Welcome to the course, everyone!

ADDIE is an acronym that stands for 5 phases of instructional design process:

1. Analysis

2. Development

3. Design

4. Implementation

5. Evaluation

In this lesson I will:

1. provide the overview of the model

2. include some of its benefits and limitations

3. and then focus on the analysis phase of ADDIE in more detail

Throughout the lesson, there will be interactive exercises included to help with review of the material.

The way instructional designers choose to apply the ADDIE model depends on the intention and context of the learning, but the underlying structure of 5 stages is what remains, whichever approach is taken.

The original version of ADDIE was linear and hierarchical, taking the instructional design process from one stage to another, without much interaction between the phases. For example, the linear model can be represented like this:

However, nowadays most instructional designers use ADDIE model in a more flexible way, where stages are in interaction within each other so that revisions among stages are possible. One of the more flexible ADDIE models can look like this:

In this flexible model, evaluation is conducted not only for the entire project but also for each stage.

Let's take a closer look into all 5 phases of ADDIE:

1. ANALYZE-  this is the phase in which we define and validate the problem, identify probable causes, determine a target audience, and performance context. This phase is critical because it informs all other phases of the ADDIE model. It can also help us get stakeholder's buy-in for the instructional design strategy that we are proposing. For example, in this phase you may do observations, surveys, conversations with SMEs, learners, etc. to help us understand the stakeholders and learners needs and instructional context. 

2. DESIGN- this is the phase in which we create the instructional strategy and learning objectives, generate sample test items, and write a design document. In this phase we use the design evaluation tool to ensure congruency between skills, objectives and assessments.

The design evaluation tool helps us plan the instructional strategy. The instructional strategy is the detailed plan for the training/learning/instruction, and its purpose is to guide learners through mental states and activities that foster learning. Gagné outlined 9 stages of activities that enhance learning. They are called Gagné's 9 events of learning, and they are:

1. gain attention

2. inform learners of objectives

3. stimulate recall of prior learning

4. present the content

5. provided learning guidance

6. elicit performance (practice)

7. provide feedback about performance

8. assess performance

9. enhance retention and transfer to the performance context

The design phase typically concludes with developing the design document to share the decisions and strategies you have made at this stage with stakeholders. If all of them are accepted, you can move on to the development phase.

3. DEVELOP- this is the most creative phase of ADDIE. In this phase we produce the instructional materials, determine resources that will be used in the training, develop assessments, instructional guides, etc. Depending on the size of the company and complexity of the training, instructional designers may be involved in some parts of the development phase. At this stage, instructional designers can create prototypes. Prototypes are representative of other instructional material, and they can be used for review and approval from stakeholders.

4. IMPLEMENT- the goal of this phase is to prepare instructors, learners, and the learning environment. You can prepare a learner and instructor plan. In this phase, the instructional designers "hand over" the work to people who actually deliver and administer the training/instruction. It is a good idea to use this phase to prepare instructors for the new training though "train the trainers" sessions. Learners can also be prepared for the training through pre-training communication, prior knowledge/skills assessment, pre-training activities, etc. And, finally, instructional designers need to prepare the learning environment and ensure that the tools and conditions needed for the training are available and enable the knowledge transfer.

5. EVALUATE- in this phase we not only assess learner performance but also measure the effectiveness and quality of the instruction. As mentioned earlier, evaluation should ideally practiced at each stage of the ADDIE process as it provides valuable and timely feedback. Thus, there are 2 phases to the evaluation phase: formative and summative. Formative evaluation is the continual evaluation throughout all ADDIE phases. Dick and Carey outline 3 stages of formative evaluation: one-to-one, small group, and field trial. On the other hand, the purpose of summative evaluation, is to evaluate the worth of training/instruction. Kirckpatrick's model outlines 4 things to evaluate: reaction, learning, behaviour, and results. 

Now that I have summarized all 5 phases of the ADDIE model, it is time to review the things we have learned so far, and then take at benefits and limitations of the ADDIE model, before we move on to take a deeper dive into the analysis stage.

ADDIE model has many benefits and some of the are:

1. Instructional designers who use ADDIE are able to produce more accurate, reliable and consistent instructional programs

2. It structures and optimizes the instructional design process, leading to cost saving

3. ADDIE makes instructional designers' work more visible to stakeholders

4. Model is flexible and feedback and evaluation can be provided at any stage, which prevents problems from escalating before the project ends

Some criticize ADDIE because:

1. It is a detailed and lengthy process that might need a lot of time to complete. In real-life context, this life is not often available. For this reason stages are sometimes skipped or merged, which can decrease ADDIE's efficiency. 

2. If we are following the cycle model of ADDIE, negative impact in one phase will impact other phases again leading to time and financial losses

But ADDIE has much more advantages than disadvantages, so overall, it serves instructional designers really well! And now it's time to look at the analysis phase of ADDIE.

Analysis phase is what we typically start with when we start with applying ADDIE to an instructional design project. It helps us answer a lot of questions that are going to inform our approach to training design, development and implementation. As we already mentioned in the overview of all 5 stages of ADDIE, The goal of the analysis phase in ADDIE is to:

1. validate performance gap

2.  create instructional goals

3.  and confirm the audience and performance context

How can we validate performance gap? I really like this "formula" provided by Dick and Carey: desired status-actual status= need

According to Branch (2009) there are 3 main reasons for performance gap: 

1. lack of motivation

2. lack of knowledge and skills

3. lack of resources

Van Tiem, Moseley, and Dessinger (2012) view performance as influenced by the worker, the workplace, the work and the world. This perspective is especially pertinent in times of crisis, e.g. during COVID or war, when people were not able to distance themselves from the political and economic context. 

To complete the needs analysis you can use focus groups, interviews, surveys, etc. You can start planning your analysis by using 5 Ws and H strategy:

You can collect the data you need in any of these methods or in a combination of these different methods. Some of them are:

1. focus groups

2. surveys

3. interviews

4. observation

4. review of existing data

Once you collect the data and confirm the performance gap, instructional designers define a goal statement. A goal statement defines the purpose of the training and its general context. Branch (2009) suggests the statement should be limited to 25 words, written in plain language, and convey the relationship between instruction and business needs.

Besides goal statement, the instructional designer would also need to define specific instructional goals in the analysis phase. Instructional goals describe what learners will be able to do after the training/instruction. The creation of instructional materials will have to align with the goals.

The instructional goals should satisfy these criteria:

1. resolve the problem that led to the need for instruction

2. be acceptable to stakeholders

3. be based on available resources

Now that we have defined how to create a goal statement and instructional goals, let's look at how to conduct learner and context analysis.

Learner analysis helps us understand the target audience for the training.

According to Dick and Carey (2015), we need to collect these 8 types of data about learners:

1. entry skills

2. prior knowledge of topic area

3. attitudes towards content and modes of delivery

4. academic motivation

5. educational and ability levels

6. learning preferences

7. attitudes towards training organization

8. group characteristics

You can again use can use the 5Ws and H tool, to ask questions in these 8 categories. For example, it can look like this, and you can add additional questions:

Besides using 5Ws and H tool, it is also useful to formulate the questions in learner analysis using Bloor taxonomy. This is helpful because questions can follow the sequential levels of complexity. 

Sometimes instructional designer complete learner analysis and goal analysis together. Very often goals may need to be revised after the learner analysis is complete. Drafting goals and completing learner analysis at the same time is very common in real-life context as it can save time and resources.

When completing a learner analysis, designers need to be mindful of potential biases. We can unintentionally design questions according to our assumptions of learner preferences. To avoid biases, it is helpful to do a test analysis with a small sample of learners and also ask your colleagues to review the analysis questions.

Once you analyzed the answers, you can create learner personas.  Learner personas are a visual representation of the group of learners. They are very effective way to capture and convey information about the learner group. For example, you can use a template like this to create a learner persona:

Once we are done with analyzing learners, we are ready to move on to context analysis. Again, this is not a linear process and context and learner analysis will keep informing each other during the analysis stage.

Dick and Carey (2015) distinguish two types of context analysis:

1. performance context- analysis of the setting in which skills and knowledge will be used

2. learning context- analysis of the setting in which skills and knowledge will be acquired

Good understanding of the context will have a positive impact on the transfer of learning. Often times, a physical visit to the site where work/learning takes place is the best way to understand the context: equipment, layout of the space, team dynamics, interpersonal relationships, etc.

The analysis phase concludes with a report that summarizes findings and proposes a solution. The report will contain a goal statement, instructional goals, and learner and context analysis. 

If the report is accepted, we can move on to the design stage.

If the report needs revisions, we would repeat some elements of analysis. this show iterative, non-linear ADDIE approach which we discussed at the beginning.

And now it is time to revise what you have learned about the analysis stage of ADDIE:

Good job for making it to the end! Hope you enjoyed this lesson. Let me know in the comments below.

SBAR reporting is an important tool to learn in nursing. It helps to ensure smooth communication between healthcare providers, which helps to decrease the incidences of miscommunication leading to errors and ultimately to patients not receiving appropriate care.

Here is a great resource for learning about SBAR reporting, take a few minutes to review it before moving on to the next part of this simulation: https://drive.google.com/file/d/1ghioDQ6ec5wNjDV7HSVoDXrWLWB9XK6I/view?usp=sharing

Simulation

You are an RPN student working in your local emergency room, assigned to the fast-track department. Joey is a 41-year-old man who comes in with acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain, which he rates as a 10 on a scale of 1 to 10. He admits to having had a similar episode of back pain years ago “after I lifted something heavy at work.” Joey has a medical history of peptic ulcer disease related to non-steroidal anti-inflammatory drug (NSAID) use. He is 6 feet (183 cm) tall, weighs 265 pounds (120 kg), and has a prominent “potbelly.” The doctor ordered a back x-ray and blood work. The lab work is back with no abnormalities and the radiologist called to say that there was nothing abnormal on the x-ray.

You discuss this case with your preceptor, who supports calling the physician and asking for a prescription that will help with a muscle strain.

Use the following SBAR tool to document what you need to say to the physician.

Joey is given a prescription from the physician for prescriptions for cyclobenzaprine (Flexeril) 10 mg tid for 3 days only, and celecoxib (Celebrex) 100 mg/day for 3 months.

He is also told to use heat applications to the lower back for 20 to 30 minutes four times a day (using moist heat from heat packs or hot towels), no twisting or unnecessary bending, and no lifting more than 10 pounds (4.5 kg). Joey is also instructed to rest his back for 1 or 2 days, getting up only now and then to move around to relieve muscle spasms in his back and strengthen his back muscles.

The physician also gives him a written letter to stay off work for 5 days and, when he returns to work, specifying the limitation of lifting no more than 10 pounds (4.5 kg) for 3 months. He is instructed to contact his primary care provider if the pain gets worse.

Use the following documentation tool to document all your care for this patient.

WELCOME to a new Educational Opportunity!

SBAR reporting is an important tool to learn in nursing. It helps to ensure smooth communication between healthcare providers which helps to decrease the incidences of miscommunication leading to errors and ultimately to patients not receiving appropriate care.

Here is a great resources for learning about SBAR reporting: https://drive.google.com/file/d/1ghioDQ6ec5wNjDV7HSVoDXrWLWB9XK6I/view?usp=sharing

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Welcome to an introduction to Library Research! This tutorial will demonstrate the basics of getting started with finding academic  journal articles to support your course assignment. 

Topic selection

Wherever you are, look around you. Find one thing in your immediate field of view that you can’t explain.

• What is it that you don’t understand about that thing?
• What is it that you need to find out so that you can understand it?
• How can you express what you need to find out?

For example: You can’t explain why your coat repels water. You know that it’s plastic, and that it’s designed to repel water, but can’t explain why this happens. You need to find out what kind of plastic the coat is made of and the chemistry or physics of that plastic and of water that makes the water run off instead of soaking through.

Part of identifying your own information need is giving yourself credit for what you already know about your topic. This exercise gives you a simple way to gauge your starting point, and may help you identify specific gaps in your knowledge of your topic that you will need to fill as you proceed with your research.

• Briefly summarize your idea.
• In the first column, list what you know about your topic.
• In the second column, briefly explain how you know this (heard it from the professor, read it in the textbook, saw it on a blog, etc.).
• In the last column, rate your confidence in that knowledge. Are you 100% sure of this bit of knowledge, or did you just hear it somewhere and assume it was right?

For example: I want to know how my water repellent jacket actually repels water. 

Follow these steps to get a better grasp of exactly what you are trying to find out, and to identify some initial search terms to get you started.

1. Whatever project you are currently working on, there should be some question you are trying to answer. Write your current version of that question here.
2. Now write your proposed answer to your question. This may be the first draft of your thesis statement which you will attempt to support with your research, or in some cases, the first draft of a hypothesis that you will go on to test experimentally. It doesn’t have to be perfect at this point, but based on your current understanding of your topic and what you expect or hope to find is the answer to the question you asked.
3. Look at your question and your thesis/hypothesis, and make a list of the terms common to both lists (excluding “the,” “and,” “a,” etc.). These common terms are likely the important concepts that you will need to research to support your thesis/hypothesis. They may be the most useful search terms overall or they may only be a starting point.

If none of the terms from your question and thesis/hypothesis lists overlap at all, you might want to take a closer look and see if your thesis/hypothesis really answers your research question. If not, you may have arrived at your first opportunity for revision. Does your question really ask what you’re trying to find out? Does your proposed answer really answer that question? You may find that you need to change one or both, or to add something to one or both to really get at what you’re interested in. This is part of the process, and you will likely discover that as you gather more information about your topic, you will find other ways that you want to change your question or thesis to align with the facts, even if they are different from what you hoped.

• HTN is a lanthanic or silent disease because it is frequently asymptomatic until it becomes severe and target-organ disease occurs.

• Target-organ diseases occur in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vasculature (peripheral vascular disease), kidney (nephron-sclerosis), and eyes (retinal damage).

• Hypertension is a major risk factor for coronary artery disease (CAD).

• Sustained high BP increases the cardiac workload and produces left ventricular hypertrophy (LVH). Progressive LVH, especially in association with CAD, is associated with the development of heart failure.

• Hypertension is a major risk factor for cerebral atherosclerosis and stroke.

• Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels, leading to the development of peripheral vascular disease, aortic aneurysm, and aortic dissection.

• Intermittent claudication (ischemic muscle pain precipitated by activity and relieved with rest) is a classic symptom of peripheral vascular disease involving the arteries.

• Hypertension is one of the leading causes of end-stage renal disease. The earliest manifestation of renal dysfunction is usually nocturia.

• The retina provides important information about the severity and duration of hypertension. Damage to retinal vessels provides an indication of concurrent vessel damage in the heart, brain, and kidney. Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and loss of vision.

• The diagnosis of hypertension is not based on a single elevated reading (if <80/110 mm Hg) but requires several elevated readings over several weeks.

• Routine urinalysis and serum creatinine levels are used to screen for renal involvement and to provide baseline information about kidney function.

• Measurement of serum electrolytes, especially potassium levels, is done to detect hyperaldosteronism, a cause of secondary hypertension.

• Blood glucose levels assist in the diagnosis of diabetes mellitus.

• Lipid profile provides information about additional risk factors that predispose to atherosclerosis and cardiovascular disease.

• ECG and echocardiography provide information about cardiac status.

• Ambulatory blood pressure monitoring is a noninvasive, fully automated system that measures BP at preset intervals over a 24-hour period.

  • Some patients with hypertension do not show a normal, nocturnal dip in BP and are referred to as “nondippers.”

  • The absence of diurnal variability has been associated with more target-organ damage and an increased risk for cardiovascular events. The presence or absence of diurnal variability can be determined by continuous ambulatory BP monitoring.

• Treatment goals are to lower BP to less than 140 mm Hg systolic and less than 90 mm Hg diastolic for most persons with hypertension (less than 130 mm Hg systolic and less than 80 mm Hg diastolic for those with diabetes mellitus and chronic kidney disease).   

• Hypertension Canada has identified a number of key recommendations for the treatment of hypertension and updates them annually.  

• Lifestyle modifications are indicated for all patients with hypertension, and include the following:

  • Dietary changes: The Dietary Approaches to Stop Hypertension (DASH) eating plan emphasizes fruits, vegetables, and low-fat dairy products; dietary and soluble fibre; and whole grains and protein from plant sources and that is reduced in saturated fat and cholesterol. The DASH diet significantly lowers BP. Dietary management also includes restriction of sodium, maintenance of potassium, calcium, and magnesium.

  • Weight reduction: Height, weight, and waist circumference should be measured and body mass index (BMI) calculated for all adults. Maintenance of a healthy body weight is recommended for individuals who are normotensive to prevent HTN and for Canadians with HTN to reduce BP. All overweight hypertensive individuals should be advised to lose weight.

  • Limitation of alcohol intake to no more than two drinks per day. o    Regular aerobic physical activity (e.g., brisk walking) of 30-60 minutes a day, 4–7 days per week. Moderately intense activity such as brisk walking, jogging, and swimming can lower BP, promote relaxation, and decrease or control body weight.

  • Avoid tobacco use (smoking and chewing).

  • Stress management

• The general goal of drug therapy is to achieve a BP of less than 140/90 mm Hg. For patients with chronic kidney disease or diabetes, target BP is less than 130/80 mm Hg.
• Drugs currently available for treating hypertension work by (1) decreasing the volume of circulating blood, and/or (2) reducing SVR.
• Diuretics promote sodium and water excretion, reduce plasma volume, decrease sodium in the arteriolar walls, and reduce the vascular response to catecholamines.
• Adrenergic-inhibiting drugs act by diminishing the SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor centre and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels.
• Direct vasodilators decrease the BP by relaxing vascular smooth muscle and reducing SVR.
• Calcium channel blockers increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells. o    Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)–mediated vasoconstriction and sodium and water retention. A-II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors in the walls of the blood vessels.
• Thiazide-type diuretics are used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes.
• If the BP is not controlled, the dosage of the first-line drug can be increased. A second drug from a different class can be substituted or added if the initial drug was ineffective or there were adverse effects to the initial drug. Most patients who are hypertensive will require two or more antihypertensive medications (taken in a single-pill format) to achieve their BP goals.
• A new drug has been authorized for use in Canada: Aliskiren fumarate (Rasilez) is an oral direct renin inhibitor (DRI).

Adverse Effects

Adverse effects of antihypertensive drugs may be so severe or undesirable that the patient does not comply with therapy.

• Hyperuricemia, hyperglycemia, and hypokalemia are common adverse effects with both thiazide and loop diuretics.
• ACE inhibitors lead to high levels of bradykinin, which can cause coughing. An individual who develops a cough with the use of ACE inhibitors may be switched to an ARB.
• Hyperkalemia can be a serious adverse effect of the potassium-sparing diuretics and ACE inhibitors.
• Impotence may occur with some of the diuretics.
• Orthostatic hypotension and sexual dysfunction are two undesirable effects of adrenergic-inhibiting agents.
• Tachycardia and orthostatic hypotension are potential adverse effects of both vasodilators and angiotensin inhibitors.
• Patient and caregiver teaching related to drug therapy is needed to identify and minimize adverse effects and to cope with therapeutic effects. Adverse effects may be an initial response to a drug and may decrease with continued use of the drug.

• The primary nursing responsibilities for long-term management of hypertension are to assist the patient in reducing BP and adhering to the treatment plan.

• Nursing actions include evaluating therapeutic effectiveness, detecting and reporting any adverse treatment effects, assessing and enhancing adherence, and patient and caregiver teaching.

• Patient and caregiver teaching includes the following:

  1. nutritional therapy

  2. drug therapy

  3. lifestyle modification

  4. home monitoring of BP (if appropriate).

• The prevalence of hypertension increases with age. HTN is common in people 60 years of age and older in industrialized countries. The SBP rises throughout the lifespan and DBP rises until age 55 or 60 years and then levels off.

• A number of age-related physical changes contribute to the pathophysiology of hypertension in the older adult.

• In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats (auscultatory gap). Failure to inflate the cuff enough may result in underestimating the SBP.

• Older adults are sensitive to BP changes. Reducing SBP to less than 120 mm Hg in a person with long-standing hypertension could lead to inadequate cerebral blood flow.

• Older adults produce less renin and are more resistant to the effects of ACE inhibitors and A-II receptor blockers.

• Orthostatic hypotension often occurs in older adults because of impaired baroreceptor reflex mechanisms, volume depletion, and chronic disease states, such as decreased renal and hepatic function or electrolyte imbalance.

• To reduce the likelihood of orthostatic hypotension, antihypertensive drugs should be started at low doses and increased cautiously.

HYPERTENSIVE CRISIS

• Hypertensive crisis is a severe and abrupt elevation in BP, arbitrarily defined as a DBP above 120 to 130 mm Hg.

• Hypertensive crisis occurs most often in patients with a history of hypertension who have failed to adhere to their prescribed medications or who have been undermedicated.

• Hypertensive crisis related to cocaine or crack use is becoming a more frequent problem. Other drugs such as amphetamines, phencyclidine (PCP), and lysergic acid diethylamide (LSD) may also precipitate hypertensive crisis that may be complicated by drug-induced seizures, stroke, MI, or encephalopathy.

HYPERTENSIVE EMERGENCY

• Hypertensive emergency develops over hours to days, and is defined as BP that is severely elevated with evidence of acute target-organ damage.

• Hypertensive emergencies can precipitate encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure with pulmonary edema, MI, renal failure, and dissecting aortic aneurysm.

• Hypertensive emergencies require hospitalization, parenteral administration of antihypertensive drugs, and intensive care monitoring.

HYPERTENSIVE URGENCY

• Hypertensive urgency develops over days to weeks, and is defined as a BP that is severely elevated but with no clinical evidence of target organ damage.

• Hypertensive urgencies usually do not require IV medications but can be managed with oral agents.

• If a patient with hypertensive urgency is not hospitalized, outpatient follow-up should be arranged within 24 hours.

• The initial treatment goal is to decrease mean arterial pressure (MAP) 10% to 20% in the first one to two hours with further gradual reduction over the next 24 hours.

• Lowering BP excessively may decrease cerebral perfusion and could precipitate a stroke.

• A patient who has aortic dissection, unstable angina, or signs of MI must have the SBP lowered to 100 to 120 mm Hg as quickly as possible.

• Antihypertensive drugs include vasodilators, adrenergic inhibitors, esmolol hydrochloride, and the ACE inhibitor enalaprilat sodium (Vasotec). Sodium nitroprusside is the most effective parenteral drug for the treatment of hypertensive emergencies.

• Regular, ongoing assessment (e.g., ECG monitoring, vital signs, urinary output, level of consciousness, visual changes) is essential to evaluate the patient with severe hypertension.

• Once the hypertensive crisis is resolved, it is important to determine the cause. The patient will need appropriate management and extensive education to avoid future crises.