In this essay I examine how the educational theories of lev Vygotsky and Robert M. Gangé account for my experience of instructing on the ALERT (Acute Life-threatening Events Recognition and Treatment) course. Gangés’ theories are apposite to the underlying structure the ALERT course and serve well as a framework from which to magnify its elements. While, Vygotsky’s theories are relevant to how an interactive social milieu creates an effective learning experience within the ALERT course. First, I will look briefly at why the course was created. Following this, I will consider how the theories of each writer manifest within the course and how much of their theory underpins it. I will then look at some similarities and differences between the theorists and, lastly, how examining the theories may impact my teaching on the course.
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Vygotsky and Gangé developed their educational theories in response to changes in society during their respective eras (Wertsch, 1988; Gangé, 1962). Likewise, ALERT was created, in 1999, to respond to change in the structure of hospitals, when the creators of the course recognised how the byzantine complexity of modern hospitals was detrimentally affecting how staff worked. As hospitals have grown in size, the profile of patients has evolved. People have a longer life span and may exist with multiple co-morbities. This places pressure on todays’ healthcare workers who manage increasingly complicated patient cases, often with diminishing resources, within ever growing hospitals.
ALERT is a national course, regulated by a central body. During the course, candidates are taught a systematic method of assessment to identify and escalate patients who are at-risk of deteriorating on hospital wards. The course is tightly structured, commencing with interactive seminars. The seminars include PowerPoint lectures, practical demonstrations, as well as mixed media. Since effective communication has been recognised as crucial to safe patient management, the sessions also focus on teaching around human factors and enhanced communication skills. The day culminates with the candidates, in groups of no more than six, undertaking a series of eight lo-fi simulations where they perform a full A-E assessment on a mannequin.
My involvement in the course is as a facilitator and instructor. The structure of the ALERT day remains consistent wherever it is taught, though instructors may fine-tune the simulations to reflect specialities where particular candidates work. While ALERT is designed for all members of the MDT, the candidates I instruct are junior nurses working in acute hospital wards who have been nominated by their managers.
Gangé, a psychologist with a background in military education, was a leader in industrial design in the USA during the 1950s. Gangé sought to streamline instruction and make it more effective for both instructors and learners in order to reach the desired outcomes with minimal ‘expenditure of time, money and wasted effort’ (Gangé, 1988, p.84). In Condition of Learning (Buscombe, 2013), Gangé distilled the elements of the adult learning process into nine events (Buscombe, 2013). These steps are designed to allow learners to process new information. He posits these learning events need to be undertaken in the correct sequence as they reflect how the cognitive process of learning take place.
Gangé’s first instructional event is ‘gaining attention’of the students (Buscombe, 2013). Gangé believed students’ curiosity must be stimulated in order to motivate them for learning. The opening PowerPoint slide of the ALERT course is entitled, ‘why are you here?’ and highlights reviews and reports that evidence compromised care on hospital wards. I encourage discussion around these reports. The stark facts and figures describing failed patient care ensure each candidate’s attention is caught. As well as explaining why poor patient care frequently manifests, I also consider the effects of sub-optimal care on patient outcomes.
After catching the students’ attention, I present the objectives of the course. ‘Objective setting’ is Gangé’s second event of the adult learning process (Buscombe, 2013). Gangé states objectives allow the candidates to understand where the course is going to take them with their learning. The ALERT objectives are a response to the issues pertaining to the problems in patient care which were discussed during the introduction. Gangé stresses that objectives must be clear and have meaning or students will not perceive any sense in them. Consequently, the students now understand why they are on a course which aims to improve team working and communication, as well as patient assessment skills.
Gangé describes his third and fourth learning events as, ‘stimulating recall of prior learning’ and ‘presenting the stimulus material’ (Buscombe, 2013). Buscombe, writes, ‘most new learning depends on connections with prior learning and experiences’ (Buscombe, 2013, p.304). The first seminar looks at A-E assessment as a whole. Following this, students work in pairs to discuss patient cases which they present to the rest of the group, highlighting what could have gone better in each case. This leads to more sessions which focus on separate elements of A-E assessment, so students comprehend each part more profoundly. During these seminars, I facilitate more group work and encourage discussion to allow students to recall prior learning, and, furthermore, to relate situations they have encountered during their professional life with the course material.
After the seminars, the format of the teaching evolves into simulation scenarios. Gangé’s fifth instructional event is ‘providing learning guidance’ (Buscombe, 2013). Prior to the students undertaking the simulations, another faculty member and I demonstrate a complete A-E assessment on a mannequin. This incorporates material from the morning and provides guidance to how the candidates are expected to perform A-E assessments during the scenarios. Additionally, this offers reinforcement of what has been covered in the morning. Buscombe writes, ‘the direct observation of correct performance emboldens learners’(Buscombe, 2013, p.306). Thus the learners on the ALERT course now gauge how they are expected to perform.
‘Eliciting the performance’ is Gangé’s sixth learning event (Buscombe, 2013). As Buscombe states the ‘primary focus is now on procedural process’ (Buscombe, 2013, p.306). The Candidates are split into groups of no more than six candidates. Each simulation scenario presents an at-risk patient who a candidate might expect to encounter on a hospital ward. Though the basis of each scenario is pre-scripted, I have the autonomy to make adjustments, so they relate to the area where particular candidates work.
Gangé posits the operator should understand why they are performing the sequence of steps in a particular order to successfully learn a mechanical task (in the case of ALERT this is A-E assessment). Indeed, he argues students should understand the ‘meaningfulness’ of a task in order to recognize how each step is related to the task (Gangé, 1965, p.85). He does not believe repetitive practice of a task is sufficient for a student to successfully achieve their learning. In fact, he eschewed theories which embodied notions of ‘learning by doing’ (Gangé, 1962, p.85). Moreover, Gagne proposes a cognitive approach which is more sophisticated then basic behaviourist models where response is merely conditioned behaviour (Gangé, 1962, p.85). This tenant is acknowledged in ALERT where seminars break down each element of patient assessment. Thus, when the candidates arrive to the simulations, they are aware of why each element is important and not merely learning a rote sequence of steps and practicing for the sake of practicing.
After each simulation, I sit down with the group and through discussion and reflection guide students to assess their own performance. Doing this incorporates Gangés’ seventh and eighth instructional events, ‘providing feedback about the correctness of the performance’ and ‘assessing the performance’ (Buscombe, 2013). Alert feedback is based around Pendletons’s rules and is descriptive rather than judgemental (Bullock et al., 2017). I do not prompt candidates during the simulations and, I notice, during the post simulation conversation, candidates frequently remember what they might have forgotten without any prompting from me. This serves to stimulate discussion as candidates reflect on why they omitted a step and how they can ensure that they do not repeat such omissions.
Students are informed during the introduction to the course that they will be continually assessed throughout the day. If I do not offer feedback, it could call into question the value of ‘passing’ the ALERT course to the students. I give students who have underperformed an opportunity to undertake a second simulation. While most students perform better on a second attempt, if a student continues to perform weakly, I take them aside after the session to inform them they have not met the required standards. I give them written feedback, and they are invited to repeat the course at a later date.
Gangé’s ninth learning event, ‘Enhancing retention and transfer’ is not wholly accounted for during the ALERT course. Though, throughout the day the discussion frequently touches on how the course material transfers to the wards. Candidates also have a comprehensive handbook to which they can refer if wish to refresh themselves with the material covered on the course.
Examining the theories of Vygotsky provides further insight into the ALERT course. Vygotsky argued that human thought is shaped by external forces of the culture in which we live. He believed that socio-cultural learning precedes cognitive development. Culture changes over time and this explains why people have held different values over the centuries (Wertsch, 1988). Likewise, the ALERT course is a product of its time and can be seen as a response to the challenges to delivering optimum patient care in the culture of the modern hospital. In fact, ALERT is an external agent of change to transform candidates’ behaviour and thought process which are currently results of the culture in which they work.
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In Mastery of Memory and Thinking (Vygotsky, 1978), Vygotsky discusses how external stimuli act as an agent to control behaviour. He considered language to be the foundation of human development and suggested it shaped cognitive growth. Vygotsky believed infants use private speech to self-guide themselves through their activities. The culture within which the infant is in has profound influence on this speech. As infants develop, this speech is internalized becoming internal thought (Vygotsky, 1988). Additionally, adults acquire the ability to use objects, for example, a knot in a handkerchief as an external reminder to undertake an action (Vygotsky, 1978). During the ALERT course we teach mnemonics such as SBAR. Using SBAR the students are using an external stimulus to describe what they have learnt during their A-E assessment to escalate a situation, in a succinct manner, to another member of the team.
Vygotsky proposes that new learning of a topic could only take place if the learner has a sufficient level of knowledge on which to scaffold it (Vygotsky, 1978). This tenant underpins the ALERT course which is premised on reinforcing the learners’ current knowledge and experiences. The students I teach are all nurses with at least six months of experience of working on hospital wards. This prior knowledge and experience, as well as reading the course handbook should ensure students are within what Vygotsky calls, ‘the zone of proximal development’ (ZPD) when they embark on the course (Vygotsky, 1978).
Vygotsky posits you reach the ZPD when a person is working at the limit of their knowledge. Within the ZPD there is a liminal moment when a more capable other (MKO), for example an instructor, can help the learner to expand upon their prior knowledge. In essence, the ZPD is the difference of what a learner, such as my students on ALERT, can already do, and what they can achieve with direction. As well as the instructor, other more skilled students may also serve as the MKO. The group discussion and reflection sessions that run through the ALERT course allow for students to contribute their knowledge and previous experiences which, I frequently observe, aids other learners to develop their own expertise. There are eight simulation scenarios which progressively become more complicated. When I am instructing, in order to ensure all students achieve the ZPD, I present the better skilled students with the most challenging scenarios, so they have the opportunity to work to the limit of their ZPD.
There is space within the ALERT course for the tenants of Vygotsky and Gangé to comfortably co-exist, and while their theories are quite distinct in some areas, their ideas do not diverge diametrically. Examining these theories through my experiences teaching ALERT demonstrates how facile pigeonholing theories into opposing schools can be. Gangé is oft placed within the rubric of ‘cognitive behaviouralist’, while Vygotsky is habitually described as a ‘social constructivist’. However, there is overlap in their theories which belies such labels.
It is possible to draw some parallels between each theorist when considering why some students underperform on the course. Both Vygotsky and Gangé embody a scaffolded approach to learning. Gangé’s theory suggests underperforming students might not succeed with their learning objectives since they lack prior experience and knowledge from which they can make connections. Moreover, Gangé holds that practice for practice sake is insufficient, so drilling students through A-E assessments on the ALERT course is ineffective if students are unable to understand why they are doing it. Vygotsky suggests that if a student is underperforming, they possibly lack the experience and prior knowledge to arrive in ZPD. Hence, they are unable to assimilate new knowledge despite the presence of MKO and they flounder. In essence both theories account for why some students do not pass the course.
Furthermore, my experience of teaching on the ALERT course exposes some limitations to Vygotsky’s ZPD. When I lead a group, which is mixed in ability and experience there are opportunities for students to act as the MKO as well as me. This creates a dynamic learning environment where students thrive and benefit greatly from the experience and knowledge of the others. However, occasionally, I have entire groups of nurses who have limited experience. While I am the sole MKO and can usually lead these candidates to successfully achieve the objectives, such groups lack the vibrant dialectic of the groups with more experienced practitioners. I argue that groups with solely low-skilled, nurses do not benefit so much during group sessions due to the lack of skilled MKOs alongside the less experienced nurses.
For my practice, this means that in order to ensure more ALERT students are successful, I should ensure candidates have adequate prior knowledge and experience before undertaking the course. In reality, I do not select the students who attend ALERT, but I would stress ward managers sending candidates should be confident the candidate has had more than a few months of experience working on local wards. However, during the seminars, I am able to glean the experiences of the nurses on the course and during the simulations and I can endeavour to ensure there is a varied skill mix within each subgroup. Thus, I will ensure that the candidates can profit from the group around them.
Lastly, I do not think that Gangé’s theories of troubleshooting necessarily apply to who I teach on ALERT. This is because the nurses are so junior. Gangé considered troubleshooting to be the most sophisticated application of learning. He stated troubleshooting is something that cannot be practiced since ‘one cannot identify a single task to be practiced’ (Gangé, 1962, p. 87). However, he believed that if learners understood the meaning of each step of a particular task, they would be capable of troubleshooting issues and understand which subordinate steps needed to be taken to solve a problem. While the nurses I instruct are encountering complicated situations, I am asking them to escalate problems to senior staff and medical teams who effectively will do the troubleshooting.
In conclusion, examining at the ALERT course through the theories of both these writers has illuminated to me what makes course effective. Additionally, it has underlined the significance the social group has to learning, and the importance of fostering this group work when I am teaching. Ultimately, ALERT is a lean and effective course which covers a lot of material in one day because it embodies Gangé’s instructional events, but also incorporates the use on the social milieu to achieve the ZPD as described by Vygotsky.
- Buscombe, C. 2013. Using Gangé’s theory to teach procedural skills. The Clinical Teacher, 10: 302-307
- Hua liu, C. Matthews, R. (2005) Vygotsky’s philosophy: Constructivism and its criticisms examined. International Education Journal. 6(3), 396-399.
- GANGÉ, R. M. 1962. Military training and principles of learning. American psychologist, 17, 83.
- Vygotsky L. 1978. Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press
- WERTSCH, J. V. 1988. L.S. Vygotsky's "New" Theory of Mind. American Scholar, 57, 83-91.
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