Learning Domains

Afza.Malik GDA

Learning Domains In Nursing Education

Learning Domains

Learning domains include.s cognitive domain , effective domain and psycho motor domain topic of health education.


    The need for clearly stated outcomes and competencies, what the student should achieve at the end of the instruction, becomes evident when the teacher translates them into test items and other methods of assessment. Test items need to adequately assess the outcome for instance, to identify, describe, apply, and analyze as it relates to the content area. Outcomes and competencies may be written to reflect three domains of learning cognitive, affective, and psychomotor each with its own taxonomy. The taxonomies classify the outcomes into various levels of complexity.

Cognitive Domain

    The cognitive domain deals with knowledge and higher level thinking skills such as clinical reasoning and critical thinking. Learning within this domain includes the acquisition of facts and specific information, use of knowledge in practice, and higher level cognitive skills. The most widely used cognitive taxonomy was developed in 1956 by Bloom, Englehart, Furst, Hill, and Krathwohl. 

    It includes six levels of cognitive learning, increasing in complexity: knowledge, comprehension, application, analysis, synthesis, and evaluation. This taxonomy suggests that knowledge, such as recall of specific facts, is less complex and demanding intellectually than the higher levels of learning. Evaluation, the most complex level, requires judgments based on varied criteria.

    In an update of the taxonomy by Anderson and Krathwohl (2001), the names for the levels of learning were reworded as verbs, for example, the knowledge level was renamed remembering, and synthesis and evaluation were reordered. In the adapted  Taxonomy, the highest level of learning is creating, which is the process of synthesizing information to develop a new product.

    One advantage in considering this taxonomy when writing outcomes and test items is that it encourages the teacher to think about higher levels of learning expected as a  result of the instruction. If the course goals reflect application of knowledge in clinical practice and complex thinking, these higher levels of learning should be reflected in the outcomes and assessment rather than focusing only on the recall of facts and other information.

   In using the taxonomy, the teacher decides first on the level of cognitive learning intended and then develops outcomes and assessment methods for that particular level. Decisions about the taxonomic level at which to gear instruction and assessment depend on the teacher’s judgment in considering the background of the learner,placement of the course and learning activities within the curriculum to provide for the progressive development of knowledge and competencies, and complexity of the concepts and content to be learned in relation to the time allowed for teaching. 

    If the time for teaching and evaluation is limited, the outcomes may need to be written at a lower level. The taxonomy provides a continuum for educators to use in planning instruction and assessing learning outcomes, beginning with remembering and recalling of facts and information and progressing toward understanding, using concepts and other forms of knowledge in practice, analyzing situations, evaluating materials and situations, and creating new products.

    A description and sample outcome for each of the six levels of learning in the taxonomy of the cognitive domain follow.

1. Remembering: Recall of facts and specific information. Memorization of specifics.

Define the term systole.

2. Understanding: Ability to describe and explain the material. Describe the blood flow through the heart.

3. Applying: Use of information in a new situation. Ability to use knowledge in a new situation.Apply evidence on non pharmacologic interventions for managing chronicpa in for patients using opioids.

4. Analyzing: Ability to break down material into component parts and identify the relationships among them Analyze the unit’s scheduling practices and their potential impact on patient safety and nurses’ health.

5. Evaluating: Ability to make judgments based on criteria Evaluate the quality and strength of evidence and applicability to practice.

6. Creating: Ability to develop and combine elements to create a new product Develop guidelines for assessment, education, and follow-up care of patients with postpartum depression.

    This taxonomy is useful in developing test items because it helps the teacher gear the item to a particular cognitive level. For example, if the outcome focuses on applying, the test item should measure whether the student can use the concept in a new situation, which is the intent of learning at that level. However, the taxonomy alone does not always determine the level of complexity of the item because one other consideration is how the information was presented in the instruction. 

    For example, a test item at the application level requires use of previously learned concepts and knowledge in a new situation. Whether the situation is new for each student, however, is not known. Some students may have had clinical experience with that situation or been exposed to it through another learning activity. As another example, a question written at the understanding level may actually be at the knowledge level if the teacher used that specific explanation in class and students only need to remember the explanation to answer the item.

Affective Domain

    The affective domain relates to the development of values, attitudes, and beliefs consistent with standards of professional nursing practice. Developed by Krathwohl,Bloom, and Masia (1964), the taxonomy of the affective domain includes five levels organized around the principle of increasing involvement of the learner and internalization of a value. This principle relates to the progression of learners from mere awareness of a value, for instance, confidentiality, to internalization of that value as a basis for their own behavior. 

    Considering the effective domain in teaching is particularly important in the clinical setting because this is where students have an opportunity to reflect on their values and use them in patient care and when collaborating with other healthcare providers. Younas and Maddigan (2019) emphasized the importance of targeting the effective domain to foster compassion among nursing students and help them to provide compassionate care. There are two important dimensions in evaluating effective outcomes. 

    The first relates to the student’s knowledge of the values, attitudes, and beliefs that are important in guiding decisions in nursing. Prior to internalizing a value and using it as a basis for decision-making and behavior, the student needs to know what are important values in nursing. There is a cognitive base, therefore, to the development of a value system. Evaluation of this dimension focuses on acquisition of knowledge about the values, attitudes, and beliefs consistent with professional nursing practice. A variety of test items and assessment methods is appropriate to evaluate this knowledge base.

    The second dimension of affective evaluation focuses on whether students have accepted these values, attitudes, and beliefs and are internalizing them for their own decision-making and behavior. Assessment at these higher levels of the affective domain is more difficult because it requires observation of learner behaviors over time to determine whether there is commitment to act according to professional values. Test items are not appropriate for these levels as the teacher is concerned with the use of values in practice and using them consistently in patient care.

    A description and sample outcome for each of the five levels of learning in the affective taxonomy follow.

1. Receiving: Awareness of values, attitudes, and beliefs important in nursing practice. Sensitivity to a patient, clinical situation, and problem. Express an awareness of the need for maintaining confidentiality of patient information.

2. Responding: Learner’s reaction to a situation. Responding voluntarily to a given situation reflecting a choice made by the learner. Share willingly feelings about caring for a dying patient.

3. Valuing: Internalization of a value. Acceptance of a value and the commitment to using that value as a basis for behavior.Support the rights of patients to make their own decisions about care.

4. Organization: Development of a complex system of values. Creation of a value system. Form a position about issues relating to quality and cost of care.

5. Characterization by a value: Internalization of a value system providing a philosophy for practice.Act consistently to involve patients and families in care.

Psychomotor Domain

    Psychomotor learning involves the development of motor skills and competency in performing clinical skills and procedures and in using technology. This domain includes activities that are movement oriented, requiring some degree of physical coordination. Motor skills have a cognitive base, which involves the principles underlying the skill. They also have an affective component reflecting the values of the nurse while carrying out the skill, for example, respecting the patient while performing the procedure.

    In developing psychomotor skills, learners progress through three phases of learning: cognitive (understanding what needs to be done), associative (gradually improving performance until movements are consistent), and autonomous (performing the skill automatically; Schmidt & Lee, 2005). 

    To progress through these levels, students need to practice the skill repetitively and receive specific, informative feedback on their performance, referred to as deliberate practice (Bosse et al., 2015; Ericsson,2004; Kardong-Edgren, Oermann, & Rizzolo, 2019; McGaghie, Issenberg, Petrusa, & Scalese, 2010; Oermann, Molloy, & Vaughn, 2015). 

    An understanding of motor skill development guides teachers in planning the instruction of skills in nursing, building in sufficient practice to gain expertise (Oermann et al., 2015; Oermann, Muckler, & Morgan, 2016).Different taxonomies have been developed for the evaluation of psychomotor skills. One taxonomy useful in nursing education specifies five levels in the development of psychomotor skills. 

    The lowest level is imitation learning; here the learner observes a demonstration of the skill and imitates that performance. In the second level, the learner performs the skill following written guidelines. By practicing skills, the learner refines the ability to perform them without errors (precision) and in a reasonable time frame (articulation) until they become a natural part of care (natuRalization; Dave, 1970; Oermann, Shellenbarger, & Gaberson, 2018). A description of each of these levels and sample objectives follows.

1. Imitation: Performance of a skill following demonstration by a teacher or through multimedia. Imitative learning.Demonstrate changing a sterile dressing. 

2. Manipulation: Ability to follow instructions rather than needing to observe the procedure or skill.Suction a patient according to the accepted procedure.

3. Precision: Ability to perform a skill accurately, independently, and without using a model or set of directions.Take vital signs accurately.

4. Articulation: Coordinated performance of a skill within a reasonable time frame.Demonstrate skill in administering an intravenous medication.

5. Naturalization: High degree of proficiency. Integration of skill within care.Competently carry out skills for care of critically ill patients.

    Assessment methods for psychomotor skills provide data on knowledge of the principles underlying the skill and ability to carry out the skill or procedure in simulations and with patients. Most of the evaluation of performance is done in the clinical setting, in skill and simulation laboratories, and using various technologies for distance-based clinical courses; however, test items may be used for assessing principles associated with performing the skill.

Use of Outcomes for Assessment and Testing

    As described earlier, the taxonomies provide a framework for the teacher to plan instruction and design assessment strategies at different levels of learning, from simple to complex in the cognitive domain, from awareness of a value to developing a philosophy of practice based on a value system in the effective domain, and increasing psychomotor competency, from imitation of the skill to performance as a natural part of care. 

    These taxonomies are of value in assessing learning and performance to gear tests and other strategies to the intended level of learning. If the outcome of learning is application, then test items also need to be at the application level. If the outcome of learning is valuing, then the assessment methods need to examine students’ behaviors over time to determine whether they are committed to practice reflecting these values. 

    If the outcome of motor skill learning is precision, then the assessment needs to focus on accuracy in performance, not the speed with which the skill is performed. The taxonomies, therefore, provide a useful framework to ensure that test items and assessment methods are at the appropriate level for the intended learning outcomes.

    In developing test items and other types of assessment methods, the teacher first identifies the outcome or competency to be evaluated, then designs test items or other methods to collect information to determine whether the student has achieved it. For the outcome “Identify characteristics of acute heart failure,” the test item would examine student ability to recall those characteristics. 

    The expected performance is at the remembering level: recalling facts about acute heart failure, not understanding them nor using that knowledge in clinical situations. Some teachers choose not to use outcomes as the basis for testing and evaluation and instead develop test items and other assessment methods from the content of the course. With this process, the teacher identifies explicit content areas to be evaluated; test items then sample knowledge of this content. 

    If using this method, the teacher should refer to the course outcomes and placement of the course in the curriculum for decisions about the level of complexity of the test items and other assessment methods. Throughout this book, multiple types of test items and other assessment methods are presented. 

    It is assumed that these items were developed from specific outcomes or objectives, depending on the format used in the nursing program, or from explicit content areas. Regardless of whether the teacher uses outcomes or content domains as the framework for assessment, test items and other strategies should evaluate the learning outcome intended from the instruction.

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