Tag Archives: cognition

Unpacking of Expertise Contributes to Effective Simulation (Education) Design

shutterstock_188725688aPart of the challenge in creating any simulation-based learning encounter is the interactions that occurs with subject matter experts to serve as a source that helps to guide the design of the event. The challenge lies within the fact that as healthcare providers ascend to a position of expertise many of their thoughts and approaches to the clinical situation at hand undergo automaticity in terms of the way decisions are made or procedures are executed. No longer does an experienced surgeon think step-by-step on how to create a knot. They rely on muscle memory, experience and packaged expertise to complete the task. DeconstructionOfExpertiseSimilarly, a skilled diagnostician will often identify a clinical condition or stratification of the level of criticality of a patient seemingly by intuition that can occur in a brief encounter. But it is not luck or intuition. It is the honed art of observation combined with a stepwise knowledge stratification process combined with experience that has been integrated over time and bundled, or packaged, into what we call expertise.

Getting the experienced healthcare provider to unpack their expertise into tangible stepwise learning events can be the key to creating effective educational encounters. More simply put, aligning the mind of the expert to walk in the shoes of the novice and try to recall their own experiences as novices will help to create more effective learning counters. It is quite difficult for experts in areas of complex cognition or psychomotor skill areas (healthcare) to relate to the needs of the junior learner.  The junior learner who is on the journey to expertise has varying needs for granular application of individual pieces of learning along with the experience and mentoring that allows the connection of seemingly disparate small chunks of information into a fluid situation that allows for analysis and application of the final product (i.e. the delivery of healthcare).

This unpacking of expertise can effectively be carried out by ensuring that curricular activities address the need of learning and multiple stages of progress. Similarly, it is often a successful practice to combine several different individuals, perhaps with different vantage points with regard to levels of proficiency and even core expertise. This promotes a design environment that promotes a successful deconstruction of an expert situation into a series of tasks that require competence in component form, integration, practice and implementation. This is exceptionally true in healthcare where there is great variability in the process of acquiring information, analysis and affecting treatment that will be eventually rendered for a given patient for a given situation. I.e. in healthcare there are often times that there are many right answers.

There are several structured method of Hierarchical Task Analysis (HTA) in the literature that are used in various forms in many different industries. The essential underlying element of the HTA is the breaking down complicated situations into their component forms. This is a method that while time-consuming, can lead to effective strategies to build learning platforms, and in particular help guide the creation of assessment tools in simulation to help promote formative step-wise learning toward expertise. While this discussion is focusing on simulation, conceptually this applies to all aspects of education design in healthcare that will likely help us increase the efficiency and effectiveness of our programs.  After all isn’t simulation a subset of healthcare education? Now there’s a concept worth remembering!

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Extra Cognitive Processing Associated With Simulation – The Cognitive 3rd Space

This is a concept I’ve observed over the years. In the design and conducting of simulation we as facilitators and faculty members develop a shared mental model in what we see in a simulated environment, how we act in a simulated environment, aCognitiveGuynd how we anticipate that our trainees will act in the simulated environment.

Embedded in the latter assumption is what I call the cognitive 3rd space of simulation. Conceptually this refers to the fact that participants of simulation in healthcare have a background thought process that is continuously assessing what they are seeing in the simulated environment and trying to decide what the facilitators are trying to indicate with the presence, and sometimes absence, of the various pieces of equipment, clinical finding replicas, and other accoutrements of the environmental stimulus associated with simulation. In other words there is a continuous background thought process trying to figure out is this that I am seeing supposed to be simulated or not.

In the real clinical environment where healthcare providers are gathering data from interviews, observations, physical examinations, test results etc. that feed into the eventual analysis which leads to a decision-making plan. This cognitive 3rd space associated with simulation is the fact that this continuous reconciliation of “what are they trying to simulate for me?” question that is continuously active in the mind of the trainees during simulation encounter in addition to the traditional process of data gathering analysis and treatment planning associated with the provision of real healthcare.

The degree of which a participant manages this third space is multifactorial and relates to many things including experience in the simulated environment, the orientation, the environment itself, their own confidence as well as the degree of buy-in that they have for the overall experience.

Reconciling this requires us to make a conscious understanding that when we provide stimulus in the simulated environment it may or may not be interpreted by the participant of simulation in the same way that it was intended. Helping to control the potential variation and confusion that can result from this is embedded into the design of our simulations, briefings and orientation, equipment selection and the interactions that go on between participants and facilitators of simulation events.

A variant to this also relates to the environmental set up of the simulation space. Participants are often focusing on “clues” in the surroundings of the simulated clinical environment. For example, if they notice an intubation set up on the bedside tray table they may think “this scenario requires an intubation.” While in the simulation they may or may not perform an intubation in the patient as a result of the observation, however this thought process or separate thread of thought is extramural to the normal cognitive processing that might go on in caring for a real patient.

As designers of simulations we must work to ensure that try to keep this interpretive grey zone minimized. This often runs afoul of the desire for many who try to recreate reality and go onto to develop the theatrics of simulations with clever remedies that may actually introduce further confusion into the mindset of the participant. The result may be an impediment in the ability to evaluate the performance in terms of the ability of the decisions to translate to the real care environment.

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