Evaluating a Case Study Using
Bloom’s Taxonomy of Education
BRENDA G. LARKIN, RN, MS, CNOR, ACNS-BC; KAREN J. BURTON, RN, ADN, TNCC
T
he Joint Commission focuses on
keeping patients safer in the
health care system by targeting
high-risk situations. One of the Joint
Commission’s National Patient Safety
Goals requires improving the effective-
ness of communication among care-
givers, including hand-off communica-
tion.1 Part of this safety goal entails
standardizing communication among
caregivers. Because clinical teamwork
often involves hurried interactions
between people with varying styles of
communication, a standardized ap-
proach to information sharing is needed
to ensure that patient information is con-
sistently and accurately imparted. This is
especially true during critical events,
shift hand offs, and patient transfers.
This article demonstrates how effec-
tive communication between care-
givers could have averted a crisis and
ABSTRACT
THE JOINT COMMISSION recognizes effective
communication among caregivers as an impor-
tant factor for ensuring patient safety, especially
at times when the patient’s care is handed off
from one caregiver or service to another.
THIS CASE STUDY reviews the course of treat-
ment for one patient throughout the periopera-
tive continuum, including the postoperative unit
where a pre-arrest situation developed.
A WORKSHOP USING BLOOM’S TAXONOMY
of Educational Objectives enabled staff members
to more clearly understand the patient’s situa-
tion. It also allowed the participants to gain an
increased understanding of significant data and
has been strategic in preventing patient compli-
cations. AORN J 88 (September 2008) 390-402.
© AORN, Inc, 2008.
390 • AORN JOURNAL • SEPTEMBER 2008, VOL 88, NO 3
how an educational intervention using
the framework of Bloom’s Taxonomy
of Educational Objectives assisted staff
members in being able to critically
evaluate the patient scenario with the
objective of preventing future patient
complications.
CASE STUDY
Ms C, a 64-year-old woman, present-
ed to the ambulatory surgery center for
an open cholecystecomy following com-
plaints of abdominal pain. She had been
assessed in the emergency department
two weeks before surgery for these com-
plaints. She was admitted in the ambula-
tory area and was found to have had
recent episodes of mild vomiting and
weight loss. Her weight was 236 lbs
and her height was 5 ft 4 inches. Her
medical history included that she
• smokes one pack of cigarettes per day,
• had a gastric bypass in 1994,
• had a stroke in 2004,
• underwent a panniculectomy in
2005,
• suffers from hypertension (HTN),
and
• is allergic to penicillin.
She takes the following medications:
• hydrochlorothiazide 12.5 mg orally
per day,
• aspirin, and
• clopidogrel.
Ms C underwent surgery without
complication; however, in the postanes-
thesia care unit (PACU) she required
extra oxygen therapy. Despite her need
for oxygen, she was transferred to the
postoperative unit without oxygen.
There was no communication between
the PACU RN and the postoperative
unit RN about Ms C’s need for oxygen.
Ms C arrived at the postoperative
© AORN, Inc, 2008
SEPTEMBER 2008, VOL 88, NO 3
unit with the following vital signs:
• blood pressure 112/61,
• pulse 91,
• respirations 16, and
• pulse oximetry 90% on room air.
She had an indwelling urinary catheter and
three Jackson Pratt drains. She also had a
patient-controlled morphine analgesia pump
for pain management.
Within the first two hours on the postoper-
ative unit, the admitting RN placed Ms C on
4 L oxygen because of decreased respiratory
effort and low pulse oximetry readings. Over
the course of 1.5 days, Ms C’s respiratory sta-
tus declined (Figure 1).
During Ms C’s course of treatment on the
postoperative nursing unit, communication
during shift changes and with other health
care team members was incomplete at best.
Figure 1 • Ms C’s original graphic record.
392 • AORN JOURNAL
Larkin — Burton
Report sheets and verbal communications
lacked consistency in highlighting Ms C’s res-
piratory status. Furthermore, the vital sign
recording method did not help the RNs to eas-
ily observe trends in the patient’s vital signs.
Although Ms C received 4 L of oxygen consis-
tently during the course of time on the postoper-
ative unit, no other interventions were initiated
by the nurses. Ms C’s status declined further
until she required a rapid response team call to
her bedside on postoperative day two. She was
then transferred to the intensive care unit with a
diagnosis of respiratory distress.
CRITICAL THINKING
Today’s nurse is faced with caring for pa-
tients with higher acuities and addressing
multiple patient needs in an atmosphere of
increased demands on the nurse’s time. Fur-
ther, much time is spent doc-
umenting or performing ad-
ministrative tasks away from
the bedside. Systems of nurs-
ing documentation can be
fragmented, with some docu-
mentation occurring on paper
and other aspects of care doc-
umented on an electronic
health record. Communica-
tion between health care team
members also can be frag-
mented, including the ex-
change of pertinent patient
information at shift changes.
Navigating through this
fragmented environment
demands that nurses exercise
critical thinking skills. It has
been assumed that students
emerging from a basic nurs-
ing education program will
have acquired some of these
critical thinking skills, but
research shows that this is not
a reliable assumption.2 In the
past decade, educators have
focused on increasing stu-
dents’ ability to think critical-
ly, but critical thinking has not
been universally evident in
SEPTEMBER 2008, VOL 88, NO 3
Nursing staff members were ineffectual
in critically evaluating the patient’s
signs and symptoms. This scenario is
congruent with a pre-arrest situation.
If the situation deteriorates further
without intervention, it can lead
to a failure to rescue.
the performance of new graduates. In fact,
some researchers argue that critical thinking
cannot be taught.3
Most medical-surgical units are staffed by a
mix of newer nurses and experienced nurses.
Theoretically, more experienced RNs will have
acquired critical thinking skills within their
specialty, and these nurses will be able to criti-
cally evaluate a patient’s deviation from
expected outcomes more easily than their
newer counterparts. This is not always the
case, as is described in literature that exam-
ines nursing failure-to-rescue scenarios.4,5
Ms C’s case scenario depicts a situation in
which nurses were unable to fully appreciate
the potential for respiratory insufficiency
based on the patient’s
• history and physical,
• postoperative vital signs, and
• responses to treatment.
Nursing staff members were ineffectual in
critically evaluating the patient’s signs and
symptoms. This scenario is congruent with a
pre-arrest situation, defined as “a life-threatening
event that requires rapid identification and
intervention to prevent cardiopulmonary
arrest.”4(p211) If the situation deteriorates further
without intervention, it can lead to a failure to
rescue, defined as “the inability to save a
patient’s life after the development of a com-
394 • AORN JOURNAL
Larkin — Burton
plication.”4(p211) Preventing these situations
requires that nurses pay careful attention to
detailed patient history, physical examination
findings, and laboratory results and ensure
thorough communication between the health
care team members.4
DESIGNING A WORKSHOP
USING BLOOM’S TAXONOMY
This case scenario occurred at a large
southeast Wisconsin teaching facility with
level I trauma designation. The nurse-to-
patient ratio on the postoperative surgical unit
is 1:5 on both morning and afternoon shifts,
although the night shift ratio is 1:8. The unit
also is staffed with certified nurse aides on all
shifts. Physician rounding occurs at least
twice daily. Attending physicians as well as
residents at all levels and medical students
make up the medical team. Nursing access to
physician consultation is always available on
all three shifts.
After this near-miss, failure-to-rescue inci-
dent, the manager, clinical nurse specialist
(CNS), and unit educator of the postoperative
inpatient unit decided to prepare a workshop
that would help staff members successfully
intervene in other critical situations. The CNS
determined that a framework was needed to
assist in the development of this educational
offering. The framework that was chosen was
Bloom’s Taxonomy of Educational Objectives.6
This framework allows the instructor to meas-
ure the outcomes of the educational activity
while moving the learners from basic to high-
er levels of cognitive function.
BLOOM’S TAXONOMY. Benjamin Bloom, an edu-
cational psychologist at the University of
Chicago, and a group of other educators
developed Bloom’s Taxonomy of Educational
Objectives in the early 1950s.6 A taxonomy is a
type of classification system, just like genus
and species is a taxonomy for living creatures.
Bloom’s taxonomy was developed as a tool
for educators to classify learning objectives
and skills for students. This taxonomy has
been used extensively by educators in allied
health fields, including nursing, to structure
lesson plans and outcome testing.7-11 Only Cas-
tle has described using this method for devel-
Larkin — Burton SEPTEMBER 2008, VOL 88, NO 3

oping education for working professionals.11

Bloom’s Taxonomy, also known as the
Revised Bloom’s Taxonomy after it was updat-
ed by Anderson and Krathwohl in 2001,12 con-
sists of a hierarchy within three different
domains of learning: cognitive, affective, and
psychomotor (Figures 2, 3, and 4).6-8 Higher-
level learning is requisite on the learner’s abili-
ty to accomplish learning at lower levels ini-
tially.6 Anderson and Krathwohl demonstrated
the utility of the revised taxonomy to achieve
congruence among intended learning, instruc-
tional activities, and assessment methods
while teaching diagnostic reasoning to clients
with myocardial infarction.9
Figure 2 • Cognitive domain of learning.
THE WORKSHOP
A workshop was devised to help staff mem-
bers navigate through the case study in a real-
istic manner. The educational goal was to
move the learners from the knowledge catego-
ry in Bloom’s Taxonomy to the application
level of the cognitive domain.
The unit educator and CNS met on five dif-
ferent occasions to design the workshop and
develop the tools that would be used. Because
the medical record is completely paper based,
the tools used and developed also were based
on paper documentation. The unit educator
and CNS led the staff in a step-by-step explo-
ration of the case so that staff members could
be guided through the steps of learning acqui-
sition as reflected in Bloom’s Taxonomy. Figure 3 • Affective domain of learning.
The tools used for this exercise included:
• a de-identified patient chart including
• progress notes,
• laboratory values,
• physician orders,
• operative reports, and
• radiology reports;
• blank graphic records;
• blank shift-to-shift report sheets; and
• a data collection worksheet (Figure 5).
The staff members were divided into
groups of four to six and were led in a shift-
by-shift time frame through the entire case
study. Staff members first were instructed to
find objective data in the record such as vital
signs, nurses’ notes, nursing shift-to-shift
reports (Figure 6), and orders. This represented Figure 4 • Psychomotor domain of learning.

AORN JOURNAL • 395

SEPTEMBER 2008, VOL 88, NO 3
Data Collection Worksheet
Shift:
Areas of concern:
Data to support any concern or interpretation of data (eg, assessment, laboratory tests, nursing notes)
Nursing diagnosis and nursing intervention needed? If so, what?
Figure 5 • Data collection worksheet used by workshop participants.
the knowledge segment of the cognitive
domain. The next higher domain, demonstrat-
ing comprehension, led staff members to
determine which aspects of data needed to be
included on the data portion of the data collec-
tion worksheet. Finally, they were to formulate
a nursing diagnosis based on their findings
and to categorize their area of concern for the
patient—the application level of the cognitive
domain.
These exercises were completed using the
original de-identified chart and nursing
reports. During this exercise, staff members
were asked to recreate the shift-to-shift nurs-
ing report to reflect their new findings. This
was then compared to the actual shift-to-shift
report. Communication breakdowns were
thus easily identified. After data collection
worksheets had been completed for all shifts,
staff members were able to determine that res-
piratory distress was an area of concern and a
nursing diagnosis.
RESULTS
On completion of the workshop, staff mem-
bers became more acutely aware of the neces-
sity to effectively communicate with each
other and with other members of the health
care team by focusing on specific, crucial
patient data. The staff practice committee
decided to incorporate the SBAR method of
hand-off reporting at shift change to standard-
396 • AORN JOURNAL
Larkin — Burton
ize hand-off communication. Originating from
the nuclear submarine service,13 and used ex-
tensively in medicine, SBAR stands for
• Situation: What is happening at the present
time?
• Background: What are the circumstances leading
up to this situation?
• Assessment: What do I think the problem is?
• Recommendation: What should we do to correct
the problem?13
In addition, the newer nurses came to real-
ize that they needed to look beyond collection
and recording of patient data toward the accu-
rate interpretation of the data in relation to
patient outcomes. This facilitated the nurses’
planning for targeted nursing interventions
and facilitated communication with other
health care team members.
Staff members also decided to incorporate the
“caret and dot” method of vital sign recording
on the graphic record for two reasons:
• it is the method that is used in the intensive
care areas and
• this method allows the RN to easily visual-
ize the trends in vital signs over time.
In fact, shortly after this workshop, the hos-
pital practice committee decided that all nurs-
ing units should chart in this manner. A re-
designed graphic record that more closely
resembles the record used in the intensive care
areas was instituted. Ms C’s vital signs were
recharted, which allowed staff members to
SEPTEMBER 2008, VOL 88, NO 3
Figure 6 • Shift-to-shift reports for Ms C.
more easily identify trends and deviations
(Figure 7). Providing nurses with methods and
forms that facilitate critical thinking processes
allows them to reach the correct nursing diag-
nosis and implement appropriate nursing
interventions in a more timely fashion.
398 • AORN JOURNAL
Larkin — Burton
PERIOPERATIVE IMPLICATIONS
Although most of Ms C’s medical distress
occurred on the postoperative unit, certain areas
of concern could have been communicated
about the patient throughout the perioperative
continuum. This communication would have
Larkin — Burton SEPTEMBER 2008, VOL 88, NO 3

Figure 6 • Shift-to-shift reports for Ms C (continued).

helped other nursing care providers in assessing • patient’s weight (ie, obese).
and caring for this patient. An SBAR report In addition, the report could have addressed
reflecting the potential for respiratory complica- the potential for circulatory complications
tions could have been initiated based on the based on the patient’s
• patient’s history of smoking, • history of HTN and
• open cholecystectomy procedure, and • history of stroke.

AORN JOURNAL • 399

SEPTEMBER 2008, VOL 88, NO 3
Figure 7 • Redesigned graphic record that incorporates the caret and dot method for recording vital signs.
An SBAR report from the ambulatory area
to the OR could resemble the following:
• S—Ms C is here for an open cholecystectomy.
• B—Ms C has history of HTN and previous
stroke. She also has a significant smoking
history of one pack per day for 45 years.
• A—Based on this data, she has the poten-
tial to develop respiratory and cardiovascu-
lar complications related to anticipated
400 • AORN JOURNAL
Larkin — Burton
postoperative pain and immobility.
• R—Ms C should be monitored for these com-
plications immediately after surgery in the
PACU as well as on the postoperative unit.
Strict adherence to postoperative use of the
incentive spirometer, early mobilization, and
excellent pain control are essential.
Use of SBAR reports, starting from the preop-
erative phase of treatment and continuing
Larkin — Burton
Figure 7 • Redesigned graphic record that incorporates the caret and dot method for recording vital signs (continued).
throughout the perioperative experience, helps
nurses to focus on problematic areas from the
beginning and assists them in examining
responses to treatment. Using SBAR communi-
cation from the preoperative phase of care can
help nursing staff members and other health
care team members accurately discern and
report significant findings.
An SBAR report can help nurses formulate
SEPTEMBER 2008, VOL 88, NO 3
their written plans as well. The written plan
reinforces the verbal report that is given when
the patient is handed off from one caregiver to
the next. Thus, the receiving nurse does not
need to rely solely on memory to adequately
plan and evaluate the next steps in nursing care.
Bloom’s Taxonomy proved to be an excellent
framework for this workshop and could easily
be used to assist RNs in any area of practice,
AORN JOURNAL • 401
SEPTEMBER 2008, VOL 88, NO 3
including the perioperative area, to more easily
evaluate patient conditions and the potential for
unexpected outcomes. Patients undergoing
complex procedures who present with comor-
bidities would make excellent case studies for
the perioperative nursing team. Using Bloom’s
framework and guiding staff members to
review current documentation with data in
small segments would allow staff members to
focus on the important clues and draw accurate
conclusions. This exercise also demonstrated
that this framework is a valuable educational
tool that can be used not only in a formal educa-
tional setting, but in the workplace as well.
CONCLUSION
Using the Revised Bloom’s Taxonomy of
Educational Objectives to structure this work-
shop proved to be extremely beneficial. The tax-
onomy itself is easy to understand and makes a
logical progression from fundamental learning
to complex synthesis. This progression helps to
structure the learning experience so that learners
are able to produce the anticipated outcomes.
Since critical thinking skills may not be attained
through the nursing curricula and practicums,
this tool facilitates on-the-job learning with great
results. Thus, using Bloom’s Taxonomy to frame
education can have long-lasting effects on im-
proving nursing practice. This is especially true
for nursing assessment and communication
with the health care team.
Finally, the nursing staff members who par-
ticipated in this workshop were not only able to
accurately interpret the data using newer meth-
ods, but they also maintained learning three
months after the workshop. Patient vital signs
were charted using the trending method of
carets and dots as reflected in random chart
reviews. No patients needed rapid response
team rescue during this period. According to
staff members, communication among all health
care team members improved. The potential for
positive patient outcomes were thus improved
after this learning experience.
REFERENCES
1. NPSG.02.05.01. In: Hospital Accreditation Program.
2009 Chapter: National Patient Safety Goals. Oakbrook
Terrace, IL: The Joint Commission; 2008:7. http://
402 • AORN JOURNAL
Larkin — Burton
www.jointcommission.org/NR/rdonlyres/31666E8
6-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG
_HAP.pdf. Accessed July 10, 2008.
2. Castle A. Assessment of the critical thinking
skills of student radiographers. Radiography. 2006;
12(2):88-95.
3. Willingham DT. Critical thinking. Why is it so hard
to teach? American Educator. 2007;Summer:8-19.
4. Ashcraft AS. Differentiating between pre-arrest and
failure-to-rescue. Medsurg Nurs. 2004;13(4):211-216.
5. Clarke SP. Failure to rescue: lessons from missed
opportunities in care. Nurs Inq. 2004;11(2):67-71.
6. Bloom B, ed. Taxonomy of Educational Objectives.
New York, NY: Longman; 1956.
7. Su WM, Osisek PJ, Starnes B. Applying the
Revised Bloom’s Taxonomy to a medical-surgical
nursing lesson. Nurse Educ. 2004;29(3):116-120.
8. Su WM, Osisek PJ, Starnes B. Using the Revised
Bloom’s Taxonomy in the clinical laboratory: think-
ing skills involved in diagnostic reasoning. Nurse
Educ. 2005;30(3):117-122.
9. Duan Y. Selecting and applying taxonomies for
learning outcomes: a nursing example. Int J Nurs
Educ Scholarsh. 2006;3:Article 10. Epub February 15,
2006.
10. Calhoun JG, Rowney R, Eng E, Hoffman Y.
Competency mapping and analysis for public
health preparedness training initiatives. Public
Health Rep. 2005;120(Suppl 1):91-99.
11. Castle A. Demonstrating critical evaluation
skills using Bloom’s taxonomy. Int J Ther Rehabil.
2003;10(8):369-373.
12. Anderson LW, Krathwohl DR, Bloom BS. A Tax-
onomy for Learning, Teaching, and Assessing: A Revi-
sion of Bloom’s Taxonomy of Educational Objectives.
New York, NY: Longman; 2001.
13. Leonard M. Effective Teamwork as a Care Strate-
gy—SBAR and Other Tools for Improving Communica-
tion between Caregivers [on-demand video presenta-
tion]. Institute for Healthcare Improvement. http://
www.ihi.org/IHI/Programs/AudioAndWebPro
grams/Effective+Teamwork+as+a+Care+Strategy+
SBAR+and+Other+Tools+for+Improving+Commu
nication+Between+Careg.htm. October 4, 2006.
Accessed July 10, 2008.
Brenda G. Larkin, RN, MS, CNOR,
ACNS-BC, is a clinical nurse specialist
for Perioperative Services at Aurora West
Allis Medical Center, West Allis, WI.
Karen J. Burton, RN, ADN, TNCC, is a
parish nurse and case manager for Hospice/
Palliative at ProHealth Home Care,
Hartland, WI.