OR instructor’s notebook

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Phyllis Wells, RN

Wrlting learner oblectlves:

A teaching plan for emergency procedures

lhis is the second in a series of sample teaching plans to help the OR inservice instructor. In a series of four articles, Phyllis Wells, RN, will give you ideas for designing a program for experienced 0 R staff nurses. The first article, published in October 1982, explained how to identi& learner needs. This article focuses on writing learner objectives. Auture articles will discuss the posttest and teaching methodology.

ldentlfylng learner needs Asthe staff development instructor in your OR, you have decided to present a series of inservice programs on nursing care in emergency situations. The first subject you plan to present is malignant hyperthermia.

Because malignant hyperthermia is

0 Phyllls Wells, FIN, is a nurse consultant and a part-time OR staff nurse at St Francis Hospital, Colorado Springs, Colo. She is a graduate of the Good Samaritan School of Nursing, Phoenix.

triggered in genetically susceptible persons by the administration of inhalation anesthetics and neuromuscular blocking agents, it is of particular interest to operating room nurses. Although its incidence is low (1/10,000), fatality rates of over 70% have been reported, and survivors are sometimes permanently and seriously impaired. These potentially disastrous consequences can usually be avoided by identifying susceptible patients before surgery, by recognizing the developing condition early, and by treating it appropriately.

Nurses working in the OR must be prepared to assist in the diagnosis and treatment of malignant hyperthermia. As the staff development instructor, you are responsible for providing information and learning experiences that will ensure appropriate behavior in this emergency. As outlined in the last article, you began your

lesson plan by identifying learner needs. After studying the diagnosis and treatment of malignant hyperthermia, you identified the following topics as appropriate for your inservice program:

0 anesthetic agents that trigger malignant hyperthermia

0 early symptoms 0 diagnostic aids 0 drug therapy 0 hypothermia therapy 0 fluids and electrolytes. Under each of these main headings you

listed specific topics such as: identifying significant changes in temperature, calculating drug dosage based on body weight, and use of hypothermia equipment.

After compiling this list (course outline), you ~~ ~

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did a needs assessment to determine how many items on the list the nurses in your department already knew. You were then able to revise your outline so you would not spend time talking about procedures they are familiar with.

Writing learner objectives With your revised list of subject matter based on learner needs, you are now ready to write learner objectives. Objectives state desired learning outcomes of an educational activity. They define precisely what the learner will be able to do as a result of participating in your inservice program. For example: “After attending an inservice program on malignant hyperthermia, the nurse (learner) will be able to list the anesthetic agents that trigger malignant hyperthermia.”

Objectives should focus on learner behavior, not teacher behavior. Incorrect “Explain to the audience the etiology of malignant hyperthermia.” (teacher objective) Correct “Identify the diagnostic test that is most definitive for susceptibility to malignant hyperthermia.” (learner objective)

each objective. Incorrect “Identify the symptoms commonly observed with malignant hyperthenia, and list the drugs used to treat those symptoms.” (multiple behaviors-“identify” and “list”) Correct “Given a list of drugs commonly used in treating malignant hyperthermia, state the usual dosage for each.” (One behavior-“state”)

measurable. Incorrect “Know what to do if an acute malignant hyperthermia reaction occurs.” (not specific and not measurable) Correct “State the first step that should be taken if an acute malignant hyperthermia reaction is suspected.” (specific and measurable)

Only one behavior should be included in

Behavior described should be specific and

There is a formula for writing learner objectives. It consists of: identifying the learner, stating the desired behavior, and listing the conditions and criteria that dre to be met. For example: “Given a list of five abnormal blood gas levels (condition), the OR nurse (learner) will indicate if the values are above or below normal (behavior) in four out of five of the examples (criteria).”

Such objectives work well in a structured program when content is specific, such as an OR inservice. These objectives tell the learner exactly what is expected and aid the instructor in developing the posttest.

It is also acceptable to write general objectives that only identify the learner and state the desired behavior. This type of objective does not limit the learner‘s response to a particular condition or criteria. General objectives are sufficient when large categories of content will be presented as in a two-day seminar. For example: “The nurse will be able to identify abnormal blood gas levels.”

When several objectives are to be written for one learning experience, you need only identify the learner once. For example: “After attending an inservice program on malignant hyperthermia, the OR staff nurse will be able to:

0 wriie at least five early symptoms common to an acute malignant hyperthermia reaction identify the rate of temperature increase in degrees centigrade that is indicative of malignant hyperthermia

establishing the patient‘s physical status during the malignant hyperthermia reaction.”

0 list the blood tests most useful in

The critical aspect of any learner objective is the word selected to describe the expected behavior. This word is always a verb and describes a behavior that can be observed and measured. Correct verbs Incorrect verbs write know identify understand list internalize recall appreciate translate believe

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state think construct realize classify enjoy

Writing objectives is not as difficult as you have been led to believe. Merely state what you want your students to be able to do. If you write this clearly, concisely, and in terms the learner can understand, you will be well on your way to completing your lesson plan.

Classification of objectlves After you have done a few lesson plans and feel comfortable writing objectives, you may want to team more about the classification of objectives. Educators and psychologists have attempted to categorize learning into three domains: cognitive, affective, and psychomotor. This classification was first done by Benjamin Bloom and is referred to as Bloom’s taxonomy. Simply stated, cognitive learning relates to intellectual activities associated with acquiring knowledge. An example of a cognitive learner objective would be: “Convert temperatures stated in degrees Fahrenheit to degrees Celsius.”

Affective learning relates to feelings associated with attitudes, values, and sensitivity. It is difficult to observe and measure feelings. The instructor must look for a behavior that demonstrates a feeling. If people smile, we assume they are pleased; if they scowl, we assume they are not pleased. An instructor might assume a nurse believes she/he should be assertive in planning and giving nursing care if the instructor observes’ the nurse initiating temperature monitoring and applying cold packs without being specifically instructed to do so by the physician. An appropriate affective learner objective would describe a behavior that demonstrates how the nurse feels about assertiveness. Incorrect “Believes she/he should be assertive in planning and giving nursing care.” Correct “Initiates nursing measures when an acute malignant hyperthermia reaction occurs.”

Psychomotor learning involves performing skills such as inserting a rectal thermometer,

mixing a medication, and applying ice packs. An example of a psychomotor learner objective is, “Prepares an arterial blood sample for transport to the laboratory.”

been identified, ranging from simple to complex. For example, listing the drugs commonly used in treating malignant hypertherrnia is a simple, cognitive behavior of memorization and recall. Determining dosage of a drug based on body weight or the acid/base condition of the patient‘s blood is a more complex cognitive behavior. Bringing the hypothermia machine into the operating room is a simple psychomotor skill. Making the machine function effectively by correctly following all operational instructions is more complex.

Some educators believe Bloom’s taxonomy of learning will establish a common language for instructors. This is already evidenced in the list of action verbs recommended for each level and domain of learning (see Bloom, Gronlund, Reilly). You should keep this list handy as an aid to writing objectives.

Identifying a desired behavior as cognitive, affective, or psychomotor will help you select the most appropriate teaching method and evaluation tool. For example, affective learning is more likely in a group discussion than in a formal lecture. Psychomotor learning is best evaluated by observing a return demonstration rather than by a written test.

The evaluation tool (posttest) and teaching methodology will be discussed in the next two articles. Before then, practice writing some learner objectives. The following references will give you additional information. These references, like Bloom’s taxonomy, are listed in order-from simple to complex.

Within each domain, levels of learning have

Suggested reading Mager, Robert F. Preparing Instructional

Objectives, 2nd ed. Belmont, Calif: Pitman Learning, Inc, 1975.

Alexander, C J; Dodge, Gwen H; McPhee, Bernice. “How to write objectives for education programs.” AORN Journal 22 (November 1975) 693-698.

Redman, B K. The Process of Patient Teaching in Nursing, 4th ed. St Louis: C V Mosby, 1980.

Reilly, Dorothy E. Behavioral Objectivesin Nursing:

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Evaluation of Learner Attainment. New York: Appleton-Century-Crofts, 1 975.

Gronlund, Norman E. Stating Objectives for Classroom Instruction, 2nd ed. New York: Macrnillan, 1978.

Cyes, Thomas E. Working with Performance Objectives in Nursing and Allied Health Sciences. Newton, Mass: Educational

Development Associates, 1975. Bloom, Benjamin S ; Krathwohl, David R. Taxonomy

of Educational Objectives: Handbook I: Cognitive Domain. New York: Longman, 1977.

Krathwohl, David R, et al. Taxonomy of Educational Objectives: Handbook 11: Affective Domain. New York: David McKay, 1964.

Does second opinion affect elective surgery? The effect of a second opinion when elective surgery is recommended is shown in a report by the American College of Surgeons. ACS reviewed second opinions in government and commercial insurance programs. Some of the programs require a second opinion, but in others, a second opinion is voluntary.

In general, mandatory second opinions for elective surgery did not confirm the initial recommendation in 23% to 35% of the cases. Voluntary second opinions failed to confirm the need for elective surgery in 5% to 19% of the cases.

The ACS report, which was recently summarized in Same Dey Surgery, showed there was less agreement between surgeons in these areas: orthopedics, gynecology, podiatry, and ophthalmology. In ambulatory centers, the two procedures that created the most disagreement among consulting surgeons were knee surgery and bunionectomy.

When patients volunteered to have a second opinion before undergoing elective surgery, 70% had the surgery when the second surgeon agreed with the primary surgeon. Only 17% of the patients agreed to have the surgery when the second surgeon thought it shouldn’t be done. Of patients required to get a second opinion, 86% had an elective procedure done when the consulting surgeon agreed with the first surgeon. Nearly one third of the patients had the surgery when the consulting surgeon disagreed with the first surgeon.

surgeon disagrees with the primary surgeon, it does not mean the surgery is

The ACS report explains that because a

unnecessary. It may mean the second surgeon thinks more tests should be done or a less invasive therapy should be tried before operating on the patient. To get an accurate opinion from the second surgeon, ACS recommends that the surgeon giving the second opinion be ineligible for performing the contemplated surgery.

Communication between the two surgeons should be encouraged for these reasons:

0 to prevent duplication of tesfs and prevent a surgeon from making a recommendation without understanding a patient‘s history

0 to allow for physician education in cases where a surgeon makes an inappropriate recommendation.

UCLA sponsors course on therapeutic touch A two-part course entitled “Practical applications of therapeutic touch, acupressure, and massage” will be presented by the UCIA schools of medicine and nursing. The course will be held once a week beginning Jan 12, 1983, and ending March 30. The course has been approved for 63 contact hours by the California State Board of Registered Nursing. Credit can be earned for each part of the course; part one has been approved for 21 hours, and part two for 42 hours.

The registration fee is $395. For additional information, write Health Sciences, UCIA Extension, PO Box 24901, Los Angeles, Calif 90024, or call (213) 825-7257.

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