Miller’s hierarchy of learning

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.

Maintenance, booster and refresher training

Dr Jarlath O’Donohoe, always in pursuit of the Holy Grail – a solution to the “skills decay” problem….

Resource: Sullivan, Anne & Elshenawy, Summer & Ades, Anne & Sawyer, Taylor. (2019). Acquiring and Maintaining Technical Skills Using Simulation: Initial, Maintenance, Booster, and Refresher Training. Cureus. 11. 10.7759/cureus.5729.

Learning Curve: shows a relationship between the amount of practice / experience of a skill and the degree of competence achieved.

Forgetting Curve: the relation between the decay of a learned skill and the time elapsed since the skill was learned.

Experience Curves: combines the learning and forgetting curves.

Activities to overcome skill decay can be qualitatively classified as maintenance , booster or refresher, according to the diagram below:

Note the amount of time spent “deficient” with “refresher” activities. An example of this is paediatricians in the UK re-certifying in APLS every 4 years. “Booster” training is possibly achieved by statutory mandatory training paediatric basic life support every year and keeps the average paediatrician “proficient”. Would lower intensity but more frequent “maintenance” activities do a better job eg. weekly simulation training sessions?

Here is Kola delivering his “booster” training sessions in neonatal resuscitation to nurse technicians in Liberia this week, using equipment left by NICHE after the first batch of instructors were trained in 2019.

Kola (centre) teaching neonatal resuscitation in Liberia, February 2021

How often does he need to run these sessions to make this maintenance training and not refresher sessions? The quest continues….

International day of education

Dr Alison Earley

On January 24th 2021, the UN General Assembly proclaimed the ‘International day of Education’ to celebrate the role of education for peace and development.

“At the peak of the pandemic, schools were actually closed for 91% of learners, or 1.5 billion pupils and students. It then became apparent to everyone that education was a global public good and school was more than just a place of learning: it was also a place that provided protection, well-being, food and freedom. (…) On this International Day of Education, UNESCO invites you to promote education as a fundamental right and the most powerful aid to development that we have. Defending the future of this right means defending the right to the future.” – Audrey Azoulay, UNESCO Director General, on the occasion of International Day of Education 2021.

Although the focus is often on the importance of educating children, the day also emphasised how lifelong learning can empower people, and is central to meeting the sustainable development goals*.

NICHE International has had success in training nurses, doctors and midwives in resource limited settings, like Cameroon and Liberia, to improve the care of newborn babies. 

Educational levels, language and experience differ among course participants, which increases the challenge of promoting their learning.  However, even when the teaching styles are unfamiliar, the overwhelming majority are very motivated and respond with enthusiasm . 

Most importantly, although training in adult education as a discipline is recent in Africa**, local trainers have been stimulated and empowered to improve their skills as teachers.  These local trainers have taken on teaching their own courses and, while unable to travel, NICHE International is supporting them remotely.

*Education is also a powerful catalyst – for combating poverty and inequality, improving health and well-being, and overcoming discrimination.   UNESCO International Day of Education.

** The Psychology of Adult Learning in Africa.  Thomas Fasokun.  Anne Katahoire.  Akpovire Oduaran PsychologyAdultlearningAfricaViaUNESCO

Best breastfeeding videos!

I have linked to the Global Media videos before. Such an amazing repository of videos for parents and healthcare workers across the world. We owe the families who agreed to take part in this project a debt of gratitude.

This one has some excellent information on proper attachment of the baby to the breast: