Cognitive Load Theory for Workplace Learning: A Scoping Review of Studies from Diverse Professions

1. Cognitive Load Theory for Workplace Learning: A Scoping Review of Studies from Diverse Professions Justin L. Sewell, MD, MPH1, Lauren A. Maggio, PhD, MS(LIS)2, Olle ten Cate, PhD1,3, Tamara van Gog, PhD3, John Q. Young, MD, MPP, PhD4, Patricia O’Sullivan, EdD1 SDRME Meeting May 2018 1University of California San Francisco 2Uniformed Services University of the Health Sciences 3Utrecht University 4Hofstra Northwell School of Medicine

2. Cognitive Load TheoryAtkinson-Schriffin Model of Human Memory Sensory memory Long-term memory Working memory Sweller J. Cogn Sci 1988. Figure adapted from Young JQ. Med Teach 2014.

3. Three types of cognitive load Intrinsic load Task complexity Learner knowledge and experience Match Extraneous load Learning environment Instructional design Minimize Learner effort and metacognitive skills Germane load Optimize

4. Cognitive load & working memory Working memory overloaded – no space for germane load Extraneous load Intrinsic load Space available for germane load Extraneous load Intrinsic load Germane load Adapted from Young JQ. Med Teach 2014.

5. Prior reviews of CLT in HPE

6. How can CLT inform HPE workplace teaching? Factors unique to the workplace • Substantial complexity and element interactivity • Fast-paced • Multiple simultaneous tasks • Urgent, emergent, crisis situations • Internal challenges • Emotional response to patient illness • Discomfort with professional role • Less controllable than classroom • Numerous distractions • Learners are not the only stakeholders

7. Systematic review questions • How do studies of cognitive load, mental effort, and mental workload in workplace settings inform, contribute to, or conflict with, theoretical tenets of CLT? • What practical implications for workplace teaching, curricular design, and educational research in the health professions can be drawn from included studies? • How has study of CLT differed in health professions versus non-health professions settings, and what lessons can be learned from these differences?

8. BEME-approved scoping review1 protocol • Identify research question • Identify relevant studies • Select studies for inclusion • Chart the data • Collate, summarize and report results • Consult with stakeholders 1Arksey and O’Malley 2005

9. Identifying relevant studies • Primary constructs: CLT and workplace learning • Eight databases: PubMed, ERIC, PsycINFO, CINAHL, Scopus, Web of Science, IEEE Xplore, Google Scholar • Search run 03/14/2016, rerun 07/21/2017 • Hand-searched references from included studies and several review articles • Did not hand-search conference proceedings

10. Example search from PubMed ("cognitive load" OR "cognitive load theory" OR “mental effort” OR “mental load” OR “human channel capacity” OR “mental workload”)AND(“education, professional” OR “professional education” OR education [sh] OR educat* OR training OR trainee* OR students [mesh] OR student* OR learner*)

11. Selecting studies • Two authors independently reviewed titles and abstracts, then simultaneously reviewed full texts • Differences reconciled by consensus or with assistance

12. Inclusion criteria

13. Charting the data Publication characteristics Profession and training level Sample size Methodology CL measurement Outcomes Theory integration1 • Data doubly extracted • Differences adjudicated 1Kumasi 2013

14. Collating, summarizing, reporting • Characteristics of included studies summarized • Knowledge synthesis: • Each author coded “implications for workplace learning” and “implications for CLT” • JLS iteratively reviewed to develop initial set of topics/themes organized around CLT aims  revised and refined through discussion • Developed set of ‘best practices’

15. Stakeholders • Expertise of authors, BEME protocol reviewers, BICC team

16. Search results • 7,098 references • 352 full texts reviewed • 116 studies included

17. Methodology of included studies (N=116)

18. Professions studied • 79% simulated, 21% actual workplace • Most had narrowly defined setting/task

19. Activities studied HPE studies Non-HPE studies Air traffic management Flight Ship navigation Teaching Police and solider training • Procedural skills • Cognitive skills • Clinical reasoning • Patient interviewing • Crisis management • Data interpretation • Home safety assessment • Electronic health record use

20. Variables studied • Outcome variables: CL, performance • Predictor variables: level of training or experience, task complexity • Few other covariates studied

21. Cognitive load conceptualization CL measured in 103 of 116 studies CL terminology When CL type not stated, inferred based on activity or intervention being studied NASA-TLX most common

22. Intrinsic load • Mostly used to compare two education approaches • Simple versus complex simulated tasks • Simulated versus authentic tasks • Higher intrinsic load associated with: • Less prior experience • Lower performance

23. How to match intrinsic load to learner level? • Use simulation for early learners (multiple studies) • Increase complexity based on experience (multiple studies) • Decision support system: reduced CL and errors, increased accuracy, among nuclear power plant operation trainees1 • Technology: heads-up display reduced pilots’ CL and improved performance compared with conventional display2 1Hsieh 2012 2Cummings 2009

24. Extraneous load • Extraneous load lower and performance* higher when: • Data displayed graphically rather than numerically (nursing1, critical care2 and helicopter piloting3) • Electronic health record formatting was improved (primary care, surgery, nursing4-6) • Tasks were standardized (aviation maintenance7, cardiac auscultation8, electrocardiogram interpretation9) • Work environment redesign to reduce disruptions (radiology10) • Teachers were confident and engaged (colonoscopy11) 1Doig 2011 2Workman 2007 3Dominessy 1991 4Saleem 2008 5Avansino 2012 6Shachak 2009 7Liang 2010 8Sibbald 2013a 9Sibbald 2013b 10Lee 2017 11Sewell 2017 *Not all studies measured performance

25. Extraneous load • Extraneous load higher and performance* lower when: • Simulations were of higher-fidelity (pharmacy medication dispensing1) • Contextual factors such as non-English speaking or emotionally volatile patients were present (clinical reasoning2) • Multi-tasking or time pressures were present (nurse operation of infusion pumps3, laparoscopic suturing4) • Distractions or disruptions were present (nurses dispensing patient medications,5 operating rooms6,7) • Tangential conversations occurred (operating room8) • Learners experienced negative emotions (aspirin overdose9, cardiac murmur auscultation10) • Learners were fatigued (colonoscopy11) 1Tremblay 2017 2Durning 2012 3Kataoka 2011 4Modi 2016 5Thomas 2017 6Weigl 2015 7Weigl 2016 8Gardner 2016 9Fraser 2014 10Fraser 2012 11Sewell 2017 *Not all studies measured performance

26. Germane load • Design of practice • Mixed or random better than blocked practice for simulated laparoscopic tasks1 and cardiorespiratory auscultation2 • Distributed versus massed practice – contradictory results • Design of teaching • More complex simulation for learners with adequate prior experience3,4 • Other strategies: situational awareness training5,6, self-explanation and asking clarifying questions7, teacher engagement with learners8, careful design of feedback9 1Chen 2015 2Shewokis 2017 3Tremblay 2017 4Dankbaar 2016 5Saus 2006 6Saus 2010 7Young 2016 8Sewell 2017 9Lee 2017

27. Practical suggestions • Curricular Design • Direct Teaching • Learning Environment • Metacognition

28. Limitations • No assessment of study quality • Missed studies • Publication bias

29. Limitations – Theory Integration1 • Theory dropping (superficial mention of CLT without citations to primary literature) • Theory positioning (limited discussion of CLT with citations to primary work) • Theory diversification (CLT and other theories discussed but relevance to study not well-articulated) • Theory conversation (CLT discussed in detail and relevance to study is evident, but CLT not integrated into the study design) • Theory application (employs CLT throughout to inform research design and data analysis) • Theory testing/verification (study designed specifically to test tenets of CLT) • Theory generation (seeks to alter or modify CLT) 1Kumasi 2013

30. Summary • CLT is relevant to workplace learning in the professions • Numerous elements in workplace environments may impose extraneous load • Approaches to match intrinsic load to learner level and to promote germane load warrant further study • Future research should address impact of CL on full, authentic workplaces with qualitative or mixed methods

31. Future questions for CLT in workplace learning • What contributes to cognitive load in professional workplaces? • Can learners and teachers recognize, articulate, and act upon cognitive overload? • Can learners de-prioritize or ignore sources of extraneous load? • Can we practically modulate complexity of non-simulated workplace learning (simultaneously for learners of different levels)? • Can we mitigate impact of negative emotion on cognitive load and learning?

32. Current status • BEME final signoff pending • Upload to Medical Teacher

33. Thank you to SDRME and mentorship team! justin.sewell@ucsf.edu