulation operations, engineering and management(1st ed., pp. 78-79). Burlington, MA: Academic Press.

3) Bloom, B.S., Engelhart, M.D., Furst, E.J., Hill, W.H., & Krathwohl, D.R. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook 1: Cognitive domain. New York: David McKay

4) Krathwohl, D. (2002). A Revision Of Bloom’s Taxonomy: An Overview. Theory Into Practice,41(4), 212-218.