Working memory is limited: improving knowledge transfer by optimising simulation through cognitive load theory

When common cognitive biases impact debriefing conversations

Healthcare debriefing is a cognitively demanding conversation after a simulation or clinical experience that promotes reflection, underpinned by psychological safety and attention to learner needs. The process of debriefing requires mental processing that engages both "fast" or unconscious thinking and "slow" intentional thinking to be able to navigate the conversation. "Fast" thinking has the potential to surface cognitive biases that impact reflection and may negatively influence debriefer behaviors, debriefing strategies, and debriefing foundations. As a result, negative cognitive biases risk undermining learning outcomes from debriefing conversations. As the use of healthcare simulation is expanding, the need for faculty development specific to the roles bias plays is imperative. In this article, we hope to build awareness about common cognitive biases that may present in debriefing conversations so debriefers have the chance to begin the hard work of identifying and attending to their potential detrimental impacts.

The Transformative Teaching Framework: A roadmap for 21st century teaching

The US healthcare system has changed dramatically in the past several decades. Nursing education, conversely, has not. This disparity, with a widening academic-practice gap prompted The National Academies to call on nursing education bodies to lead transformational change in nursing education to create the entry level and advanced practice nurses needed in the 21st century healthcare system (Wakefield et al., 2021). The Publication of The Essentials: Core Competencies for Professional Nursing Education is the catalyst for this change. Revising curricula in nursing schools will not affect the changes needed without a transformation in how nurse educators approach their practice. The Transformative Teaching Framework provides a roadmap for faculty to embody their role differently. Adopting the new role of Faculty Coach, nurse educators cultivate a teacher-learner relationship grounded in the neuroscience of learning, relational and developmental actions aimed at the professional formation of clinicians, and mutual trust. The Transformative Teaching Framework has the power to guide faculty as they develop clinicians who can thrive in the 21st century healthcare system.

Augmented reality visualization for ultrasound-guided interventions: a pilot randomized crossover trial to assess trainee performance and cognitive load

BACKGROUND

Augmented reality (AR) technology involving head-mounted displays (HMD) represents a significant innovation in medical education, particularly for training in guided invasive procedures. Novice physicians often face challenges in simultaneously identifying anatomical landmarks and performing procedures when learning point-of-care ultrasound (POCUS). Our primary objective was to determine the effectiveness of AR in enhancing physician training for ultrasound-guided interventions using AR visual overlays. The secondary objective was to compare cognitive load between traditional ultrasound training settings and AR-assisted training settings.

METHODS

This randomized crossover study, conducted from 2021 to 2022, compared performance and cognitive load of trainees attempting accurate central venous catheter (CVC) placement using an AR-HMD to display ultrasound images (AR-US), compared with standard ultrasound without visual overlay (S-US). We enrolled 47 trainees, including 22 final-year undergraduate medical students and 25 postgraduate physicians (years 1-4) from three hospitals in Taiwan. All participants had basic training in US-guided CVC placement but lacked AR-US experience. Performance and cognitive load were assessed using time measurements and NASA Task Load Index (NASA-TLX), covering the dimensions of Mental-, Physical- and Temporal Demand, and Performance, Effort and Frustration.

RESULTS

We found AR technology reduced the time required for critical steps in CVC placement, while minimizing users' neck strain. Female and junior trainees using AR-US identified anatomy and localized veins faster than those using S-US. Using AR-US, female trainees significantly outperformed males in anatomical identification [mean difference (MD): -10.79 s (95% CI: -2.37 to -19.21)]. The NASA-TLX cognitive load assessment showed mental workload trending lower in all dimensions except performance while using AR-US, compared to S-US. Similarly, junior trainees' effort- and frustration scores were lower [MD: -2.73 (95% CI: -5.04 to -0.41) and -2.41 (95% CI: -4.51 to -0.31), respectively], as were female trainees' effort scores [MD: -3.07 (95% CI: -6.10 to -0.03)] when using AR-US, compared to S-US, whereby these differences were statistically significant.

CONCLUSIONS

AR technology helped improve trainee performance and reduced cognitive load during ultrasound-guided CVC placement. These findings support the application of AR technology to enhance physician training in ultrasound-guided interventional procedures, suggesting that AR-HMDs could be a valuable tool in medical education.

TRIAL REGISTRATION

The trial was registered with Clinicaltrials.gov on 20/09/2023 as a clinical trial, under the identifier NCT06055400.

Implementing a student-centered stroke intervention and prevention education program; evaluating motivation, cognitive load, and performance among middle school students

Background

In this study, we investigated the association between motivation, cognitive load, difficulty, and performance in a stroke education outreach program implemented for middle school students.

Methods

Various interactive instructional activities were developed to engage students throughout the program to assess cognitive and intrinsic load arising from learner implementation of various tasks in a stroke education program for middle school kids. Performance was measured using a post-test to assess knowledge gained by the 6th, 7th, and 8th-grade middle school students. A short questionnaire was also administered to collect data on students' motivation using the ARCS model to asses attention, relevance, confidence, and satisfaction. In addition, we evaluated difficulty level and cognitive load. The relationship between performance and motivation was assessed using Pearson's correlation.

Results

In our results, there was no significant difference (p > 0.05) in performance between the 6th, 7th, and 8th-grade students. The difference in performance, cognitive load (mental effort and difficulty), or motivation between the 6th, 7th, and 8 t-grade students was not significant (p > 0.05). The correlation between motivation and performance was significant (r = 0.87, p = 0.001), while the correlation between mental effort and performance was not significant (r = 0.34, p = 0.270). Also, the correlation between difficulty and performance was not significant (r = 0.38, p = 0.361). In the ARCS motivation model, attention, and confidence received the lowest mean scores (3.9), while relevance received the highest score (4.3).

Conclusion

Our findings reveal the importance of implementing novel activities to enhance students' motivation to improve performance in the implementation of stroke education outreach programs for middle school students.

Evaluating an obstetrics and gynecology teaching program for medical students incorporating simulation-based education underpinned by cognitive load theory

Although there have been previous publications on curriculum innovations in teaching O&G to medical students, especially utilizing simulation-based education, there have been none, as far as we know, incorporating and evaluating the outcomes using cognitive load theory. The aim of this article was to describe the introduction, implementation, and evaluation of an innovative teaching program in O&G, incorporating simulation-based education, underpinned by cognitive load theory. Cognitive load is defined as the amount of information a working memory can hold at any one time and incorporates three types of cognitive load-intrinsic, extraneous, and germane. To optimize learning, educators are encouraged to manage intrinsic cognitive load, minimize extraneous cognitive load, and promote germane cognitive load. In these sessions, students were encouraged to prepare in advance of each session with recommended reading materials; to limit intrinsic cognitive load and promote germane cognitive load, faculty were advised ahead of each session to manage intrinsic cognitive load, an open-book MCQ practice session aimed to reduce anxiety, promote psychological safety, and minimize extraneous cognitive load. For the simulation sessions, the faculty initially demonstrated the role-play situation or clinical skill first, to manage intrinsic cognitive load and reduce extraneous cognitive load. The results of the evaluation showed that the students perceived that they invested relatively low mental effort in understanding the topics, theories, concepts, and definitions discussed during the sessions. There was a low extraneous cognitive load. Measures of germane cognitive load or self-perceived learning were high. The primary message is that we believe this teaching program is a model that other medical schools globally might want to consider adopting, to evaluate and justify innovations in the teaching of O&G to medical students. The secondary message is that evaluation of innovations to teaching and facilitation of learning using cognitive load theory is one way to contribute to the high-quality training of competent future healthcare workers required to provide the highest standard of care to women who are crucial to the overall health and wellbeing of a nation.

Relationship Between Cognitive Load Theory, Intrinsic Motivation and Emotions in Healthcare Professions Education: A Perspective on the Missing Link

Cognitive Load Theory (CLT) is one of the key cognitive theories that have been used to assess learners' information and working memory load. CLT has been applied to Simulation Based Education (SBE) and optimizing instructional design. However, a challenge that occurs is that these high-fidelity simulations and mannequins of critically ill patients can elicit negative emotions in learners which can unfavorably impact the learning process. There is also a potential for cognitive overload if the simulation is more authentic and requires more dynamic interactions and lead to high levels of anxiety due to a novel learning environment, which can also have detrimental effects on learning process. Hence, it is critical for health professional educators (HPE) to know how to minimize cognitive load to improve learning as a professional in a workplace setting. The literature on the role of emotions, intrinsic motivation, cognitive load is scarce in HPE literature. Specifically when not being studied together at once since they move dynamically together and affect the learning for the learner. Therefore, the purpose of this perspective paper is to cover the gap in the literature and propose a framework and recommendation for future HPE research.

Embedding patient safety in a scaffold of interprofessional education; a qualitative study with thematic analysis

BACKGROUND

Regardless of a proliferation of interest in reducing unsafe practices in healthcare, threats to patient safety (PS) remain high. Moreover, little attention has been paid towards the role of interprofessional education (IPE) in enhancing PS. This qualitative study was conducted to unfold the insights of the senior medical, dental and health sciences students at the University of Sharjah (UoS) in the United Arab Emirates (UAE) about PS in an online IPE-based workshop.

METHODS

This inductive thematic analysis study was conducted on senior medical and health students at the Colleges of Medicine, Dental Medicine, Health Sciences, and Pharmacy of UoS. During an online workshop, students discussed plausible solutions for four real practice-based clinical scenarios with elements of unsafe healthcare practices. During the breakout rooms, the students exhibited high level of articulation and proactively participated in discussions. The data from the online workshop were transcribed and then coding, categorizing, and labelling of recurrent themes were carried out. Multiple individual deliberations, consolidation, incorporation of the identified preliminary themes, and merging and reorganizing sub-themes led to a final thematic framework.

RESULTS

This work delved into the perspectives of 248 students regarding teamwork, communication, problem-solving, and other aspects concerning PS in interprofessional settings in an online workshop. The iterative process of data transcription, curating and qualitative analysis surfaced 32 codes. Later, the inductive themaric analysis yielded five themes with distinct yet interconnected nested subthemes in the context of PS in IPE settings. These themes of information sharing and grounding (problem-solving, social skills), maintaining communication (clinical reasoning, shared mental model), executing interprofessional activities (collaborative practice, collaboration scripts), professional cognitive abilities (cognitive maturity, metacognition), and negotiating professional identities (systematic change, socio-economic scaffolding) emerged as fundamental pillars for enhancing PS in healthcare.

CONCLUSION

Our study demonstrated the outcome of an innovative and team-based workshop which embedded PS within a scaffold of IPE environment. This research calls for incorporation of the emerging areas of clinical reasoning, problem solving, collaborative practice, and shared mental model into medical curricula for structured IPE in improving PS domains in medical education. These findings underscore the need for multifaceted dimensions of IPE imperatives for cultivating collaborative competence.

Developing a virtual reality (VR) application for practicing the ABCDE approach for systematic clinical observation

BACKGROUND

The Airways, Breathing, Circulation, Disability, Exposure (ABCDE) approach is an international approach for systematic clinical observation. It is an essential clinical skill for medical and healthcare professionals and should be practiced repeatedly. One way to do so is by using virtual reality (VR). The aim was therefore to develop a VR application to be used by inexperienced health students and professionals for self-instructed practice of systematic clinical observation using the ABCDE approach.

METHODS

An iterative human-centred approach done in three overlapping phases; deciding on the ABCDE approach, specifying the requirements, and developing the application.

RESULTS

A total of 138 persons were involved. Eight clinical observations were included in the ABCDE approach. The requirements included making it possible for inexperienced users to do self-instructed practice, a high level of immersion, and a sense of presence including mirroring the physical activities needed to do the ABCDE approach, allowing for both single and multiplayer, and automatic feedback with encouragement to repeat the training. In addition to many refinements, the testing led to the development of some new solutions. Prominent among them was to get players to understand how to use the VR hand controllers and start to interact with the VR environment and more instructions like showing videos on how to do observations. The solutions in the developed version were categorised into 15 core features like onboarding, instructions, quiz, and feedback.

CONCLUSION

A virtual reality application for self-instructed practice of systematic clinical observation using the ABCDE approach can be developed with sufficient testing by inexperienced health students and professionals.

The influence of the simulation environment on teamwork and cognitive load in novice trauma professionals at the emergency department: Piloting a randomized controlled trial

INTRODUCTION

This pilot study aimed to test the feasibility of conducting a randomized controlled trial to examine how simulation environments (in situ versus laboratory) influence teamwork skills development and cognitive load among novice healthcare trauma professionals in the emergency department.

METHOD

Twenty-four novice trauma professionals (nurses, medical residents, respiratory therapists) were assigned to in situ or laboratory simulations. They participated in two 15-minute simulations separated by a 45-minute debriefing on teamwork. After each simulation, they completed validated teamwork and cognitive load questionnaires. All simulations were video recorded to assess teamwork performance by trained external observers. Feasibility measures (e.g., recruitment rate, randomization procedure and intervention implementation) were recorded. Mixed ANOVAs were used to calculate effect sizes.

RESULTS

Regarding feasibility, several difficulties were encountered, such as a low recruitment rate and the inability to perform randomization. Outcome results suggest that the simulation environment does not affect novice trauma professionals' teamwork performance and cognitive load (small effect sizes), but a large effect size was observed for perceived learning.

CONCLUSION

This study highlights several barriers to conducting a randomized study in the context of interprofessional simulation-based education in the emergency department. Suggestions are made to guide future research in the field.

Critical design choices in healthcare simulation education: a 4C/ID perspective on design that leads to transfer

BACKGROUND

Healthcare simulation education often aims to promote transfer of learning: the application of knowledge, skills, and attitudes acquired during simulations to new situations in the workplace. Although achieving transfer is challenging, existing theories and models can provide guidance.

RECOMMENDATIONS

This paper provides five general recommendations to design simulations that foster transfer: (1) emphasize whole-task practice, (2) consider a cognitive task analysis, (3) embed simulations within more comprehensive programs, (4) strategically combine and align simulation formats, and (5) optimize cognitive load. We illustrate the application of these five recommendations with a blueprint for an educational program focusing on simulation activities.

CONCLUSIONS

More evidence-informed approaches to healthcare simulation might require a paradigm shift. We must accept that a limited number of simulations is not enough to develop complex skills. It requires comprehensive programs that combine simulation sessions with workplace learning.

Impact of the PEARLS Healthcare Debriefing cognitive aid on facilitator cognitive load, workload, and debriefing quality: a pilot study

BACKGROUND

The Promoting Excellence and Reflective Learning in Simulation (PEARLS) Healthcare Debriefing Tool is a cognitive aid designed to deploy debriefing in a structured way. The tool has the potential to increase the facilitator's ability to acquire debriefing skills, by breaking down the complexity of debriefing and thereby improving the quality of a novice facilitator's debrief. In this pilot study, we aimed to evaluate the impact of the tool on facilitators' cognitive load, workload, and debriefing quality.

METHODS

Fourteen fellows from the New York City Health + Hospitals Simulation Fellowship, novice to the PEARLS Healthcare Debriefing Tool, were randomized to two groups of 7. The intervention group was equipped with the cognitive aid while the control group did not use the tool. Both groups had undergone an 8-h debriefing course. The two groups performed debriefings of 3 videoed simulated events and rated the cognitive load and workload of their experience using the Paas-Merriënboer scale and the raw National Aeronautics and Space Administration task load index (NASA-TLX), respectively. The debriefing performances were then rated using the Debriefing Assessment for Simulation in Healthcare (DASH) for debriefing quality. Measures of cognitive load were measured as Paas-Merriënboer scale and compared using Wilcoxon rank-sum tests. Measures of workload and debriefing quality were analyzed using mixed-effect linear regression models.

RESULTS

Those who used the tool had significantly lower median scores in cognitive load in 2 out of the 3 debriefings (median score with tool vs no tool: scenario A 6 vs 6, p=0.1331; scenario B: 5 vs 6, p=0.043; and scenario C: 5 vs 7, p=0.031). No difference was detected in the tool effectiveness in decreasing composite score of workload demands (mean difference in average NASA-TLX -4.5, 95%CI -16.5 to 7.0, p=0.456) or improving composite scores of debriefing qualities (mean difference in DASH 2.4, 95%CI -3.4 to 8.1, p=0.436).

CONCLUSIONS

The PEARLS Healthcare Debriefing Tool may serve as an educational adjunct for debriefing skill acquisition. The use of a debriefing cognitive aid may decrease the cognitive load of debriefing but did not suggest an impact on the workload or quality of debriefing in novice debriefers. Further research is recommended to study the efficacy of the cognitive aid beyond this pilot; however, the design of this research may serve as a model for future exploration of the quality of debriefing.

The consistency of the influence of pride and shame on cognitive flexibility: Evidence from ERP

This study uses simple tasks to induce self-conscious emotions and event-related potentials to investigate the effects of pride, neutral, and shame emotions on cognitive flexibility. The behavior results revealed that the switching tasks had a longer reaction time and a lower accuracy rate than the repetitive tasks. Furthermore, the reaction time was longer, and the accuracy rate was lower for individuals in the shame and pride emotions group than the neutral group. ERP results revealed that the switching task induced a larger P3 wave amplitude than the repetitive task. In addition, the P3 difference wave for pride and shame emotions was significantly smaller than that of neutral emotions. However, there were no significant differences in N2 wave. These findings imply that pride and shame may inhibit conversion ability and consistently affect cognitive flexibility. This consistency may be manifested in late decision-making tasks. Our finds provide a theoretical basis for management of students' pride and shame.

Fundamental underpinnings of simulation education: describing a four-component instructional design approach to healthcare simulation fellowships

Although in 2020, there are more than 120 healthcare simulation fellowships established globally, there is a paucity of literature on how to design fellowship programs most effectively, to equip graduates with the knowledge, skills, and attitudes of a competent simulation educator. Offering a systematic structure to approach simulation fellowship programmatic design may aid in better achieving program goals. In this manuscript, we present the application of the 4-component instructional design model as a blueprint to the development of Simulation Education Fellowships. We offer examples used at the NYC Health + Hospitals simulation fellowship to illustrate how the 4-component model informs fellowship program design which promotes the development of a simulation educator. This manuscript will provide a roadmap to designing curricula and assessment practices including self-reflective logbooks to focus the path toward achieving desired skills and shape future conversations around programmatic development.

Changes in performance during repeated in-situ simulations with different cases

Introduction

The aim was to describe changes in the performance of clinical actions, during repeated in-situ simulations with different cases, by teams of healthcare professionals with different experiences of the systematic clinical observation of deteriorating patients, after an introduction to the Airways, Breathing, Circulation, Disability, Environment/Exposure (ABCDE) approach.

Methods

A descriptive observational study was conducted of repeated in-situ simulations using a patient simulator (SimMan 3G), carried out by teams in a public nursing home (NH, least experienced), an out-of-hours general practice (OOH-GP) service and a hospital emergency department (ED, most experienced). The cases had similar clinical presentations but different underlying diagnoses unknown to the teams. Four blinded clinical experts independently assessed the simulations on the basis of transcripts, providing comments, an overall score and scores for the clinical actions.

Results

The assessors commented on the overall lack of a systematic ABCDE approach in the NH and OOH-GP in all simulations, while the comments for the ED concerned the choice of treatment. Across the teams, the overall score was highest in the first simulation and second highest in the third simulation. The team in the NH received low overall scores for all simulations, but the last simulation received markedly better scores on the clinical actions. The teams in the OOH-GP and ED had no such clear pattern in the scores for clinical actions and thus no indications of improvement with repeated simulations.

Conclusion

The observation in this study was that the overall assessment by the blinded assessors showed no consistent improvement in clinical actions from repeated in-situ simulations, and the teams did not seem to adhere to the ABCDE approach throughout the simulations. This indicates that the teams were not able to apply their newly acquired experiences of using the ABCDE approach from one case to another, different case.

Cognitive Load Theory for debriefing simulations: implications for faculty development

The debriefing is an essential component of simulation-based training for healthcare professionals, but learning this complex skill can be challenging for simulation faculty. There are multiple competing priorities for a debriefer's attention that can contribute to a high mental workload, which may adversely affect debriefer performance and consequently learner outcomes. In this paper, we conceptualize the debriefer as a learner of debriefing skills and we discuss Cognitive Load Theory to categorize the many potential mental loads that can affect the faculty debriefer as learner. We then discuss mitigation strategies that can be considered by faculty development programmes to enhance professional development of debriefing staff.

Twelve tips for integrating team reflexivity into your simulation-based team training

Due to increasing complexity in healthcare, clinicians must often make decisions under uncertain conditions in which teams must be flexible and process emerging information "on the fly" in order to adapt to changing circumstances. A crucial strategy that helps teams to adapt, learn, and develop is team reflexivity (TR) - a team's ability to collectively reflect on group objectives, strategies, processes, and outcomes of past and current performance and to adapt accordingly. We provide 12 evidence-based tips on incorporating TR into simulation-based team training (SBTT). The first three points elaborate on basic principles of TR, when TR can take place and why it matters. The following nine tips are then organized according to three phases in which teams are able to engage in TR: pre-action, in-action, and post-action. SBTT represents an ideal venue to train various TR behaviors that foster team learning and improve patient care.

Evaluation of cognitive load and emotional states during multidisciplinary critical care simulation sessions

BACKGROUND

The simulation in critical care setting involves a heterogeneous group of participants with varied background and experience. Measuring the impacts of simulation on emotional state and cognitive load in this setting is not often performed. The feasibility of such measurement in the critical care setting needs further exploration.

METHODS

Medical and nursing staff with varying levels of experience from a tertiary intensive care unit participated in a standardised clinical simulation scenario. The emotional state of each participant was assessed before and after completion of the scenario using a validated eight-item scale containing bipolar oppositional descriptors of emotion. The cognitive load of each participant was assessed after the completion of the scenario using a validated subjective rating tool.

RESULTS

A total of 103 medical and nursing staff participated in the study. The participants felt more relaxed (-0.28±1.15 vs 0.14±1, P<0.005; d=0.39), excited (0.25±0.89 vs 0.55±0.92, P<0.005, d=0.35) and alert (0.85±0.87 vs 1.28±0.73, P<0.00001, d=0.54) following simulation. There was no difference in the mean scores for the remaining five items. The mean cognitive load for all participants was 6.67±1.41. There was no significant difference in the cognitive loads among medical staff versus nursing staff (6.61±2.3 vs 6.62±1.7; P>0.05).

CONCLUSION

A well-designed complex high fidelity critical care simulation scenario can be evaluated to identify the relative cognitive load of the participants' experience and their emotional state. The movement of learners emotionally from a more negative state to a positive state suggests that simulation can be an effective tool for improved knowledge transfer and offers more opportunity for dynamic thinking.