Implementation and Learning Domains In Nursing Education
The Cognitive Domain In Nursing Education
The cognitive domain is known as the “thinking” domain. Learning in this domain involves acquiring information and addressing the development of the learner's intellectual abilities, mental capacities, understanding, and thinking processes (Eggen & Kauchak, 2012).
Objectives in this domain are divided into six levels (Bloom et al., 1956), each specifying cognitive processes ranging from the simple (knowledge) to the more complex (evaluation), as seen in Figure 10-2.
Levels of Behavioral Objectives and Examples in the Cognitive Domain
Knowledge level: Ability of the learner to memorize, recall, define, recognize, or identify specific information, such as facts, rules, principles, conditions, and terms, presented during instruction. Example: After a 20-minute teaching session, the patient will be able to state with accuracy the definition of chronic obstructive pulmonary disease (COPD).
Comprehension level: Ability of the learner to demonstrate an understanding of what is being communicated by recognizing it in a translated form, such as grasping an idea by defining it or summarizing it in his or her own words (knowledge is a prerequisite behavior).
Example: After watching a 10-minute video on nutrition following gastric bypass surgery, the patient will be able to give at least three examples of food choices that will be included in his diet.
Application level: Ability of the learner to use ideas, principles, abstractions, or theories in specific situations, such as figuring, writing, reading, or handling equipment (knowledge and understanding are prerequisite behaviors). Example: On completion of a cardiac rehabilitation program, the patient will modify three exercise regimens that can fit into his or her lifestyle at home.
Analysis level: Ability of the learner to recognize and structure information by breaking it down into its separate parts and specifying the relationship between the parts (knowledge, understanding, and application are prerequisite behaviors). Example: After reading handsouts provided by the nurse educator, the family member will calculate the correct number of total grams of protein included on average per day in the family diet.
Synthesis level: Ability of the learner to put together parts into a unified whole by creating a unique product that is written. oral, or in picture form (knowledge, comprehension, application, and analysis are prerequisite behaviors). Example: Given a sample list of foods, the patient will devise a menu to include foods from the four food groups (dairy, meat, vegetables and fruits, and grains) in the recommended amounts for daily intake.
Evaluation level: Ability of the learner to judge the value of something by applying appropriate criteria (knowledge, understanding, application, analysis, and synthesis are prerequisite behaviors). Example: After three teaching sessions, the learner will assess his readiness to function independently in the home setting.
Teaching in the Cognitive Domain In Nursing Education
Several teaching methods and tools exist for the purpose of developing cognitive abilities. The methods most often used to stimulate learning in the cognitive domain include lecture, group discussion, one-to-one instruction, and self-instruction activities, such as computer-assisted instruction.
Verbal, written, and visual tools are all particularly successful in enhancing the teaching methods to help learners master cognitive content. For example, research has shown computer-assisted instruction to be effective in teaching clients about HIV prevention (Evans, Edmunson-Drane, & Harris, 2000: Ford, Mazzone, & Taylor, 2005).
However, cognitive skills can be gained by exposure to all types of educational experiences, including the instructional methods used primarily for affective and psychomotor learning. For example, the concept of group discussion for prenatal care has been shown to improve perinatal outcomes (Rotundo, 2012).
Cognitive domain learning is the traditional focus of most teaching. In education of patients, as well as nursing staff and students, emphasis remains on the sharing of facts, theories, and concepts.
Perhaps this emphasis has evolved because educators typically feel more confident and more skilled in being the giver of information than in being the facilitator and coordinator of learning. Lecture and one-to-one instruction are the most frequently used methods of teaching in the cognitive domain.
With respect to cognitive learning, how much time for practice is necessary to influence the short-term and long-term retention of information? Cognitive scientists have been exploring the allocation of practice time to the learning of new material. Generally, research findings indicate that learning distributed over several sessions leads to better memory than information learned in a single session.
This phenomenon has been described by Willingham (2002) as the “spacing effect.” That is, learning information all at once on one day, an approach known as massed practice, is much less effective for remembering facts than learning information over successive periods of time, an approach known as distributed practice.
Massed practice, commonly identified as “cramming,” might allow the recall of information for a short time, but evidence strongly supports that distributed practice is very important in forging memories that last for years.
The effect of spreading out learning over time is very clear. The average person exposed to distributed practice remembers 67% better than people who receive massed training. That is, spacing the time allocated for learning significantly increases memory. The longer the delays between practice sessions, the greater and more permanent is the learning.
In fact, if learning is distributed over time, not only does this spacing effect hold, but it becomes even more robust (Willingham, 2002). This evidence, when applied to the education of patients, staff nurses, or student nurses, strongly suggests the need to allocate time for the acquisition of knowledge.
Such scientific findings explain, for example, why teaching a patient on the day of discharge from the hospital is ineffective or why students who cram for a test do not retain the information as well as their counterparts who distribute their learning over an extended length of time (Willingham, 2002).
The Affective Domain In Nursing Education
The affective domain is known as the “feeling” domain. Learning in this domain involves an increasing internalization or commitment to feelings expressed as emotions, interests, beliefs, attitudes, values, and appreciations. whereas the cognitive domain is ordered in terms of complexity of behaviors, the affective domain is divided into categories that specify the degree of a person's depth of emotional responses to tasks.
The affective domain includes emotional and social development goals. As stated by Eggen and Kauchak (2012), educators use the affective domain to help learners realize their own attitudes and values.
Although nurses recognize the need for individuals to learn in the affective domain, constructs such as a person's attitudes, beliefs, and values cannot be directly observed but can only be inferred from words and actions (Maier Lorentz, 1999). Nurse educators tend to be less confident and more challenged in writing behavioral objectives for the affective domain.
This is because it is difficult to develop easily measurable objectives and evaluate learning outcomes based on inferences of someone's observed behavior (Goulet & Owen Smith, 2005; Morrison et al., 2010).
Reilly and Oermann (1990) differentiate among the term's beliefs, attitudes, and values. Beliefs are what an individual perceives as reality; attitudes represent feelings about an object, person, or event; and values are operational standards that guide actions and ways of living. Objectives in the affective domain are divided into five categories (Krathwohl et al., 1964) each specifying the associated level of affective responses.
Levels of Behavioral Objectives and Examples in the Affective Domain
Receiving level: Ability of the learner to show awareness of an idea or fact or a consciousness of a situation or event in the environment. This level represents a willingness to selectively attend to or focus on data or to receive a stimulus. Example: During a group discussion session, the patient will admit to any fears he may have about needing to undergo a repeat angioplasty.
Responding level: Ability of the learner to respond to an experience, at first obediently and later willingly and with satisfaction. This level indicates a movement beyond denial and toward voluntary acceptance, which can lead to feelings of pleasure or enjoyment resulting from some new experience (receiving is a prerequisite behavior).
Example: At the end of one-to-one instruction, the child will verbalize feelings of confidence in managing her asthma using the peak-flow tracking chart.Valuing level; Ability of the learner to regard or accept the worth of a theory, idea, or event, demonstrating sufficient commitment or preference to an experience that is perceived as having value.
At this level, there is a definite willingness and desire to act to further that value (receiving and responding are prerequisite behaviors). Example: After attending a grievance support group meeting, the patient will complete a journal entry reflecting her feelings about the experience.
Organization level: Ability of the learner to organize, classify, and prioritize values by integrating a new value into a general set of values; to determine interrelationships of values; and to establish some values as dominant and pervasive (receiving, responding, and valuing are prerequisite behaviors).
Example: After a 45-minute group discussion session, the patient will be able to explain the reasons for her anxiety and fears about her self-care management responsibilities.
Characterization level: Ability of the learner to display adherence to a total philosophy or worldview, showing firm commitment to the values by generalizing certain experiences into a value system (receiving, responding, valuing, and organizing are prerequisite behaviors).
Example: Following a series of teaching sessions, the learner will display consistent interest in maintaining good hand-washing technique to control the spread of infection to patients, family members, and friends.
Teaching in the Affective Domain
Several teaching methods are powerful and reliable in helping the learner acquire affective behaviors. Role model, role play, simulation, gaming, questioning, case studies, and group discussion sessions are examples of methods of instruction that can be used to prepare nursing staff and students as well as patients and their families to develop values and explore attitudes, interests , and feelings.
The affective domain encompasses three levels (Menix, 1996) that govern attitudes and feelings:
The intrapersonal level includes personal perceptions of one's own self, such as self-concept, self-awareness, and self-acceptance.
The interpersonal level includes the perspective of self in relation to other individuals. The extra personal level involves the perception of others as established groups.
All three levels are important in affective skill development and can be taught through a variety of methods specifically geared to affective domain learning Focusing on behaviors in the affective domain is critically important but is often underestimated. Unfortunately, priority is rarely given to teaching in the affective domain.
The nurse's focus more often emphasizes cognitive and psychomotor learning, with little time being set aside for exploration and clarification of the learner's feelings, emotions, and attitudes (Miller, 2014; Morrison et al., 2010; Zimmerman & Phillips, 2000) .
Nurses must address the needs of the whole person by recognizing that learning is subjective and value driven (Schoenly, 1994). For nurses practicing in any setting, affective learning is especially important because they constantly face ethical issues and value conflicts (Tong, 2007). The pluralistic nature of US society requires nurses to respect racial and ethnic diversity in the population groups they serve (Marks, 2009).
Additionally, advancing technology also places nurses in advocacy positions when patients, families, and other healthcare professionals struggle with treatment decisions. In turn, patients and family members face the prospects of making moral and ethical choices as well as learning to internalize the value of adhering to prescribed treatment regimens and incorporating health promotion and disease prevention practices into their daily lives.
The teaching and learning setting is key in helping learners achieve affective behavioral outcomes. An open, trusting, empathetic, and accepting attitude by nurses sets the foundations for engaging patients and their families in learning. Staff nurses' beliefs, attitudes, and values significantly influence their affective behavior and therefore the quality of nursing care they deliver, as they integrate cultural competency into their nursing practice.
A nurse who is teaching students must have a personal value system that coincides with the values of the profession. Three American Nurses Association documents-Code of Ethics for Nurses with Interpretive Statements (2015), Nursing's Social Policy Statement (2010a), and Standards of Clinical Nursing Practice (2010b), provide nurse educators with ethical and values guidelines for professional practice.
Although most teaching and learning of students and staff emphasize the cognitive domain, the affective domain can facilitate their professional identity and values formation (Taylor, 2014), enhance their critical thinking and clinical judgment about ethical and moral issues, and increase their cultural competence in the delivery of fair and equal treatment in caring for people from many different backgrounds.
The Psychomotor Domain In Nursing Education
The psychomotor domain is known as the “skills” domain. Learning in this domain in- volves acquiring fine and gross motor abilities such as walking, handwriting, manipulating equipment, or performing a procedure. Psychomotor skill learning, according to Reilly and Oermann (1990), “is a complex process demanding far more knowledge than suggested by the simple mechanistic behavioral approach” (p. 81).
According to Eggen and Kauchak (2012), “while intellectual abilities enter into each of the psychomotor tasks, the primary focus is on the development of manipulative skills rather than on the growth of intellectual capability” (p. 17).
To develop psychomotor skills, integration of both cognitive and affective learning is required. The affective component recognizes the value of the skill being learned. The cognitive component relates to knowing the principles, relationships, and processes involved in the skill.
Although all three domains are involved in demonstrating a psychomotor competency, the psychomotor domain can be examined separately and requires different teaching approaches and evaluation strategies (Reilly & Oermann, 1990). Psychomotor skills are easy to identify and measure because they include primarily movement-oriented activities that are relatively easy to observe.
Psychomotor learning can be classified in a variety of ways (Dave, 1970; Harrow, 1972; Moore, 1970; Simpson, 1972). Simpson's system seems to be the most widely recognized as relevant to patient, staff, and student teaching. Objectives in this domain, according to Simpson (1972), are divided into seven levels, from simple to complex.
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