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Learning Objectives

The formulation of learning objectives occupies a crucial place in systematic instructional planning, because learning objectives form the framework for any instructional program where student mastery of learning is the anticipated outcome.

Stated learning objectives communicate to the student:

• What is to be taught and learned;
• What will be required of the student;
• The basis for evaluating both the student's learning and the effectiveness of the instructional program;
• The type and extent of activities that are required for successfully carrying out the learning.

The statement of learning objectives can also help the planning team to think in specific terms and to organize the sequence of the subject matter of the proposed educational activity.

Clearly stated learning objectives permit the prospective physician student to identify the relevancy of the proposed educational activity to his own CME needs, so that he may elect participation in those CME programs which are more likely to return him educational dividends on his investment of time and/or money.

Formulating learning objectives is often given pre-eminence only in the planning process -- right after programmatic needs assessment has been accomplished. Though his may be correct sequentially, it does not always work out in actual practice. Sometimes objectives are not fully stated until subject content has been outlined. Occasionally, only after learning activities have been selected or evaluation methods stated, do the "real" objectives for an education program become evident. Writing learning objectives, then, is a developmental activity that requires refinements, changes and additions as the writer develops subsequent planning steps.

Learning objectives should be stated in unambiguous, specific terms describing behavioral outcomes of students following the conclusion of the educational activity. Ideally, statements of objectives should be couched in such a way that evaluation of student learning is possible.

General terms, such as those listed below in Table 1, are often used in the formulation of learning objectives; however, these words are inadequate, because they are open to many interpretations (they are non-specific) and are not accessible to quantification.

Table 1

• to know
• to understand
• to really understand
• to appreciate
• to fully appreciate
• to internalize
• to grasp the significance of
• to have an awareness of

What does a recipient of a notice announcing a CME program on "New Perspectives in Diabetes" learn from a statement of educational objectives that indicates those attending the program will be able "to really understand diabetes mellitus", or "to fully appreciate the management of diabetes"? These statements, while they may be true, give no real indication of what is going to happen during the educational encounter. And, if the physician-student is going to experience an educational outcome, these statements provide no clue of how he or she (or the teacher) will know that it has taken place.

A learning objective (which describes how the learner is supposed to behave after instruction) offers the ready possibility of assessing the degree to which the learner can actually behave that way. Concrete terms, which can form the basis of specific learning objectives, are listed below in Table 2.

Table 2

How much more informative is the CME program announcement on "New Perspectives in Diabetes" with the following learning objectives: "Those attending the program will be able to: (1) explain open loop delivery systems in the management of diabetes; (2) identify the acute and chronic effects of insulin in a diabetic ..."

There are four steps, in a simplified method of writing learning objectives:

1. Start with an action verb that describes a specific behavior or activity desired of the learner:

• name
• identify
• explain
• describe
• compare
• perform

2.Follow the action verb with the content reference that describes the subject being treated:

• Name the three major elements in the management of perennial rhinitis
• Identify the psycho-social factors important in the development of the child abuse syndrome
• Explain the dangers of using hexachlorophene in skin prophylaxis of the newborn
• Describe the sequence of clinical events in Reye's Syndrome
• Perform CPR

3. If the objectives above lend themselves to quantification, a performance standard may be added to the statement:

• Students will correctly perform CPR maneuvers 100% of the time.

4. As necessary for student understanding and in order to set evaluation requirements, add any criteria or conditions under which the learning must take place:

• Using the Resusci-Annie mannequin and recorder, students will correctly perform CPR maneuvers 100% of the time.

These learning objectives have all been stated in terms relating to educational outcomes from the viewpoint of the student. Learning objectives, in addition, may include statements relating to subject matter (content) as well as educational process. Included in this category are course outlines, syllabi as well as statements describing techniques to be used in educational activity (film strips, lecture, patient-demonstration, student-teacher dialogue, role-playing, group "buzz" sessions, etc.). These objectives may be considered teacher-oriented objectives in that they deal with the "What?" and "How to" planning aspects of educational activities. While teacher-oriented objectives do not focus on learner outcomes as such, they do provide the prospective physician-student with more information relative to the proposed educational activity, allowing him or her to be more selective in choosing those educational activities which are most relevant to his own personal CME needs.

In the final analysis, CME efforts should be directed at helping physicians acquire and develop the skills of self-directed learning, which is a life-long process.

References:

The following material, excerpted from the "Continuing Medical Education Newsletter", June 1983, Vol. XII, No. 6, was written by Adrienne Rosof. It was included in the Alliance for Continuing Medical Education (ACME) CME Primer.

Stating Objectives

Introduction

This chapter deals specifically with program objectives rather than institutional objectives. The ACCME Essentials clearly differentiate between the two:

1. The overall CME endeavor of a sponsor institution consists of a group of educational activities consistent with the institution's mission statement. Institutional objectives are general, broad and all-inclusive.

2. Each individual CME program is a coherent educational activity based on defined needs and having explicit objectives that can be measured. Program objectives are specific, narrow and precise.

Obviously, your program objectives should be compatible with the objectives of your institution; indeed, the same basic process can be applied in determining both.

Once you master the art of stating clear and realistic objectives, you will have taken a giant step toward achieving successful CME programs.

Objectives: Definitions

Webster's Dictionary defines "objective" as something toward which effort is directed, an aim or end of action.

Some people like to break this concept into two parts. They use the word "goal" as being somewhat more abstract, distant and general; it is an umbrella statement, under which specific "objectives" -- which are relatively concrete, short range, and usually measurable -- can be clustered. Both goals and objectives should be realistic and obtainable, and both should define intended outcomes.

Example. The program objective "to measure proficiency in CPR of Emergency Room nurses" is part of the goal "to familiarize hospital professional staffs with CPR techniques," which in turn, is part of the institutional goal "to provide hospital personnel with educational activities designed to keep them abreast of modern techniques."

You probably have heard people, particularly those with educational training, add one or another modifier to the single word "objective".

"Educational" is a generic modifier, used simply to distinguish what we're talking about from other kinds of objectives, such as administrative, financial, political, commercial or social. Under the general hading of educational objectives, there are three other commonly used modifiers, each reflecting a different view of the subject:

1. Learner objectives reflect what the student should know or be able to do at the end of a learning period.

2. Instructional objectives reflect what the instructor intends to accomplish.

3. Behavioral objectives reflect what the learner might be expected to do differently (behavior change) as a result of what he has learned.

Example. If the program is "The Use of CAT Scans in Head Injuries," and if the instructor expects to list situations in which the CAT scan should be used, then the learner should expect to know and understand that list, and as a result to stop ordering other procedures and instead use the CAT scan.

A word of caution: Not all CME can be, or need be, measured in terms of behavioral change. While change, on the part of physicians in the treatment of their patients is what we expect to happen as a result of an educational activity, such behavioral change is often subtle and hard to measure, and educational researchers face constraints of time, funding and cooperation when they try to make the measurements.

One more point. We usually think of behavior change in terms of the actual performance of physicians in patient care. But the noted educational expert, Alan B. Knox, in his paper, "Some Observations About Establishing Conference Objectives As A Prelude To Evaluation," uses the word "behavior" in a much broader sense -- to refer to all aspects of human activity, what people know and feel as well as what they do. In this context, the simple acquisition of new knowledge is a change in behavior. Some educators subscribe to this definition and accept the concept that all education results in behavioral change, whether or not methods of measuring this change are available.

In any event, educators agree that program objectives are better stated in terms of what students should be able to know or do at the end of a learning period, rather than what the teacher plans to do in the process of the course. A statement is not the same as a course description.

Objectives: Why Write Them?

At the conceptual level, the answer to this question is given well by Mager in his book "Preparing Instructional Objectives": If we do not know where we are going, it is difficult to select a suitable means of getting there, or, for that matter, even to know if or when we have arrived.

At a more pragmatic level, both the AMA and the ACCME have made it a requirement that a program have stated objectives in order to qualify for Category 1 credit:

The information booklet (1978-1979 edition, p. 9) for the AMA Physician's Recognition Award says "Educational objectives for a planned program of CME should be based on clearly identified CME needs and should identify the target group. Where group or individual CME needs cannot be based on a private profile, peer review, self-assessment, case audits, or individually identified CME needs or interests, new medical knowledge can be used as a basis for developing the educational objectives that are specific for a knowledge level of performance capability." The booklet further recommends that brochures and announcements for CME activities should display both the education objectives and the intended audience in order to help physicians decide whether or not to participate.

In ACCME's list of Essential Areas, Element 2.3 states:

Communicate the purpose or objectives of the activity so the learner is informed before participating in the activity.

Other experts in the CME field have also written statements in support of formulating explicit educational objectives. Dr. Emmanuel Suter of the Association of American Medical Colleges advocates involvement of the learner in the process:

Setting Education Objectives

1. Define potential audience for educational projects

2. Obtain involvement of learner(s) to define desirable learning outcomes from identified needs.

3. Establish relevant, achievable, and assessable objectives from identified learning outcomes.

Dr. Robert K. Richards focuses his attention right on the CME workplace, listing five ways in which clearly formulated objectives can facilitate the work of the CME director and/or committee.

1. They provide clear guidelines by which to select learning methods.

2. They offer potential participants clear information on what they can expect to learn. The other side of that coin is that the process of formulating learning objectives enables the educators to plan for specific groups of clinicians whose learning needs have already been identified.

3. They provide visiting experts with an unequivocal statement of what they are expected to offer the audience.

4. They permit precise decisions on how to evaluate learning achievement as a result of the learning activity provided.

5. The existence of a number of sets of objectives enables the CME Committee to make sound judgments about possible overlap and duplication among various learning sessions and activities.

In summary, the writing of sound educational objectives brings benefits to all the parties involved. For the program director, the drafting of objectives causes one to think seriously and deeply about what is worth teaching, can highlight the methods used for instruction, and can provide a basis for improving it; when clearly defined objectives are lacking, there is no sound foundation for the design of instruction.

For physicians, who today have access to an abundance of high quality CME, the statement of clear objectives makes it easier to select CME activities geared to their needs and knowledge level; learners can thereby focus their attention and register for courses that are targeted to meet their expectations.

Objectives: How To Write Them

Stating instructional objectives can be made easier by asking the question: What is the intended result of the instruction in terms of the learner? According Mager, to be absolutely clear, an objective should be stated in such a way that both the prospective learner and the teacher should ideally be able to answer three questions about their expectations:

1. What should the learner be able to do?
2. Under what conditions?
3. How well? (e.g., speed, accuracy)

The first question is obligatory. The second is important, and the third may not always be practical to include.

Writing educational objectives is not only an exercise in clear thinking about the desired results of education, it is also an exercise in effective communication. And one of the best ways to communicate effectively is to use specific action verbs in the statement of learning objectives. A list of good action verbs that have been found useful in writing objectives is attached. At the bottom are some words that should be avoided because they are vague and subject to multiple interpretations. The more specific the words are, the greater the chance will be that the evaluation process can then be based on eliciting the participant's perception of how well the program objectives were met.

An excellent way to introduce the statement of objectives is: "Upon completion of this (session, course, workshop, clinical conference, etc.), participants will be able to ..."

The choice of verb depends, to a considerable degree, on the material being presented. If the purpose of a conference is to refresh the memory of the attendees on basic information, it is not sufficient merely to make the general statement that "Physicians will reinforce their knowledge about ..." The statement should be as specific as possible, listing what categories of knowledge will be reinforced and when and how the possession of that knowledge will be helpful to practitioners. Thus, a statement of objectives might say "Physicians will reinforce their knowledge about the use of cephalosporins in the office treatment of Gram-positive and Gram-negative respiratory and urinary tract infections."

Similarly, if the material to be presented is new or is expected to be unfamiliar to physicians, it is not sufficient to say "Physicians will learn about ..." or "Physicians will increase their understanding of .." unless those phrases are followed by specifics "... the comparative usefulness of third-generation cephalosporins and the newer aminoglycosides for Gram-negative septicemia in hospitalized patients."

If a training workshop is being held with the purpose of teaching a specific skill, the objective should state the performance level expected, e.g., "Physicians will be able to use the flexible sigmoidoscope in the diagnosis of inflammatory and neoplastic disease of the lower bowel."

If, as is often the case, a conference is designed to present both new and review material, the statement of objectives should cover both aims.

Objectives: How To Write Them

Program objectives should be written after:

1. The need is assessed.
2. The target audience is determined.

But they should be written before:

1. Teaching methods are determined.
2. The kind of evaluation technique is decided.

Objectives: Summary Hints

When writing educational objectives, strive:

• Not to confuse a LEARNING OBJECTIVE, which is stated from the perspective of the learner with a TEACHING OBJECTIVE, which describes an educational process. While teaching objectives are very helpful in good educational planning, your announced objective should describe learning outcomes rather than what will be taught.
• To involve prospective students as much as possible in formulating objectives.
• Not to make your course objectives be just a course description.
• Touse phrases containing action verbs to describe what the learner will accomplish.
• To eliminate all unnecessary words and phrases; include a statement of conditions or criteria for performance only if they really clarify the objective.

Don't try to take on everything; be realistic enough to accept that:

• Your CME activity is meant to augment education already received in medical school, residency training, practice experience, and reading.
• CME can make it "possible" for each physician to use in his/her practice the modern medical knowledge that continuously becomes available, but cannot "guarantee" that this knowledge will be applied to patient care.
• Attitudes and behavior cannot always be influenced by the presentation of facts. Even though CME activities can help a learner want to do something by teaching how to and why, it cannot make him/her do it.
• The CME process cannot be held accountable for attitudes, behavior and conditions that cannot be influenced by educational means.

Objectives: Supplementary Reading

First read:

"Preparing Instructional Objectives," Robert Mager (2^nd edition). Belmont, California: Fearon Publishers, Inc. (An extremely easy-to-read introduction to objectives writing aimed at those in general education, but easily applied to CME).

Then refer to:

"Continuing Medical Educators Handbook," Kevin Bunnell, Ed.D. Colorado Consortium for Continuing Medical Education, 1601 East 19^th Avenue, Denver, CO 80218. (A handbook designed for the community-based physician who has responsibilities for CME, but who may have little or no training in educational processes. See Chapter 2 "Using Behavioral Objectives.")

"Continuing Medical Education in the Community Hospital," James J. Bergin, MD, Geraldine C. Homes, Ph.D. Bethany Medical Center and University of Kansas Medical Center. Port Washington, NY 11050: Romaine Pierson Publishers, Inc. (A guide to designing, organizing and conducting Category 1 programs. See Chapter 6 "Goals and Objectives.")

"Educational Handbook for Health Personnel," J.J. Guilbert. World Health Organization.

The following verbs have been found to be effective in formulating educational objectives:

1. Those that communicate knowledge.

Information

Comprehension

Application

Analysis

Synthesis

Evaluation

2. Those that impart skills

3. Those that convey attitudes.

These verbs are better avoided:

1. Those that are often used but are open to many interpretations.

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