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Some theory

Two educational models help us understand how learning outcomes or objectives relate to learner's professional development as they move along the ‘novice to expert’ continuum.

The first is found in Bloom’s Taxonomy of Objectives in the Cognitive Domain (1956), which describes how learning objectives related to cognitive development increase in complexity as learners develop deeper understanding, start to apply this knowledge, and ultimately synthesise and evaluate what they have learned. See also Learning theories in ‘Explore around this topic’. You wll recognise from your own experience, that as your clinical understanding developed, you became better able to handle complex information from multiple sources and synthesise it quickly and precisely to make consistently accurate diagnoses and decisions.

The diagram below shows how the six levels increase in complexity as learners advance through formal education. Bloom’s model can be used to help write learning objectives or outcomes where they are mapped on to the appropriate level, depending on what learners are expected to achieve. A common mistake in writing outcomes is that they are at the wrong level; either expecting learners to be able to do something for which they are not yet ready, or inappropriately linking them to particular teaching and learning methods or assessments.


Taxonomy diagram

For example, it would probably be unrealistic for one of the learning outcomes for first-year medical students in their first term to be: ‘to be able to “evaluate” the impact of rationing herceptin on the long-term survival rates of breast cancer patients in the UK’. They would not have had the range of information, the experience or the strategic overview at that stage to be able to carry out the task. If you set the same learning outcome for someone studying a public health masters degree, then it would probably be entirely feasible and appropriate. Learners also tend to need to work up to the higher-level outcomes. They need the underpinning knowledge before they can understand, apply it, synthesise and so on. Although this model runs somewhat counter to more experiential learning approaches in which learning happens ‘by doing’ (Kolb, 1984), Bloom’s Taxonomy has been highly influential in all areas of education

When planning sessions, build in opportunities (even if they are quick checks and rechecks) to make sure that learners have the background knowledge and understanding before you move into the higher-level domains.

Another model that is particularly useful for thinking about learning outcomes in relation to assessment of clinical competence is Miller’s (1990) pyramid.

Miller's pyramid

This model is similar to Bloom’s Taxonomy in that there is a marked shift (as professionals develop expertise) from being able to demonstrate knowledge that underpins clinical competence (for example knowing the theory – learned from video, demonstration and reading – about how to take a history or examine an abdomen) to ‘doing in action’ where theory (intellectual skills), psychomotor skills and professional attitudes are synthesised and internalised into a seamless routine that can be carried out in different contexts.

Both these models help us to match learning outcomes with what we might expect the learner to be able to do at any stage. Learning outcomes, and their assessment, for students or trainees, usually relate to knowledge and understanding at a more basic level – possibly in an artificial or limited context – than the actual high-level performance expected of consultants.

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