Abstract
High-fidelity simulation-based training, such as those aimed at teaching the management of medical crises, constitutes a highly complex learning task. To be effective, its design must be guided by sound learning principles. Cognitive load theory is a well-developed framework and has been extensively used in other settings to improve instructional designs in medical education. We explain this theoretical framework and its relevance to the educational design of high-fidelity simulation using as an exemplar the McGill University internal medicine crisis resource management learning activity. We then conclude with a few practical suggestions on how to apply cognitive load theory in the design of high-fidelity simulation-based learning activities.
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The authors report no conflict of interest, financial or otherwise.
Authors contribution
Simulation has been increasingly used in health professions education and is rapidly gaining traction as the preferred instructional methods for team training for high-stake situations such as response to medical emergencies. High-fidelity simulation allows training to occur in authentic context without harm to patients. However, the complexity of such authentic learning activity can be overwhelming for learners if it is not designed based on sound adult learning principles. Cognitive load theory is a well-known framework that has commonly be used to guide instructional designs in order to maximize learning. Though it can also be used to optimize learning outcome in simulation-based activities, example of its formal application to this setting is lacking in the literature. Our article explains the key principles of cognitive load theory, walks the readers through an exemplar application to these in real life, and then concludes with a brief list of practical suggestions on how to optimize simulation-based learning using this theoretical framework. Even though the exemplar we describe is one of health professions education, the principles of cognitive load theory can be applied to simulation-based learning in any discipline and setting.
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Appendix
Appendix
1.1 Description of the pulmonary embolism scenario
Four first to third year internal medicine residents are selected to form the team who will manage this medical emergency. Three more residents will be observing the case from outside the room through a one-way mirror. Two faculty debriefers will also be observing from outside the room. The case facilitator will be in the room when the scenario begins and will also role play the obstetrical nurse.
A sign is placed at the entrance to the simulation room with the following information: ‘You are the internal medicine residents on the Rapid Response Team in a community hospital. You are called to see a 32 year-old pregnant lady on the pre-partum unit.’ A high-fidelity mannequin (either Laerdal or METI) is used to simulate a 32 year-old female who is 29-week pregnant and critically ill from a massive pulmonary embolism (i.e. large blood clot in the pulmonary blood vessels obstructing blood flow). The simulation room is set up to mirror a typical obstetrical patient room and the resident team has access to the standard hospital equipment including the necessary equipment and medication for monitoring and stabilization of a critically ill patient. To better simulate real life practice, the resident team are also allowed to contact consultants in subspecialties (e.g. anesthesia) by phone. Standardized responses to these are designed to provide just-in-time procedural information (e.g. drug dosage).
As the resident team enter the room and engage in conversation with the obstetrical nurse, they learn that this patient was admitted 1 week ago for management of hypertension of pregnancy, and that they were called in because she was found by the nurse to have very low blood pressure. More information about the patient’s medical history, current symptoms and recent clinical progression are provided by the obstetrical nurse (i.e. the facilitator) and the patient (i.e. the simulation controller via speaker on the mannequin).
As soon as the residents attach the right monitoring device to the patient, vital signs appear on a screen next to the patient. All vital signs were pre-programmed to change in response to interventions by residents on a background of steady deterioration reflective of the natural progression of the disease process should there be no intervention.
The resident team have to seek and interpret information (e.g. blood test results, electrocardiogram tracings, chest X-ray film…) to arrive at the correct diagnosis of pulmonary embolism while working on stabilize the patient (e.g. giving intravenous fluid to increase blood pressure, intubating to protect airway as patient’s level of consciousness declines…). In addition to these technical skills, the team also has to demonstrate the crisis resource management (CRM) skills of leadership, problem solving, situational awareness, resource utilization and communication. An additional level of difficulty can achieved by introducing a standardized distractor whereby the obstetrical nurse draws the residents’ attention to deteriorations in fetal heart rate tracing and insists with increasing alarm on the need for urgent caesarian section.
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Sun, N.Z., Anand, P.A. & Snell, L. Optimizing the design of high-fidelity simulation-based training activities using cognitive load theory – lessons learned from a real-life experience. J Simulation 11, 151–158 (2017). https://doi.org/10.1057/s41273-016-0001-5
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DOI: https://doi.org/10.1057/s41273-016-0001-5