• Teaching and evaluating the affective domain in paramedic education

    by Alan Batt. Last modified: 13/06/15


    Originally published in Canadian Paramedicine, Voluime 38, Issue 1. Click here to subscribe.

    Teaching and evaluating the affective domain in Paramedic education

    Alan Batt1

    1. National Ambulance LLC, Abu Dhabi, United Arab Emirates


    The delivery of education in health professions, including paramedicine, follow standard curricula with learning and skills objectives. In Canada, Paramedic education program learning objectives are generally reflective of the National Occupational Competency Profiles (NOCPs), whilst in the USA the National Standard Curricula are utilised for. The Republic of Ireland and the United Kingdom also utilise national educational standards to guide program development. These guidelines utilise an adaptation of Bloom’s taxonomy (Krathwohl et al., 1964) to allow educators to categorise the learning objectives they set for their students. These are commonly divided into three domains: cognitive (theoretical knowledge), affective (feelings and attitude), and psychomotor (practical skills).

    Many Paramedic educators will be familiar with the delivery and assessment of cognitive performance and psychomotor skills. For example, basic life support skills are taught, and assessed through standardised written examination and skills testing. However, our assessment of the affective domain is limited because of the inherent difficulty in measuring learning gains in this domain.

    The affective domain in Paramedic education addresses learned behaviours that directly affect clinical and operational performance. McKeachie (1976) emphasises the need to understand humans holistically; the cognitive and affect domains should not be viewed as separate entities. In fact several studies have shown that affect has a direct influence on cognition, and many authors believe that critical thinking relies on both cognitive and affective domains (CPAL, 2013; Hughes, 2008; Labouvie-Vief and Diehl, 2000)

    affectiveFigure 1: Adapted from CPAL – Community Partnership for Adult Learning Principles of Learning, Module 3. [http://www.c-pal.net/course/module3/pdf/PrinciplesofLearning.pdf]

    The importance of incorporating objectives from the affective domain in Paramedic education cannot be understated. Paramedics draw heavily on the affective domain on a daily basis. Characteristics of the affective domain utilised by Paramedics in their clinical practice include awareness, teamwork, clarification, internalisation and critical thinking. According to Simpson and Courtney (2002) critical thinking in is necessary not only in clinical practice, but should also be an integral component of education programs to promote the development of critical-thinking skills. Affective characteristics can be taught in an educational environment by integrating them into the core curriculum.


    We regularly set affective learning objectives for Paramedic students, but how do we teach and assess these?


    One potential solution for teaching and assessing the affective domain is the use of immersive simulation. Immersive simulation aims to place the learner in their clinical environment as much as is physically possible in a simulation setting. Active engagement in a role, with associated psychomotor, cognitive and emotional aspects allows for effective learning to occur.

    Immersive simulation can add much-needed real-life value to traditional education and assessment techniques, providing Paramedic students with reproducible, targeted learning experiences that cannot be readily obtained using traditional techniques or in real patient care situations.

    Simulation can assist in teaching the affective domain due to the unique ability to provide reproducible events (allowing for repeated exposure), the freedom to make mistakes (allowing for reflection and subsequent learning) and the ability to provide detailed feedback and evaluation to students (allowing for reflection on self-concept as a clinician)

    Some recommendations on developing effective simulations include:

    • Match the practitioners clinical space as closely as possible (space, temperature, time)
    • Use equipment that is currently in use in the organisation (monitor, stretcher, airway equipment)
    • If using a manikin, use wigs, clothing, wounds, dressings etc. to strengthen immersive element
    • Use props to enhance critical thinking (medication dispensers, mobility aids, pets)
    • Use a validated scoring tool for assessing simulation outcomes
    • Remember that debriefing and reflection are the two most critical elements of a simulation

    (Kardong-Edgren et al.,2010; Olson, 2014)


    Debriefing after simulation is a conversation reviewing the events, allowing learners to explore, analyse and synthesise their actions, thought processes and emotional states to improve performance in real situations. A systematic review by Issenberg et al. (2005) of high fidelity simulation literature identified feedback (including debriefing) as the most important feature of simulation-based medical education.

    Debriefing is a facilitated reflective process, allowing the learner or group to reflect on their performance, to discuss aspects of the events they were comfortable or uncomfortable with, and allowing individuals to analyse and assimilate the learning experience.

    Fanning and Gaba (2007) in their article titled “The Role of Debriefing in Simulation-Based Learning”, provide an excellent outline of the role of the facilitator, the structure of the debriefing session and practical points on debriefing.


    Evaluating the affective domain can also be achieved through a process of self-reflection on practice (Boyd et al, 2006). Reflective practice is “an approach to learning and practice development which is patient-centred and which acknowledges the untidiness and confusion of the practice environment” (Burns and Bulman, 2000).

    Reflective practice remains a relatively unknown concept in paramedic practice compared to other healthcare professions such as nursing, where it has been embraced as an essential foundation of professional practice and continuous development.

    Learning to be a reflective practitioner includes not only acquiring knowledge and skills, but also the ability to establish a link between theory and practice, providing a rationale for actions. Reflective practice is the link between theory and practice and a powerful means of using theory to inform practice thus promoting evidence based practice (Tsingos et al., 2014). It can be used by both students and qualified paramedics to reflect on their strengths, weaknesses and areas for development.

    Done regularly, reflective practice enables Paramedics to pay attention to details of their clinical practice, and student Paramedics to reflect on their learning experiences and their experiential placements. They will be able to anticipate upcoming situations as being new learning experiences, and in doing so, become more informed, safer and more skilful practitioners. This addresses key characteristics of the affective domain, namely attitude, self-concept, motivation and internalisation.


    The teaching and evaluation of the affective domain need not be a source of anxiety for Parmaedic educators. It can be easily incorporated into current curricula using simulation, facilitated debriefing after simulation sessions and an emphasis on reflection as both a student and a clinician. Facilitating development of characteristics of the affective domain in Paramedic students may also assist in the further development of cognitive and psychomotor domains, moulding perceptive and versatile clinicians.


    Boyd, B., Dooley, K., Felton, S. (2006) Measuring learning in the affective domain using reflective writing about a virtual international agriculture experience. Journal of Agricultural Education; 24(3)

    Burns, S. and Bulman, C. (2000). Reflective Practice in Nursing: The Growth of the Professional Practitioner. (2nd Ed.). Oxford, Blackwell Science.

    CPAL – Community Partnership for Adult Learning. (2014) Principles of Learning, Module 3. [http://www.c-pal.net/course/module3/pdf/PrinciplesofLearning.pdf. Accessed 6th November 2014]

    Fanning RM1, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc. 2007 Summer;2(2):115-25. PMID: 19088616.

    Hughes R. (Ed). (2008) Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); Chapter 6.

    Issenberg SB1, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005 Jan;27(1):10-28. PMID: 16147767.

    Kardong-Edgren, S. Fitzgerlad, C. and  Adamson K.A. (2010) A Review of Currently Published Evaluation Instruments for Human Patient Simulation. Clinical Simulation In Nursing 6(1);e25–e35

    Krathwohl, D.R., Bloom,B.S. and  Masia, B. B. (1964).Taxonomy of educational objectives, Book II. Affective domain. New York, NY. David McKay Company, Inc.

    Labouvie-Vief G1, Diehl M. Cognitive complexity and cognitive-affective integration: related or separate domains of adult development? Psychol Aging. 2000 Sep;15(3):490-504. PMID: 11014712.

    McKeachie, W. (1976). Psychology in America’s bicentennial year. American Psychologist, 31, 819-833.

    Morris, W. N. (1989). Mood: The frame of mind. New York: Springer.

    Olson, S. (2014) Developing Effective Simulations – UW Health Clinical Simulation Program. Presentation [http://www.med.wisc.edu/files/smph/docs/clinical_simulation_program/developing-effective-simulations.pdf. Accessed 6th November 2014]

    Simpson E1, Courtney M. Critical thinking in nursing education: literature review. Int J Nurs Pract. 2002 Apr;8(2):89-98. PMID: 11993582.


    Tsingos C1, Bosnic-Anticevich S2, Smith L1. Reflective practice and its implications for pharmacy education. Am J Pharm Educ. 2014 Feb 12;78(1):18. PMID: 24558286.
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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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