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Using Gagne’s instructional model in phlebotomy

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Advances in Medical Education and Practice
31 August 2016
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Wee Hong Woo Abstract: As the role of a phlebotomist in a clinical setting involves patient interactions, ­correct
School of Chemical & Life Sciences, patient identification, and blood specimen accessioning, it is essential that the phlebotomy
Singapore Polytechnic, Singapore education pay attention to these procedural tasks to inculcate a culture of patient safety. Using
the Gagne’s nine events of instruction as the basis of teaching model, this paper describes the
lesson plan for teaching the topic of patient approach to a group of phlebotomy students without
prior clinical experience.
Keywords: venipuncture, Gagne’s model, instructional design, patient handling, Peyton’s steps

Introduction
In polytechnic, teaching a group of phlebotomy students without clinical experiences,
the topic of “approaching the patient; the role of a phlebotomist” is challenging, yet
fulfilling. The challenging part is to ensure the learners are able to comprehend the
implications of patient safety taught in the topic and apply what they have learnt. If
the learners demonstrate the desired clinical skills, the sense of fulfillment is realized.
Gagne’s instructional model1 has been used widely to teach procedural skills.2–5 As Rob-
ert Gagne has categorized the five learning outcomes as intellectual skills, verbal informa-
tion, cognitive strategies, attitudes, and motor skills, the Gagne’s nine events of instruction
(Table 1) provide an instructional framework to achieve these outcomes. Consequently, I
deliberated on the contextualization process of Gagne’s events of instruction in phlebotomy
education, and describe here the lesson plan for the topic of approaching the patient.

Prerequisites
It is necessary that the learners have prior knowledge about the topic of preanalytical variables.
Preanalytical variables refer to those factors that are associated with the pre-examination
phase of the clinical laboratory testing process.6 Generally, preanalytical variables can be
categorized into patient variables, variables in blood collection technique, transportation
variables, and specimen variables. Table 2 presents a myriad of preanalytical variables that
Correspondence: Wee Hong Woo are related to blood specimen collection. As these variables address the quality of the blood
School of Chemical & Life Sciences,
Singapore Polytechnic, 500 Dover Road, specimens collected in a clinical setting, knowledge of these variables forms the prerequi-
Singapore 139651 site for the lesson. Usually, a separate lesson is required to address this topic in its entirety.
Tel +65 6772 1899
Fax +65 6772 1976
To highlight some of the preanalytical variables listed in Table 2, the role play
Email [email protected] activity (Table 3) is employed to set focus on patient variables (fasting), variables of

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Table 1 Gagne’s nine events of instruction technique (patient identification), transportation variables
Instructional event Cognitive process (pneumatic tube), and specimen variables (specimen label-
1. Gaining attention Reception ing). Learners need to pay attention to the requirement of
2. Informing learner of objectives Expectancy
a fasting blood sample and should be able to pick up the
3. Stimulate recall of prior learning Retrieval
4. Presenting stimulus Selective perception wrongly typed patient name on the laboratory requisition
5. Providing learning guidance Semantic encoding form. Hence, the intent of such a role-play activity is to train
6. Eliciting performance Responding
the learners to take a conscientious effort in ensuring quality
7. Providing feedback Reinforcement
8. Assessing performance Retrieval blood collection. Such procedural tasks, although cumber-
9. Enhancing retention and transfer Generalization some, are highly recommended, as it reduces errors related
Note: Adapted from Gagne RM, Wager WW, Golas KG, Keller JM. Principles of to patient identity.7 Conversely, learners are also encouraged
Instructional Design. 5th ed. © 2005 South-Western, a part of Cengage Learning, Inc.
ISBN: 9780534582845 (0534582842).1 to ponder upon the consequences of a nonfasting lipid test
result. Learners need to point out that a nonfasting lipid test
Table 2 The preanalytical variables associated with blood result misinterpreted as a fasting one could possibly lead to
specimen collection a patient being put on an aggressive course of statin therapy
Patient Variables in Transportation Specimen unnecessarily or subject a patient to an unwittingly adjusted
variables technique variables variables
dosage of an ongoing statin without the evidence of a reliable
Age Patient Delivery (by hand, Identification
blood test result.
Sex identification pneumatic tube) and labeling
Special needs Tourniquet Temperature/light Equipment/ A lesson plan for the topic was developed using the
Diet application Timing supplies Gagne’s nine events of instruction1 and each of the events is
Smoking Site selection Anticoagulants
described in the following sections.
Drugs/alcohol Decontamination Specimen
Exercise Equipment/supplies processing
Stress (centrifugation) Contextualizing Gagne’s nine events
Diurnal/circadian
variations
Storage prior to
testing
of instruction
Altitude Gaining attention
Dehydration To engage learners at the beginning of a lesson, I call for
Notes: Adapted from Garza, Diana; Becan-McBride, Kathleen, Phlebotomy
their attention to watch a poignant video that shows how
Handbook, 9th, © 2015. Adapted by permission of Pearson Education, Inc., New
York, New York.23 Data from McCall and Tankersley.24 a simple blood test can make a big difference to a person’s

Table 3 Role-play scenario

Place: The phlebotomy room in a medical laboratory
Characters: 1) Phlebotomist, 2) adult patient; Ms Tan Lee Lee (or) Mr Tan Sin How
Equipment: Two chairs and a table
Prelabeled laboratory requisition form
Unlabeled prefilled blood tubes
Background: The medical laboratory is a facility that analyses clinical specimens for the purpose of health and disease management. Blood is a body
fluid that is commonly used for such investigational purposes. Upon the order of a medical doctor, the patient will turn up at the medical
laboratory with the prefilled laboratory requisition form for the blood tests. It is the role of the phlebotomist to ensure correct patient
identification and rightful specimen collection, while paying attention to the quality of specimen collected.
Depending on the role-play pair, the adult patient can be a female (Ms Tan Lee Lee) or a male (Mr Tan Sin How). Adult patients are told
what their names are and they are to carry the stapled prelabeled laboratory form to the phlebotomist. The laboratory requisition form is
purposely labeled wrongly as Ms Tan Lily or Mr Tan Sing Howe. All other patient identifiers remain correct. As lipid profile is ordered, a
fasting status is required. Fasting is defined as no caloric intake for at least 8 hours.
Scenario: An adult patient has been scheduled to go for a blood test. Holding a prelabeled laboratory requisition form, the patient enters the medical
laboratory and requests for the blood testing service. The patient is directed to the phlebotomy room by the counter receptionist. You are
a phlebotomist and you are going to approach the patient.
Objectives: · To uphold the positive first impression of a professional phlebotomist
· To ensure positive patient identity (using two unique patient identifiers)
· To ensure proper blood specimen identification (labeling)
· To ensure quality of blood specimen collected (mindful of preanalytical variables; fasting)
The student · Greet patient with a smiling face and in a friendly tone, and maintain comfortable eye contact
should: · Identify the patient by using at least two unique patient identifiers (eg, name [to spell out] and NRIC number)
· Check the status of dietary restriction (fasting; “Have you taken any food or drink for the past 8 hours?”)
· Label the blood tube immediately after blood collection using simulated prefilled blood tube
· Send the labeled blood tube to the laboratory using mock pneumatic tube
Abbreviation: NRIC, National Registry Identification Card.

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Dovepress Gagne’s instructional model in phlebotomy education

life (first 1 minute 31 seconds; https://www.youtube.com/ and engages linguistic, intrapersonal, and interpersonal
watch?v=Ph4H1AuvOH0). This video is used to capture the intelligences.13
attention of visual and auditory learners.8 Furthermore, the After spending approximately 5 minutes on recalling, I
sadness associated with a widow reminiscing about her late will move on to deliver my presentation. The intent is not to
husband would engage the learners emotionally and trigger drag the recalling phase so long that the learners lose focus
them to be more conscientious in proper blood collection and interests.
procedures, and thus be more ready to learn.9
I am mindful that a poignant video may trigger previous Presenting stimulus
bad experiences. In such cases, rather than to dwell into Here, I will deliver my content using PowerPoint presentation.
the negativities of bad experiences, staying focused on the There are four topics, namely:
learning the objectives and being positive toward a safer and
∑ positive first impression;
better health care is a preferred option.10,11
∑ ensure quality of blood specimen collected;
Informing learner of objectives ∑ positive patient identification;
Immediately after the video, I will move on to state the les- ∑ proper blood specimen identification.
son objectives. This helps in preparing the learners for the Each topic is covered in two to three slides. Pictures and
imminent learning process and establishing the learners’ topical tabulated checklists are included to help the learners
achievable expectations for the lesson. To maintain the learn- to learn in “chunks” and help them to assimilate the new
ers’ interest, I will relate the importance of the objectives to information.14,15 To engage the learners, I encourage them
the video just seen, so that the learners can appreciate them to recall the service they received for the hepatitis B blood
in real-world contexts. Such practice concurs with the law test and try using the checklist designed for positive first
of intensity.10 For this lesson, the objectives are presented as: impression and positive patient identification. This process
Upon completing this lesson, you will be able to: engages their linguistic and intrapersonal intelligences13 and
∑ state three ways to uphold the positive first impression of appeals to visual, auditory, and kinesthetic styles of learn-
a professional phlebotomist; ers.8 In addition, I endeavor to deliver the content in a lively
∑ list four general criteria for a quality blood collection; and enthusiastic manner, as this will influence the learners
∑ perform positive patient identification; to learn positively.16
∑ perform proper blood specimen identification.
Providing learning guidance
Stimulate recall of prior learning There is a saying that goes, “first impressions last.” Hence, the
The constructivism theory put forth that the learning process first rightful demonstration with step-by-step explanation is
is facilitated if prior knowledge and personal experience can a good starting point for learning. This practice concurs with
be associated with new information.12 Hence, it is necessary the law of primacy10 and the first step in the Peyton’s four-
to stimulate recall of prior learning. Yet, for this lesson, the step approach to teaching (demonstration–deconstruction–­
learners have no relevant clinical experience in handling comprehension–performance).17 To begin, I “demonstrate”
patients. To overcome this, the learners will be asked to recall how I approach the patient politely, identify the patient
their recent experience in getting a hepatitis B blood test correctly, label the blood tubes rightfully and dispatch the
done while I project a picture of a mock hepatitis B report blood tubes in a timely manner. Next, I “deconstruct” the
on the projector screen. Here, the learners are placed on the patient approach by explaining the rationale for each step
receiving end and they could comment on the standard of taken, and encourage the learners to ask questions for bet-
service they received as patients. With questions like, “Did ter “comprehension.” This process engages the learners’
the ­clinical staff handle the whole procedure with profession- linguistic, kinesthetic, and interpersonal intelligence,13 and
alism?” If yes, “What were the professional behaviors?” If no, stimulates the reflectors to ponder.18 Furthermore, the read/
“What was lacking?”, and, “What would you do differently write style of learners8 can be engaged by encouraging them
if you were the clinical staff?”. The learners are triggered to jot down notes for future references.
to ponder on the procedures, deliberating on how to make To demonstrate effectively, I have to position myself
a difference from a personal perspective. This thinking and before the whole class and ensure all learners can hear and
sharing process appeals to visual and auditory learners,8 see me and my “patient” before I begin.

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Eliciting performance (Table 3) has to be written purposefully to accommodate the

In this session, learners are grouped in small groups to learning objectives of the lesson. Learners need to understand
practice the skill of approaching the patient via the role-play the purpose of the role-play activity and hence time is needed
activity. I have chosen the role-play activity because it can to prepare them adequately. Learners are told to take turns to
simulate actual work conditions and has its focus on com- “perform” as a phlebotomist, a patient, and an observer (the
munication and affective interaction.19 A detailed scenario fourth step in the Peyton’s four-step approach). An observer

Phlebotomy competency assessment

Approaching the patient

Competency: Demonstrate proper patient identification and specimen identification.

Behavior: Patient identification

Specimen identification
Patient care/customer service

Procedures Satisfactory Improvement Unsatisfactory Remarks

performance needed performance
5 3 0
1 Greets patient and introduces self

2 Checks requisition for all pertinent information

3 Identifies patient correctly using two identifiers

4 Washes hands

5 Explains procedure to patient

6 Checks for diet restriction and latex allergies

7 Selects correct tubes and equipment for

procedure
8 Assembles equipment

9 Notifies patient of the imminent puncture

10 Performs venipuncture procedure

(not done)
11 Labels specimen properly

12 Checks puncture site when procedure is

complete
13 Thanks and releases patient

14 Transports specimen to laboratory

Total points for each category:

Total of all categories:

/65

Student’s name and signature: Date:

Lecturer’s name and signature: Date:

Figure 1 Phlebotomy checklist.

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Dovepress Gagne’s instructional model in phlebotomy education

is encouraged to share or discuss with the performing Conclusion

“phlebotomist” on what was done well and what needs to The Gagne’s instructional model is a systematic approach to
be improved. Such activity engages the students’ linguistic, learning and its usefulness has been advocated in ­medical
kinesthetic, intrapersonal, and interpersonal intelligence,13 and nursing education.2,22 Using the Gagne’s nine events
and stimulates the activists and pragmatists to act.18 of instruction, it caters to the different learning styles of
It is important to encourage all learners to play a par- learners and facilitates the learning processes of learners.
ticipative role. As mentioned, adequate preparation time is To maximize its usefulness, the lesson plan can be contex-
needed for role-play activity to be fruitful and meaningful.20 tualized to the other topics of phlebotomy like venipuncture
and capillary puncture.
Providing feedback
As the learners are practicing in their role-play, I observe Disclosure
them closely and provide immediate feedback if they have The author reports no conflicts of interest in this work.
done well or have missed out certain issues, such as inquiring
good arms for venipuncture, checking for dietary restriction, References
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