Peyton’s 4 Step Approach for Skills Teaching

We have all either delivered or been on the end of a “see one, do one” or “do one, teach one” approach to learning, often delivered in simulation with the aim for skill development. But maybe we should add another two-steps into the approach and follow Peyton’s four-step method. To aid the processing of information (learning) and then apply this new knowledge in context (situational awareness) the four-stage technique can be utilised.

Peyton’s Four-Step Approach: 

1. “The teacher demonstrates the skill at his normal pace without any comments (Demonstration)

2. The teacher repeats the procedure, this time describing all necessary sub-steps (Deconstruction)

3. The student has to explain each sub-step while the teacher follows the student’s instructions (Comprehension)

4. The student performs the complete skill himself on his own (Performance)” (Nikendei et al, 2014).

There are clearly defined instructional steps to guide educator and student. Provides small group or a 1:1 teacher:student ratio for successful instructional training in skills learning sims.

Keywords: Simulation; skills labs; 4-step; experiential learning; technical skills.


Bullock, I., Davis, M., Lockey, A., & Mackway-Jones, K. (Eds.). (2015). Pocket Guide to Teaching for Clinical Instructors. John Wiley & Sons.

International Clinician Educators (ICE) Blog. (2017). Effective teaching of technical skills requires more than see one do one. KeyLime podcast No. 142. ICE blog.

Münster, T., Stosch, C., Hindrichs, N., Franklin, J., & Matthes, J. (2016). Peyton’s 4-Steps-Approach in comparison: Medium-term effects on learning external chest compression–a pilot studyGMS journal for medical education33(4).

Nikendei, C., Huber, J., Stiepak, J., Huhn, D., Lauter, J., Herzog, W., … & Krautter, M. (2014). Modification of Peyton’s four-step approach for small group teaching–a descriptive study. BMC medical education14(1), 68.

Walker, M., & Peyton, J. W. R. (1998). Teaching in theatre. Teaching and learning in medical practice. Rickmansworth, UK: Manticore Europe Limited, 171-180.

Wang, T. S., Schwartz, J. L., Karimipour, D. J., Orringer, J. S., Hamilton, T., & Johnson, T. M. (2004). An Education Theory–Based Method to Teach a Procedural Skill. Archives of dermatology140(11), 1357-1361.



Experiential Learning: Kolb and Schon

Through discovering and reading all the different education theories, research and technology, I find myself returning to the concepts of experiential learning (hands on learning), to focus educational approach for the adult learner. The education delivered is thus more relevant, meaningful and engaging for participants and facilitators. You can add problem based and collaborative training to this philosophy to provide a more rounded education session.

“Learning is best conceived as a process, not in terms of outcomes” (Kolb, 2008).

Experiential learning (Kolb, 1984) is learning from experiences, and mainly in the active sense and is the cornerstone of nurse development. On the job learning, is a large component of postgraduate nurse training, and is a planned and supported process for the nurse to experience increasingly challenging situations whilst developing knowledge and skills. Piaget’s concept of schema theory and the organized structure of memories elicit that past experience and the knowledge we possess develop over time (Winn and Snyder, 1996). This schematic learning process really exemplifies nurse’s development in the workplace environment. To complete Kolb’s learning cycle: Concrete Experience, Reflective Observation, Abstract Conceptualization, and Active Experimentation are required in the learning process.

Reflection in action, reflection on action

Schon’s reflection theory focuses on everyday action by professional workers. Reflection-in-action” and “reflection-on-action” provides critical reflection on what informs practice and how they subsequently develop or hinder workplace practices.

  • Reflecting and deciding what works best at that particular time, for that unique event/incident (Reflection-in-action).
  • Reflecting post an event on how practice can be developed (Reflection-on-action).


Reflection is a major component of development and learning throughout nurse training , and applying Gibbs (1988) and Johns (2009) reflective processes in nursing, help make sense of experiences and summarise events. Be careful not to try to make every reflection ‘a critical event’, sometimes we can miss the important events of power and hierarchy, as we often focus on the exciting code blue or conflict scenario. Meaning and understanding can be found in everyday workplace activities as healthcare is never without incident.


Kolb, A. Y., & Kolb, D. A. (2008). Experiential Learning Theory: A Dynamic, Holistic Approach to Management Learning. Journal of Education and Development, 17(9), 312-317.

Kolb, D, A. (1984). Experiential learning: Experience as the source of learning and development.

Gibbs, G. (1988). Learning by Doing: a Guide to Teaching and Learning Methods. London: FEU.

Johns, C. (2009). Becoming a Reflective Practitioner. Chichester, U.K: Wiley-Blackwell.

John Hattie & Visible Learning

Journal Club Article: Hattie, J. (2008). Visible learning: A synthesis of over 800 meta-analyses relating to achievement. Routledge [sample].


Aimed “to synthesize over 800 meta-analyses about the influences on achievement to present a more global perspective on what are and what are not key influences on achievement” (Hattie, 2008). Hattie found 138 influences of learning from the synthesis of over 800 meta-analyses.

Big Data in Education

Hattie is bringing big data into the field of education. Using the meta-analysis approach of healthcare, like Cochrane and combining the research to provide a dataset with more impact.

Visible Learning, Visible Teaching

According to Hattie, learning is the explicit goal and this occurs when feedback is given, active participation from student and teacher, learning strategies are provided, development of self-regulatory attributes and the student becomes the teacher. Teachers see learning though the eyes of the student and aid them to become the students to become their own teachers. The teacher role becomes one of support, guidance and instruction and knowing when support is required. When all this occurs in teaching we have:

  1. Visible Learning
  2. Visible Teaching

The 2 infographics below, summarise the work of John Hattie very succinctly. The question for the nurse educator is to work out what relevant from Hattie’s work that can be transferred from the school setting (pedagogy) into adult learning (andragogy).

Areas Relevant For Nurse Education

Like any education research from the school setting it must be considered if this is relevant and transferable to the adult and workplace education setting. But it’s always good to visit new and different ways to deliver education.

  • Piaget’s cognitive development theory and learning how to learn.
  • Providing meaningful and regular feedback.
  • Use of formative assessment to gauge learning progress.
  • Micro-teaching- small group work with engagement and discussions.
  • Discussions on important issues.
  • Teacher clarity.
Visual Learning Infographics

Video Resources


Hattie, J. (2012). Visible learning for teachers: Maximizing impact on learning. Routledge. [Goodreads blurb]

Hattie, J. (2008). Visible learning: A synthesis of over 800 meta-analyses relating to achievement. Routledge [sample].

Paulo Freire and Critical Pedagogy

“To the oppressed, and to those who suffer with them and fight at their side” (Paulo Freire). 

Freire states that thinking educational practice and liberation are intertwined. Education can be humanistic and remove the shackles of the oppressed, by liberating themselves and the oppressors as well.

Education should not be divorced from politics and the act of teaching and learning are political components. The education process is therefore not a neutral process. Freire’s belief was to provide native populations with an education which was both new and modern (rather than traditional) and not simply an extension of the culture of the colonizer. Just look at World Bank and their “education for all policy’, all linking in with the International Monetary Fund (IMF) and UNESCO and using national qualification frameworks devised for the western world, is this what Freire would call ‘the colonizers”?

In education the freedom to say ‘why’. Remember when higher education was a place to question authority, broaden your knowledge and political convictions not just become a ‘work ready’ product of the education system.

No one is born fully-formed: it is through self-experience in the world that we become what we are.” (Paulo Freire)

Critical pedagogy

“Critical pedagogy is a philosophy of education and social movement that has developed and applied concepts from critical theory and related traditions to the field of education and the study of culture. Advocates of critical pedagogy view teaching as an inherently political act, reject the neutrality of knowledge, and insist that issues of social justice and democracy itself are not distinct from acts of teaching and learning. The goal of critical pedagogy is emancipation from oppression through an awakening of the critical consciousness, s a philosophy of education and social movement that has developed and applied concepts from critical theory and related traditions to the field of education and the study of culture” (Wikipedia, 2017).

Critical pedagogy  is a continuous process of:

  • unlearning,
  • learning,
  • and relearning,
  • reflection,
  • evaluation.

For Freire the goal of creating not only a better learning environment but also a better world is the focus. It’s interesting to read and reflect at where we are at today, as if you consider the world of higher education you could be forgiven in thinking that maybe the key focus of education in it’s ability to transform at a personal and society level has been forgotten in a business driven education system. Or is critical thinking alive and well and we are actually more aware of critical pedagogy and social movement due to the nature of connectivity and the internet?


To the oppressed, and to those who suffer with them and fight at their side” (Friere, 2000).

“Education thus becomes an act of depositing, in which the students are the depositories and the teacher is the depositor. Instead of communicating, the teacher issues communiques and makes deposits which the students patiently receive, memorize, and repeat. This is the “banking” concept of education, in which the scope of action allowed to the students extends only as far as receiving, filing, and storing the deposits” (Freire, 2000).

If the structure does not permit dialogue the structure must be changed.” (Paulo Freire)

“In the banking concept of education, knowledge is a gift bestowed by those who consider themselves knowledgeable upon those whom they consider to know nothing. Projecting an absolute ignorance onto others, a characteristic of the ideology)of oppression, negates education and knowledge as processes of inquiry”  (Freire, 2000).

The passive nature of “banking”in education according to Freire is the attempt to control students thinking and action, and inhibits the creative ideology of generations. This makes for a passive society. Get revolutionary people!

Keywords: critical pedagogy; banking; praxis; critical thinking; power; oppressed.


Freire, P. (2000). Pedagogy of the oppressed. Bloomsbury Publishing.

Freire Institute (2017) Paulo Freire.

Wikipedia (2017) Paulo Freire.

Rosemary For The Brain

Small studies but maybe worth a try to gain that extra boost come examination time even if this works out of expectation.

“A small, but growing body of research has been carried out to investigate the possible influence of the aromas of essential oils on cognition and mood in the healthy population. Given that the properties of aromas are to a great extent defined by folk wisdom rather than scientific evaluation, expectancy might be a reasonable candidate or at least a confounding variable worthy of addressing. A second potential mode of influence of aromas is the hedonic valence mechanism that describes the relationship between the pleasantness of an aroma, the associated effect on mood and the consequential impact on behaviour/performance.” (Moss & Oliver, 2012).

Population: 20

Objective: The study was designed to assess the potential pharmacological relationships between absorbed 1,8-cineole following exposure to rosemary aroma, cognitive performance and mood.

Methods: Mood assessments were made pre and post testing, and venous blood was sampled at the end of the session.

Results: Participants remember events that will occur in the future by 60-75 percent and to “remember to complete tasks at particular times.”

Conclusion: Moss & Oliver (2012) findings “suggest that compounds absorbed from rosemary aroma affect cognition and subjective state independently through different neurochemical pathways. With regard to the behavioural effects of exposure to rosemary essential oil aroma, the results reported here support previous work indicating that rosemary aroma can influence cognitive performance and mood.”



Coughlan, S. (2017). Exam revision students ‘should smell rosemary for memory’. BBC website.

Moss, M., & Oliver, L. (2012). Plasma 1, 8-cineole correlates with cognitive performance following exposure to rosemary essential oil aroma. Therapeutic advances in psychopharmacology, 2(3), 103-113.

Nurse as educator: Principles of teaching and learning for nursing practice

Book Club: Bastable, S. (2014). Nurse as educator: Principles of teaching and learning for nursing practice (4th ed.). Burlington, MA: Jones & Bartlett Learning. [link to 2nd edition]

It’s good to return to the true literature (time depending) and read a holistic overview of nursing education. This USA flavored (flavoured) book covers a historical and contemporary view of the challenges facing educating nurses. The complex nature of today’s healthcare systems and transforming nursing education are discussed. Bastable also provides a reminder to retain the focus and importance of patient education not just solely educating nurses, to increase competence and confidence of clients to enable greater self-management.

Teaching & Learning of Nurses

“The education process is a systematic, sequential, logical, scientifically  based, planned course of action consisting of two major interdependent operations: teaching and learning” (pg. 13).

The two interdependent players in the learner and education and growth occurs in both parties. That the role of the educator is to promote learning and provide a conductive learning environment.

Relates the education process to the nursing process:

  • ascertain learning needs
  • develop a teaching plan
  • deliver teaching
  • determining behaviour, attitude or skill changes

That the actual act of teaching and instruction is one component of this education process.

Barriers to teaching and learning:

  • lack of time
  • lack of motivation and skills
  • negative environment
  • lack of confidence and competence

Motivation Factors:

  • personal attributes
  • environmental influences
  • relationship systems
  • state of anxiety
  • learner readiness
  • realistic goal setting
  • learner satisfaction and success

Also provides helpful guidance on motivational interviewing techniques.


Bastable, S. (2014). Nurse as educator: Principles of teaching and learning for nursing practice (4th ed.). Burlington, MA: Jones & Bartlett Learning. [link to 2nd edition]


Making The Internet and Resources Accessible

This is my consideration to reviewing accessibility of this blog and to aid future creation of resources. After reading this post by Finn Gardiner on neurodiversity inclusiveness it really makes you consider how you create education items. At times I have created short video recordings and added them into YouTube for students to access, normally talking over a few powerpoint slides explaining focus of upcoming course content or discussing an article for journal club but had never thought to add captioning or subtitles. The below resources explain the reasons for inclusivity and then a how to guide to add captions ‘Charlie Chaplin’ style. At the bottom right of this blog, is a translate option that hopefully allows more accessibility.

I try to add a mix of text, image and video resource to provide a variety of sources of information and to keep it light and interesting (#microlearning). What I am not sure about is the accessibility or loading speed for those accessing around the world. The open access approach means quick access, no passwords, payments but access to published articles is dependent on publisher rights so sometimes only a link to a abstract can be provided.

Make The Internet Accessible by Annie Elainey.


Creating Subtitles and Closed Captions on Your Youtube Videos by Derral Eves


Finn Gardiner (2017) 5 ways to make your web content more neurodiversity inclusive.

National Association of The Deaf (2017) Captioning on the internet.


Contrasting Perspectives on Learning: A Historical View

This historical review on student learning by Entwistle (1997) provides a focus on higher education from the experience of learning for the student from the point of view from lecturers, psychologists and educational researchers. The message, is clear and in it’s simplest form, that as educators we need to think carefully about the quality of learning in higher education. Teaching and assessment can induce a passive, reproductive form of learning which is contrary to the aims of the purpose of the teaching itself.

Lecturers’ Perceptions of Student Learning

If we are interested in understanding the outcome of learning, then a sensible start is by reviewing the actual aims of the education. By examining what is actually achieved in relation to what is intended and considering what are the students expected to learn in this training? A common aim of higher education learning can be summarised by the term ‘critical thinking’ as well as the importance of acquiring skills and detailed course knowledge. These critical thinking skills adhere to higher education and the ‘work ready aims of generic skills and personal transferable skills’ which are increasingly valued by employers. These skills include problem-solving, communication skills, and working effectively with others (sometimes discussed as soft skills).

“This connection between the ‘teaching objectives’ (what lecturers say they want to do) and their ‘teaching activity’ (what they actually do) – a lack of relationship between intention and performance. This unrecognised contrast between intent and the effects of teaching is often expressed as a distinction between the formal and the hidden’ curriculum” (Entwistle, Percy & Nisbet, 1971, Vol. 2, Cht. 13, p. 12).

Psychological Research on Learning

Education looked to psychologists for explanations and understanding of the fundamental principles of learning. The view of the teachers approach was being intent on helping pupils to build meaning. Early education research noted that humans tend to repeat behaviour which leads to satisfying consequences (law of effect). “Many have resented the image of the teacher as a ‘manipulator of learning’, criticising the view of learning as solely the acquisition of information, and found the principles of programmed learning to be of limited value in the classroom”. Behaviourist researchers such as Skinner demonstrated that complex sequences of behaviour and reinforcement represented programmed learning. Knowledge was considered to be able to efficiently assembled, like a brick wall, out of its component blocks.

Intelligence and individual differences

IQ was used for it’s general validity as an indicator of educational potential. The idea that a single set of tasks could provide a good indicator of ‘general intelligence’ has been difficult to shift. Its simplicity is appealing and remains ongoing, think of standardised testing during school, the number of tests school children must complete in some countries is amazing (and not in good way). “Gardner (1984) argued for a broader definition of intelligence to include ‘multiple intelligences’ derived from a whole range of human competencies. He has suggested that we should recognise at least seven distinct intelligences, including linguistic, musical, logical-mathematical, spatial, and bodily-kinaesthetic. His list also includes two forms of personal intelligence, ‘intrapersonal’ which depends on a ‘sense of self’ and ‘interpersonal’ which involves the capacity to ‘read’ other people’s intentions and feelings in a social setting”.


“Competence motivation describes the positive orientation towards learning created by the repeated experience of successful learning activities. Extrinsic motivation describes the seeking after external reinforcement for learning, from school marks, grades, or qualifications. Intrinsic motivation takes two forms, one in which learning is explained by interest and perceived relevance, and another generally described as achievement motivation, relies on a striving for success which feeds on perceived success and boosted self-confidence”.

Cognitive Structure and Processes.

“A simple information processing model envisages a short term, working memory which sorts out incoming perceptions and relates them to previous knowledge, and a long-term memory in which experiences and conceptual knowledge are stored. They are built up from sets of experiences which are only partially shared with others. Learning thus becomes a matter of the individual construction meaning, and this view of learning (constructivism) has recently become widely accepted within education.  Ausubel et al., (1978) suggest that students develop learning ‘sets’ which predispose them to utilise either rote (memorisation) or meaningful learning in tackling academic tasks”.

Carl Rogers believed that “students and teachers should recognise that emotions are an essential part of learning – that is of ‘significant, existential’ learning, learning which develops personality as well as the intellect. Rogers wanted to establish a ‘community of learners’, free to pursue those ideas which excite them, ideas which have intense personal meaning. He wants, above all, to free curiosity; For Rogers these qualities are ‘realness’ (the teacher shows authentic feelings such as boredom, interest, anger, or sympathy), ‘prizing, acceptance, trust’ (of the student’s personal and intellectual qualities), and ‘empathetic understanding’ (the ability to feel how learning seems to the student). This view of learning has a richness, and immediacy of impact, which is lacking from the mainstream psychological research in learning”. This is an interesting discussion on learning as personal development and highlights some of current discussion in the educational approach of school; and higher education. A heutagogy approach to allow student development is similar t Rogers theory, that provides learner exploration, development, connection with learning networks and wider communities of practice.

Educational Research on Student Learning

Selection and prediction research studies where the selection for higher education by using head-teachers’ ratings or tests of academic aptitude. “Entwistle and Wilson (1977) reported the use of cluster analysis to demonstrate the existence of groups of students with contrasting forms of motivation. Two main clusters were described as having ‘fear of failure’, and ‘self-confident, hope for success’; other types of students were described as ‘radical and extraverted’, and ‘idle and unmotivated’. The first three groups all achieved above average degree results, while the last group did very badly indeed. Wankowski (Raaheim & Wankowski, 1981) has argued that students who come to university for clearly defined reasons and with distinct vocational goals, are more likely to be successful than students with diffuse, unarticulated goals. An alternative qualitative approach involves approaches to research rooted in phenomenology which derive from a direct exploration of students’ experiences of learning. The traditional research paradigm involves explaining student behaviour from the outside, as a detached, objective observer. The alternative approach seeks an empathetic understanding of what is involved in student learning derived from students’ descriptions of what learning means to them. It involves a shift not just of methodology, but of perspective”.

The concepts and categories describing learning and studying highlight the differences for students coming into higher education, with some having a vocational orientation and for others the orientation may be more academic, personal, or social. “The students also come into higher education with differing conceptions of learning based on past educational experiences, students may see learning as mainly a matter of acquiring information and reproducing it accurately as required by the teacher. Alternatively they may believe that learning depends on transforming information in the process of reaching personal understanding”.

Defining features of approaches to learning:

  • Deep Approach 
    • Intention – to understand ideas for yourself
    • Relating ideas to previous knowledge and experience Looking for patterns and underlying principles
    • Checking evidence and relating it to conclusions
    • Examining logic and argument cautiously and critically Becoming actively interested in the course content
  • Surface Approach
    • Intention – to cope with course requirements
    • Studying without reflecting on either purpose or strategy
    • Treating the course as unrelated bits of knowledge
    • Memorising facts and procedures routinely
    • Finding difficulty in making sense of new ideas presented
    • Feeling undue pressure and worry about work
  • Strategic Approach
    • Organising Intention – to achieve the highest possible grades
    • Putting consistent effort into studying
    • Finding the right conditions and materials for studying
    • Managing time and effort effectively
    • Being alert to assessment requirements and criteria
    • Gearing work to the perceived preferences of lecturers

“Different types of assessment seem also to encourage either deep or surface approaches, with essay questions or problems encouraging a deep approach, but only if the questions set demand the demonstration of personal understanding. The quality of teaching also influences the approach to learning. Some lecturers seem to be able to provide students with a vicarious experience of relevance, which evokes a deeper approach to the course”.


Entwistle, N. (1997). Contrasting perspectives on learning. Chapter 1 from Marton, F., Hounsell, D., & Entwistle, N. J. (Eds.). (1997). The experience of learning: Implications for teaching and studying in higher education. Scottish Academic Press.

Bloom’s Taxonomy & Constructivism

The use of Blooms Taxonomy to provide focus for the delivery of education and meeting educational objectives is a commonly used structure. The taxonomy can aid developing curriculum learning objectives, assessments and activities to align and scaffold education delivery. Organising levels of expertise of Bloom’s taxonomy categorises and orders from simple to complex and from concrete to abstract, and cover the learning objectives in the cognitive, affective and sensory domains.

Bloom's Taxonomy

For The Educator

“This connection between the ‘teaching objectives’ (what lecturers say they want to do) and their ‘teaching activity’ (what they actually do) – a lack of relationship between intention and performance. This unrecognised contrast between intent and the effects of teaching is often expressed as a distinction between the formal and the hidden’ curriculum” (Entwistle et al, 1971, pg. 12).

  • What are the aims of the education?
  • What level of knowledge and understanding is expected of the student?
  • Scaffolding towards critical thinking.
  • Guides and aligns type of assessment.

For The Student

  • What is expected of me (what educators want students to know)?
  • What am I going to develop by attending this course?
  • Are values, attitudes, and interests affected?
  • To understand and use concepts, to demonstrate particular skills.


The updated taxonomy by Krathwohl (2002) using the knowledge and cognitive domains states that “the Taxonomy of Educational Objectives is a scheme for classifying educational goals, objectives, and, most recently, standards. It provides an organizational structure that gives a commonly understood meaning to objectives classified in one of its categories, thereby enhancing communication”.


Krathwohl, D. R. (2002). A revision of Bloom’s taxonomy: An overviewTheory into practice, 41(4), 212-218.

Iowa State University (2016) Revised Blooms Taxonomy. Center for Excellence Learning & Teaching.

Nursing Education Network (2016) Intended Learning Outcomes

Sameness and Difference in Transfer

What Is Transfer?

Transfer of learning can be described as the process  to which past experiences affect learning and performance in a new situation. Transfer theory is to consider how individuals transfer learning in one context to another similar context.

What Is Learned?

If we think of transfer in terms of considering how learners do something in a situation thanks to having done something similar in a previous situation. From an educational point of view, Marton makes us consider that the learner may be able to do something different in other situations, thanks to perceived differences (and also the similarities) between situations.

So in nursing we may relate to past experience to deal with a clinical situation. This can be a positive aspect where we can be systematic and provide effective and timely interventions. The nurse educator needs to train staff to follow process (such as the A-E of assessment in clinical deterioration), to avoid our ‘priors’ making us think this situation is identical to a past experience, we may miss something new related to this unique situation.

Historical origins and culture of transfer

The Behaviour Paradigm: Thorndike (1913) the human mind makes “particular reactions to particular situations” (pg 249). Do not expect learning something specific to have a general effect on other things. “Learning is conceived as the constitution of bonds between stimuli (features of the environment) and responses (reactions of the learner)”.

The Cognitivist Approach: Judd (1908) where learning involves the constitution of more and more powerful representations of the world around us.

The Functionalist View: Lave (1988) provides the metaphor of knowledge, as a set of tools stored in the memory of the learner for use in different situations.

Situated learning suggests that what surrounds the learning event is also important in understanding learning.


“Transfer is about people being able to do similar things in different sitautions because of similarities between those situations. The key aim is that “by learning (now) how to learn (in the future), learners will be better able to cope with novel situations”.


Marton, F. (2006). Sameness and difference in transfer. The Journal of the Learning Sciences, 15(4), 499-535.