Highlights
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Cognitive Load Theory is an important element to consider to maximise learning.
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Specific evidence based instructional design methodologies can be utilised to develop the curriculum.
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Educators need to consider faculty education and development to enhance program maturity.
Educational Aims
The reader will come to appreciate that:
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Cognitive Load Theory is an important element to consider to maximise learning.
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Specific evidence based instructional design methodologies can be utilised to develop the curriculum.
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Educators need to consider faculty education and development to enhance program maturity.
Abstract
Simulation based education (SBE) is an educational tool increasingly used in the approach to the initial and ongoing education of healthcare professionals. Like all education tools, SBE needs to be used appropriately to achieve the desired outcomes. Using Cognitive Load Theory (CLT) in the instructional design of simulations is essential to maximise participant learning by reducing extraneous load and optimising intrinsic load. Educators can modify task fidelity, task complexity and instructional support to optimise learning. Specific methodologies can be used in program design such as rapid cycle deliberate practice, round the table teaching, low dose high frequency and flipped classroom. Fidelity and authenticity are important factors to consider when choosing design elements to ensure learner engagement, but not to overwhelm cognitive load. An integral part of SBE is the feedback or debriefing component. Several evidence-based methodologies can be employed to facilitate post simulation learning, including Debriefing with Good Judgement and PEARLS. Educators also need to consider faculty education and development, such as the discovery, growth and maturity model.
How to deliver effective paediatric simulation based education.
Simulation based education (SBE) is an educational tool increasingly used in the approach to the initial and ongoing education of healthcare professionals. Like all education tools, SBE needs to be used appropriately to achieve the desired outcomes. Der Sahakian et al. have proposed a 5-step methodology to build training programs: ADDIE (analysis, design, development, implementation, evaluation) .
The Boston Children’s Hospital Simulation program has been at the forefront of paediatric simulation worldwide. Roussin and Weinstock acknowledge the volume and complexity of SBE and have identified five major issues: 1) supporting both single and double loop learning experiences, 2) managing the training of simulation teaching faculty, 3) optimising the participant mix to ensure learning, 4) balancing in situ, node-based and centre-based delivery, and 5) organising research and measuring outcomes. They describe how the development of four SimZones can help alleviate these problems ( Table 1 ).
| Zone | Scope |
|---|---|
| 0 | Practiced by individual learners, with auto feedback and may include virtual reality skills practice. |
| 1 | Foundation Instruction, with procedural skills workshops or clinical orientation using pause and correct feedback from instructors |
| 2 | Acute Situation Instruction, with acute situational training or mock codes. Feedback is generally after uninterrupted action |
| 3 | Team and System Development, with crisis team training, human factors development and facilitator guided reflection and development at post event debriefing. Zone 3 uses the full native team |
| 4 | Real life debriefing and development |
Theories
Cognitive load theory
Cognitive Load Theory (CLT) describes the role of working memory in learning, where working memory is limited in quantity and duration when processing novel information. When working memory becomes overwhelmed learning is impaired. There are three components of CLT: Intrinsic load (IL), Extraneous load (EL) and Germaine load (GL), ( Fig. 1 ). IL is the load inherent to the task itself, a function of task complexity, prior knowledge, and the number of information elements in working memory. EL is imposed by instructional design, the environment or personal elements external to the learning task and should be minimised. In simulation ineffective case design, poor instructions and environmental factors contribute to high EL. GL comes from deliberate use of cognitive strategies for learning and should be maximised by providing tasks with appropriate complexity, enhancing schemata formation and transfer of knowledge from short to long term memory .
IL can be optimised by bringing previously processed, organised and stored information from long term into short term memory in the form of schemata. These elements do not take up the short-term memory space as they are already learnt and can be automatically applied. EL can be minimised by specific techniques such as worked example effect (e.g. ‘call for help’ in simulation), reducing split-attention effect and use of a dual modality effect of simultaneous visual and auditory instruction. The expertise reversal effect states that the best instructional format changes with expertise and in simulation an instructional design beneficial to a novice leaner may be detrimental to an expert, and vice versa .
Emotion is also an important factor in CLT. Emotions in simulation can be a result of the patients’ outcome, peer pressure, frustration with the simulation environment and self-monitoring and increased EL. Emotions can also be part of the instructional design, e.g. breaking bad news, and be a part of the IL. Stress, the biological and emotional responses when encountering a threat that one feels that they don’t have the resources to cope with, has a complex relationship to learning and performance. Stress can cause a reduction in the size of working memory, consistent with a EL effect. A degree of stress is beneficial for memory consolidation and directly related to the task, however retrieval is impaired. Achievement emotions are also an important factor in simulation and directly linked to learning, instruction and performance. Pekrun’s control value theory suggests these emotions arise from a cognitive appraisal of the controllability of success or failure and the value of this assigned by the learner. Examples of this in simulation include joy with a successful outcome or frustration with an unrealistic manikin and the perceived attitudes of peers or faculty effects the value assigned by the trainee. Therefore, from a CLT perspective creating a ‘safe learning environment’ is imperative .
A systematic review of simulation design features and novice health care professionals cognitive load showed that cognitive load was reduced by pre-briefing, feedback during or after the simulation, repetitive practice (repeating the same simulation), repeated exposure to simulation education and increased time allowance. An increase in cognitive load was found with technology based instruction, use of high fidelity manikins and debriefing .
Leppink and Van den Heuvel describe six strategies to reduce extrinsic load: use worked examples, use completion tasks, start with non-specific goals, avoid split attention, respect modality boundaries and avoid redundancy. They also discuss optimising intrinsic load by gradually increasing task complexity and task fidelity and emphasise that learning, and assessment are two sides of the same coin, where assessment criteria can influence learning for the better. They suggest a three-dimensional cube: task fidelity (all the way from literature to real patients), task complexity (the number of information elements in a task), and instructional support (all the way from worked examples to autonomous problem solving). These three dimensions together constitute three steps to proficient learning: (I) start with high support on low-fidelity low-complexity tasks and gradually fade that support as learners become more proficient; (II) repeat I for low-fidelity but higher-complexity tasks; and (III) repeat I and II in that order at subsequent levels of fidelity ( Fig. 2 ).
There are three major clinical skill acquisition models: Dreyfus and Dreyfus , Simpson and Harrow and Kovacs .
Dreyfus and Dreyfus have five skill levels: novice, competence, proficiency, expertise and mastery. As learners progress mental processes change: recollection changes from non-situational to situational, recognition from decomposed to holistic, decision from analytical to intuitive and awareness from monitoring to absorbed.
Simpson and Harrow have five levels of psychomotor skills: guided response, mechanism (where skills have become habitual), complex overt response, adaptation and originating (where the learner can create new movement patterns for new situations).
The four steps of Kovacs procedural skills training are: Learn, See, Practice, Do – on patients.
Sawyer had built on the principles of these and developed a six step pedagogical framework for procedural skills straining: Learn (didactic knowledge acquisition), See (observation of the procedure), Practice (psychomotor skill acquisition on a simulator), Prove (trainee to prove mastery in simulation before moving onto patients), Do (perform procedure on patient sunder supervision) and Maintain (Continued clinical practice or simulation) .
Rapid cycle deliberate practice
“Rapid Cycle Deliberate Practice” (RCDP) is a SBE approach initially described by Hunt et al . RCDP focuses on rapid acquisition of procedural and teamwork skills, with learners receiving direct feedback and being encouraged to repeat the skill or scenario. The model works by adding new skills to each subsequent scenario and allowing participants to practice previous skills each time. Participants receive feedback in the scenario, rather than a debrief afterwards. RCDP was evaluated in paediatric residents leading a paediatric simulated arrest 3 months after initial RCDP training and resulted in nearly 80 % retention for overall PALS performance at the 3 month interval . Won et al. compared RCDP to post simulation debriefing (PSD) in a simulated paediatric resuscitation 1–12 months post initial training and showed that participants in the RCDP group had 5 times the odds of achieving defibrillation than those in the PSD group. The RCDP group also had a higher mean Resident Team Leader Evaluation Score . Yan et al. evaluated the effect of RCDP on primary and secondary survey skill retention in real paediatric trauma patients. The RCDP showed improved primary and secondary surveys, compared to controls, most notably within the domains of breathing, circulation and disability . RCDP has also been implemented in PICU and a 3-phase run: debrief cycle was evaluated on a simulated cardiac infant. Evaluation showed significant improvement in completion of time sensitive tasks by the third replay, such as appropriate fluid administration, vasoactive agent management, ventilator adjustment, and calcium and sodium bicarbonate administration .
Round the table
Round the table teaching combines clinical skill acquisition with scenario-based teaching in a low fidelity simulation environment. It is designed for interdisciplinary small groups and allows scaffolding of clinical skills, practiced by everyone before moving onto the next step, in a scenario format. Like RCDP, this method can be used several times in a single session to gain benefits of repetitive practice. Fig. 3 illustrates the methodology using the RESUS4KIDS course as an example .
Low dose high frequency simulation
A Norwegian study on newborn resuscitation comparing low dose high frequency insitu simulation, after an instructor led initial session, with as desired training showed no difference in performance between the two groups at nine months. The authors discuss that the frequency of the repeat practice may not have been enough to show a benefit. This study also shows, despite follow up practice, there is still skill loss over the study period . The “Helping Babies Breath” program added 3–5 min weekly on site simulation training to the standard one day training course and showed improved outcomes in management and neonatal mortality .
A recent systematic review by the ILCOR group on spaced learning versus massed learning in resuscitation reported improved performance with the use of spaced learning. There was a lack of data on the effectiveness of spaced learning on skill acquisition compared to maintaining skill performance and/or preventing skill decay. The review concluded that spaced learning could improve skill performance at 1 year post course conclusion .
Flipped classroom/E-Learning
Video based instruction (VBI) has been shown to be superior to conventional lecture approach in simulated neonatal life support. The authors suggest this may be due to observational learning increasing self-efficacy, repetition of key messages and peer demonstration in the video. VBI may also be more cost effective, reducing requirement for expensive instructors, less time consuming and enable a standardised and perfect demonstration compared to a live demonstration .
Virtual reality simulation (VRS) by novices in fibreoptic bronchoscopy allowed earlier achievement of a learning plateau than by training on a manikin .
E-learning alone has been shown to improve participants knowledge and competence in simulated paediatric CPR. Evaluation of the RESUS4KIDS E-learning package has shown an improvement in Basic Life Support, 58 % for medical students, 51 % for doctors and nurses; as well as advanced life support (ALS), 80 % improvement for medical students and 57 % for doctors and nurses. Significant improvements were also seen in time to rhythm recognition and first defibrillation .
Blended learning, defined as a combination of virtual or online education strategies with traditional face to face strategies, is often combined with SBE. This has several advantages including knowledge acquisition prior to the SBE so that clinical reasoning can be the focus of the SBE rather than knowledge, standardised learning that is freely available, reduces the face-to-face time as knowledge is covered prior to the SBE, knowledge test can occur as part of the prelearning. Examples of well-established courses using this approach include RESUS4KIDS and APLS .
Procedural skills
The Society for Academic Emergency Medicine Simulation Based Procedural Training (SBPT) workgroup has identified 13 challenges in the three domains of learner, educator and curriculum. They identified six challenges within the learner domain as most important and eleven ‘special treatments’ for mitigating the impact of these challenges ( Table 2 ).
| Important challenges in SBPT | Mitigation strategies for SBPT |
|---|---|
| Maximising active learning | Experiential learning theory |
| Maintaining learner engagement | Socratic questioning |
| Embracing learner diversity | Psychological fidelity |
| Optimising cognitive load | Andrology |
| Promoting mindfulness and reflection | Social learning theory |
| Emphasising deliberate practice for mastery learning | Peer assisted learning and near-peer assisted learning |
| Cognitive load theory | |
| Zone of proximal development and flow | |
| Mindfulness and growth mindset | |
| Reflective practice | |
| Mastery learning | |
| Deliberate practice |
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