As the design architects of simulation scenarios, we must remain cognizant of our ability to have influence over the cognitive load of those experiencing our simulations in the role of learners.
When caring for patients in real life, we expend cognitive energy in doing so to ensure we make the right decisions to provide the absolute best care for every patient. We engage in critical thought processes, that guide our interpretation of the enormous number of facts surrounding each patient so we can make further decisions to provide various therapies, or advice to the patient.
When we design simulations for our learners, we are creating similar environments noted above that demand a significant amount of cognitive workload to be endured for the participant to successfully navigate the case and care the [simulated] patient. In addition, I argue that we are adding additional cognitive workload by subjecting someone to the simulated environment insofar as they are engaged in a conscious or perhaps subconscious pursuit of deciding what is simulated and what is not. I have previously written about this and dubbed it the cognitive third space of simulation.
Nonetheless, there is mental energy spent in the care of the patient as well as the interpretation of the simulation. We also must realize that our design choices inside of the scenario contribute to the adjustment of the cognitive load endured by the learner(s) associated with our simulations. It is important that we be deliberate in our design to ensure that we are allowing all involved to achieve the desired learning outcomes.
Some specific examples of this cognitive load influence may help to bring forth an understanding. Take a test result for example. If one looks in the electronic health record and sees the values reported for a simple test, like a basic metabolic profile (which consists of a sodium, chloride, potassium, CO2, BUN, creatinine and glucose) there is a certain amount of mental energy goes into the interpretation of the numeric data presented for each of the seven items of the basic metabolic profile. Some electronic health records may color-code the results to assist in the processing of normal versus normal, and some may not.
Such a decision involved in the human factors design of electronic health record actually influences the amount of cognitive spend on the interpretation of the given value. Further, as experienced clinicians are keenly aware, we must interpret the lab value in the context of the patient for whom the test has been ordered. What is normal for one patient, may not be normal for another. Thus, even in the interpretation of a simple test, there is a significant amount of cognitive process (critical thought) that should be applied.
How does this relate to simulation scenario design? We have the ability to engineer the scenario design to help the participants channel cognitive energy into those things that are important and away from those those things that are not. If we continue to run with the example of the basic metabolic profile as an example, we have choices on how said values are reported to the participants of our simulation.
We could have the participants look it up in the simulated electronic health record which takes time and cognitive processing as described above. We could give them a piece of paper or display the results on a screen demonstrating the seven values. This still takes significant cognitive processing to interpret the data. We could simply indicate that the basic metabolic profile result was “normal”. This method significantly decreases the cognitive processing associated with the seven values of the basic metabolic profile and how it is to be interpreted into the context of the scenario. Also, one could make the argument that we are offering subtle, or perhaps not-so-subtle clues to the case that the basic metabolic profile is not a major part of what needs to be processed in the care of this particular patient.
It is important to realize that all the examples above are viable options and there is not one that is superior to another. It is important that the decision is made during the design of the case that allows the participant(s) of the scenario to focus the appropriate cognitive spend on that which the designers of the scenario feel are most important. In other words, if it is part of the learning objectives that the participant should evaluate the actual values of the basic metabolic profile, then of course it would be appropriate to provide the requisite information at that level of detail. If, however, the results of the same test are perfunctory to the bigger picture of the case then one should consider a different mechanism of resulting values to the simulation participant.
A common misperception in the design of healthcare simulation scenarios is to try to re-create the realistic environment of the clinical atmosphere. While this is always a tempting choice, it is not without consequences. It comes from the mistaken belief that the goal of simulation scenarios is to re-create reality. Modern, successful simulationists need to recognize this outmoded, immature thought process.
In the context of a case where the basic metabolic profile is not significantly important that we should not design the “dance” (scenario) to include the steps of looking in the electronic health record and making determinations of the values associated with the test. It is a waste of time, and more importantly a waste of cognitive processing which is already artificially increased by the participant being involved in the simulation in the first place. It is in my opinion a violation of the learner contract between faculty and students.
While I am focusing on a simple example of a single test, I hope that you can imagine that this concept extrapolates to many, many decisions that are made in the scenario design process. For example, think about a chest x-ray. Do you result a chest x-ray as “normal”, “abnormal” or otherwise during the run time of the scenario? Or do you show an image of a chest x-ray and have your participants interpret the image? One answer is not superior to the other. It is just critically important that you evaluate what is best for the cognitive load of the learners involved in your scenario and how the decision relates to the details of the learning objectives you wish to achieve during the course of the simulation activity.
In moderate to complex cases associated with healthcare simulation the designer of the simulation, or architect, has a responsibility to craft the scenario to accomplish the learning objectives that are intended. In many scenarios, hundreds of decisions are made in terms of how participants extract data from the experience to incorporate into their performance of the simulation. It is critically important that as the designers of such learning events that we remain cognizant of the cognitive load placed upon our learner(s) that is associated with the normal care of patients, as well as the extra that is imposed upon them from participating in a simulation-based case.
Many of the decisions that we incorporate into the design of our scenarios have significant influence over this cognitive load, and the mental energy participants will spend to engage in the participation. We need to understand the impact of our choices and be deliberate with our design decisions to enhance the overall simulation-based learning process efficiency and effectiveness.