Miller’s hierarchy of learning

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Dr Jarlath O’Donohoe

To truly know whether our learners are achieving what we want them to achieve we should assess them in the setting that we expect these skills to be delivered.

Miller’s pyramid depicts four levels of learning which a student of a subject must pass through to truly perform: “knows”, “knows how”, “shows how” and “does”.

In the Neonatal Care Course, our novice learners gather facts and take an MCQ paper to “show that they know”. Workshops, discussion groups, skills sessions and simulations get them to the orange and green levels. The local champion and trained instructors then take over from NICHE for the “Performance Integrated into Practice” level at the top of the pyramid, completing the trainees’ journey from novice to expert.

I would like to see time better represented in this model. International NICHE instructors can skim the surface of the first 3 bands in one course but to achieve the competence and automacity inherent in the blue band at the top of the hierarchical model requires time, experience and supervised practice that only a local faculty can contribute to.

Cameroon Instructor Development Days

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We have been busy putting together suitable programmes for our on-going development and support of the local instructors in both Cameroon and Liberia.  We have been asked by Grace and her team in Cameroon to return there once a year for the next 3 years to take them from Step 8 of the “10-steps to sustainability” plan to Step 10 (where they can train their own instructors).  We are actively fundraising for this project at the moment if anyone wants to help out – https://www.nicheinternational.org.uk/ways-to-donate/.

We have begun to put together a tentative programme for a 2-day instructor development course, termed CIDD, which will be delivered in-country to ensure instructors are up to date in both the content and delivery of their provider course, the Neonatal Care Course (NCC), and to furnish them with the skills needed to keep themselves developing professionally after 2023.

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Maslow’s hierarchy of needs

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We have been teaching the Generic Instructor Course today, one of the best train the trainer short courses in the world I think and it travels well.  We learnt about Maslow’s hierarchy of needs in one of the sessions.

Maslow (1943) divided this five-stage model into deficiency needs and growth needs. The first four levels are often referred to as deficiency needs (D-needs), and the top level is known as growth or being needs (B-needs).

Deficiency needs arise due to deprivation and are said to motivate people when they are unmet. Also, the motivation to fulfill such needs will become stronger the longer the duration they are denied. For example, the longer a person goes without food, the more hungry they will become.

We had a beautiful example of this here in Liberia where our learners have been a bit vexed by a misunderstanding over food provision during the courses.  They were hoping to get money to buy their food with (and no doubt save some of the money out of this allowance) and were not pleased to find out that “their” food money had been given to caterers to provide the food.  This was compounded when the caterers failed to turn up with the food!  Jo and I were trying to persuade them to prepare for the GIC course over the weekend but they could not do that because they were still animatedly discussing the issue around food allowances.  It was not until that issue had been sorted out this morning that they could start to move up Maslow’s pyramid.  In one day we’ve gone from level 1 to level 4 and will nudge our learners into level 5 by (complimentary) morning coffee tomorrow.

Evaluation – how to avoid the “not knowing what you don’t know” trap

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Dr Jarlath O’Donohoe instructs on life support courses in many different countries (he has lots of embroidered shirts to prove it).  He is the educator on our Generic Instructor Courses and has been doing a lot of work on our course evaluation forms.  Here are some recent thoughts from him on “pre-post evaluation”:
“No one likes to waste their time. In developing country health services this is even more important since human resources are so scarce. Equally important is to avoid thinking you are wasting your time when you are not. In evaluating a training exercise it seems obvious that asking questions before and then after the training will help identify what is worth doing and what is not worth doing.  
However, like in so many other spheres of life, what is obvious is not always true and what is true is not always obvious. It turns out (Academic Emergency Medicine: Educational Advance: Bhanj F, Gottesman  de Grave W.  The Retrospective Pre–Post: A Practical Method to Evaluate Learning from an Educational Program, Feb 2012) that asking questions at both the beginning and end may fail to identify useful learning. The example given is of someone who thinks himself quite knowledgeable at the beginning of a course and scores himself 7/10.  Then, having learned a lot more about the topic, he again scores himself 7/10 at the end.  There has been a lot of learning and the 10 at the end of the course is a much bigger 10 and therefore the 7 is a much bigger 7.  This can not be shown statistically.
The term the authors use is retrospective pre-post (RPP) evaluation. Experience has shown some people scoring themselves as highly capable at the beginning of our training sessions but who are not able to do things like bag and mask ventilation. So we have moved to an RPP approach to evaluation.”
This entails giving our learners just one questionnaire at the end of the course which asks them how confident they felt before the course in certain skills and areas of knowledge and how confident they feel at the end of the course.  It seems that recall bias might be a lesser evil than “not knowing what you don’t know”.