Applying Bloom's Taxonomy in Primary Care Behavioural Health Training

ABSTRACT

Bloom's cognitive learning taxonomy is widely used in medical education. The revised taxonomy published by Kathwohl and colleagues describes the levels in action forms to support learner thinking: Remember, Understand, Apply, Analyse, Evaluate and Create. The taxonomy has been commonly used to design and structure educational goals and objectives. However, most uses occur at the course or rotation curriculum level, whereas applying the taxonomy at the level of individual educational activities remained limited. This article addresses this limitation by applying the taxonomy in daily clinical teaching in Primary Care Behavioural Health education by providing practical clinical teaching examples and encourages its use in such real‐life primary care learning contexts. Particularly, this article will provide clinical educators with a roadmap on teaching in primary care that takes into account the complexity of the patient and presenting concerns.

1. Introduction

Bloom's taxonomy has been used to explain cognitive learning common with adult learning theory [1]. The initial taxonomy included six levels of objectives: Knowledge, Comprehension, Application, Analysis, Synthesis and Evaluation [1]. In 2001, the taxonomy was revised to describe the thinking process of learners: Knowledge became Remember, Comprehension became Understand and Synthesis became Create [1]. Although Bloom's cognitive learning levels are used to design and organize educational goals and outcomes, these cognitive learning levels are typically only applied in the design of curricula and the evaluation of clinical rotation, courses or didactics [2].

Bloom's cognitive learning levels have been applied less often to daily clinical teaching activities because of a lack of examples specific to Primary Care Behavioural Health [3]. Thus, the aim of this article is to provide practical, clinical teaching examples of applying all levels of Bloom's taxonomy in daily teaching activities specific to Primary Care Behavioural Health education when working with pre‐licensure level behavioural health (e.g., psychology, clinical mental health counselling, clinical social work, marriage and family therapy) learners. This article would be the first structured application of Bloom's taxonomy in day‐to‐day clinical teaching rather than curriculum design related to Primary Care Behavioural Health education, addressing an important gap in the literature. This will provide support to those who are clinical supervisors, preceptors and faculty members to encourage their trainees to learn at a higher cognitive level [3].

This article would be the first structured application of Bloom's taxonomy in day‐to‐day clinical teaching … related to Primary Care Behavioural Health education ….

2. Principles

Primary care practice has been also known as a complex adaptive system [4], which can be challenging for clinicians but even more challenging for pre‐licensure level learners. Because of the complexity and uncertainty of primary care practice [5], primary care clinical educators are encouraged to create clinical learning environments that invite higher cognitive levels rather than focusing solely on rote memorization. Helping learners develop higher order thinking skills using Bloom's taxonomy is an aim of Primary Care Behavioural Health education. In other words, ‘… learning that leads to evaluating and creating new knowledge is the highest known cognitive learning level’ [1].

So, how is this done daily in a busy primary care practice? Clinical education should review Bloom's taxonomy regularly to be able to apply the different levels in various clinical scenarios. In daily teaching, it is important to understand the developmental level of the learner (i.e., Integrated Developmental Model of Supervision; [6]) as higher cognitive levels of the taxonomy can be employed with more advanced learners. For example, when discussing behavioural treatment recommendations for a patient with uncontrolled Type 2 diabetes with a doctoral clinical psychology intern, the discussion goes beyond the types of evidenced‐based psychological interventions such as cognitive–behavioural approaches (applying knowledge), which might be suitable for a third‐year clinical psychology doctoral student. Instead, it would include reviewing the evidence and critically appraising the literature (analysing and evaluating) regarding an intervention approach while considering contextual factors and social determinants of health. Contextually sensitive applications of evidence‐based interventions are likely to align with patient values and preferences, therefore the greater the likelihood of faithful implementation by the patient in between visits. Because behavioural health consultations in primary care aim to improve self‐management of acute and chronic health conditions, the proficiency of a learner to adapt evidence‐based interventions contextually across the lifespan is critical [3].

3. Clinical Training and Practice Examples

Examples of three clinical topics from Primary Care Behavioural Health will be reviewed to demonstrate the application of Bloom's taxonomy levels in ascending complexity. These examples were based on real‐world experiences of common presenting concerns in primary care settings. Topics in ascending complexity will then be discussed to expand the taxonomy application further. Finally, all the taxonomy levels will be applied to each example to minimize confusion and simplify understanding.

3.1. First Example: Clinical Depression

• Level 1: Memorize/Remember the definition, clinical criteria and description of clinical depression.

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    Example question: What are the common symptoms of clinical depression?
  • ○
    Example activity: List the criteria for clinical depression.
• Level 2: Understand the aetiology, pathophysiology, evolution and/or clinical presentation of clinical depression.

  • ○
    Example question: How does clinical depression differ from normal sadness/adjustment?
  • ○
    Example activity: Using a biopsychosocial approach, summarize risk factors for clinical depression.
• Level 3: Apply knowledge to diagnose, confirm and propose management of clinical depression, including psychological treatment and medication management.

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    Example question: How would you conceptualize this from a cognitive–behavioural approach?
  • ○
    Example activity: Describe an evidence‐based intervention for clinical depression.
• Level 4: Analyse knowledge such as the value of reviewing lab work to identify contributing/explanatory factors (e.g., uncontrolled chronic medical conditions) or the evidence supporting treatment approaches.

  • ○
    Example question: What is the relationship between uncontrolled thyroid levels and depression?
  • ○
    Example activity: Compare and contrast behavioural management and medication management of clinical depression.
• Level 5: Evaluate the validity and reliability of the information (knowledge) used to diagnose clinical depression in various patient populations, such as patients with chronic health conditions.

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    Example question: How effective are behavioural interventions compared with medication for the long‐term management of depression?
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    Example activity: Critique a research study on the management of depression among patients with cardiovascular disease.
• Level 6: Create a new approach that is contextually based to employ evidence‐based interventions across the lifespan.

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    Example question: What would an intervention for clinical depression tailored to a patient's context look like?
  • ○
    Example activity: Develop an intervention integrating mindfulness‐based stress reduction for patients with comorbid depression and chronic medical conditions.

3.2. Second Example: Medication Non‐Adherence

• Level 1: Memorize/Remember the definition of non‐adherence, clinical criteria and the interventions used to improve adherence.

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    Example question: What is non‐adherence?
  • ○
    Example activity: List signs of medical/treatment non‐adherence
• Level 2: Understand the spectrum of clinical presentations across the lifespan.

  • ○
    Example question: How does non‐adherence differ from non‐compliance?
  • ○
    Example activity: List factors that contribute to non‐adherence.
• Level 3: Apply knowledge to diagnose the condition and identify contextual factors impacting non‐adherence (e.g., health literacy).

  • ○
    Example question: What contextual factors are important to consider in the presentation of non‐adherence?
  • ○
    Example activity: Describe factors to target to effectively address non‐adherence.
• Level 4: Analyse the evidence concerning best treatment approaches in various clinical presentations and across the lifespan.

  • ○
    Example question: What are common interventions for the management of non‐adherence?
  • ○
    Example activity: Describe an evidence‐based intervention to address non‐adherence.
• Level 5: Evaluate the intervention options based on patient outcomes and the literature.

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    Example question: How effective are cognitive–behavioural techniques compared to the use of incentives when managing non‐adherence?
  • ○
    Example activity: Critique a research study on approaches to improving adherence in patients with low health literacy.
• Level 6: Create/Innovate new knowledge using an approach that is contextually based to employ evidence‐based interventions across the lifespan.

  • ○
    Example question: What would an intervention at the level of the clinic look like?
  • ○
    Example activity: Develop a quality improvement project to improve adherence among patients with low health literacy.

3.3. Third Example: Fibromyalgia (Figure 1)

FIGURE 1.

Bloom's taxonomy with an example from Primary Care Behavioural Health (fibromyalgia).

• Level 1: Memorize/Remember the definition and treatment approaches of fibromyalgia.

  • ○
    Example question: What are common symptoms of fibromyalgia, and how is it typically diagnosed?
  • ○
    Example activity: List the criteria for fibromyalgia.
• Level 2: Understand pathophysiology, aetiology, predisposing factors, complications or indications of treatment approaches for fibromyalgia.

  • ○
    Example question: How does fibromyalgia differ from other types of chronic pain?
  • ○
    Example activity: Summarize the risk factors for fibromyalgia and factors contributing to pain experience.
• Level 3: Apply knowledge to diagnose psychological factors impacting the management of fibromyalgia.

  • ○
    Example question: What would you include in a pain management plan for fibromyalgia?
  • ○
    Example activity: Describe an evidence‐based plan to improve functioning in a patient with fibromyalgia.
• Level 4: Analyse the diagnostic value of imaging or flare‐up recurrence in specific patient groups using the literature.

  • ○
    Example question: What factors contribute to flare‐up recurrences?
  • ○
    Example activity: Describe what the literature suggests about the role of diagnostic imaging in fibromyalgia.
• Level 5: Evaluate fibromyalgia treatment options in complex situations, such as in patients with comorbid psychiatric and substance use disorder conditions.

  • ○
    Example question: What are effective behavioural interventions for the management of fibromyalgia among patients with comorbid substance use disorders?
  • ○
    Example activity: Critique an article comparing pharmacological and nonpharmacological management of fibromyalgia.
• Level 6: Create a new approach that is contextually based to employ evidence‐based interventions, modify intervention approaches or handle unusual situations (e.g., patient with fibromyalgia experiencing homelessness).

  • ○
    Example question: What would an intervention for a patient with fibromyalgia experiencing homelessness look like?
  • ○
    Example activity: Conduct a quality improvement project on the implementation of a clinical pathway for fibromyalgia (Table 1).

TABLE 1.

Summary of clinical conditions.

Bloom's level: Questions to ask the trainee	Clinical depression	Medication non‐adherence	Fibromyalgia
One	What are the common symptoms of clinical depression?	What is non‐adherence?	What are common symptoms of fibromyalgia, and how is it typically diagnosed?
Two	How does clinical depression differ from normal sadness/adjustment?	How does non‐adherence differ from non‐compliance?	How does fibromyalgia differ from other types of chronic pain?
Three	How would you conceptualize this from a cognitive–behavioural approach?	What contextual factors are important to consider in the presentation of non‐adherence?	What would you include in a pain management plan for fibromyalgia?
Four	What is the relationship between uncontrolled thyroid levels and depression?	What are common interventions for the management of non‐adherence?	What factors contribute to flare‐up recurrences?
Five	How effective are behavioural interventions compared with medication for the long‐term management of depression?	How effective are cognitive–behavioural techniques compared with the use of incentives when managing non‐adherence?	What are effective behavioural interventions for the management of fibromyalgia among patients with comorbid substance use disorders?
Six	What would an intervention for clinical depression tailored to a patient's context look like?	What would an intervention at the level of the clinic look like?	What would an intervention for a patient with fibromyalgia experiencing homelessness look like?

4. Summary

In conclusion, clinician educators could better utilize Bloom's taxonomy and apply it in day‐to‐day point‐of‐care teaching encounters in primary care. To help with this application, clinical examples such as the ones provided in this article can help educators conceptualize how to apply the different levels to support learner education. In addition, the use of common clinical scenarios and exercises will familiarize educators with the taxonomy and enable its broader use and implementation, leading to an overall better assessment and education within Primary Care Behavioural Health. Future directions in educational research include piloting this approach in a clinical teaching environment to gather trainee and faculty/clinical supervisor feedback on ease of application and teaching effectiveness.

Author Contributions

Stacy A. Ogbeide: conceptualization, writing – original draft, writing – review and editing. Yajaira Johnson‐Esparza: writing – review and editing. Deepu George: writing – review and editing.

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.