Professional healthcare students often need help understanding complex clinical concepts in a traditional didactic format. However, innovative teaching methods allow visual and kinesthetic learners the experiential opportunity to comprehend and apply these concepts to patient care using clinical simulation. Scaffolding the concept from didactic to skills lab, and then using clinical simulation assists the learners to comprehend the concept. This HealthySimulation.com by Teresa Gore, PhD, DNP, APRN, FNP-BC, CHSE-A, FSSH, FAAN, will explore innovative visual strategies for teaching complex clinical concepts through various modalities of clinical simulation. To learn more, join today’s webinar (or watch the recording) onHow to Increase Clinical Simulation Knowledge Retention with Scaffolding Cognitive Load Theory.
Theoretical Approach: Scaffolding – the Zone of Proximal Development and Cognitive Load Theory
Scaffolded learning is a theoretical approach that allows various approaches of learning activities to enable the learners to work from simple to more complex concepts and tasks. Consider this a step-wise approach to learn the parts and place them together to form the whole concept. Vygotsky’s Zone of Proximal Development and Scaffolding is the difference between what a learner can do independently and what requires external learning facilitation. Our job as educators and facilitators is to build upon previous learning and scaffold in more complex concepts to develop critical thinking and comprehension.
Scaffolding helps the learner to use the available resources to assist with their learning. This allows them to learn what to consider to prioritize needs and actions. This promotes the learner to develop higher thinking processes and guides them to use self-assessment during learning. The principles discussed apply to incorporating multiple approaches to facilitate learning. The Zone of Proximal Development, developed by the Russian psychologist Lev Vygotsky, is particularly relevant to healthcare education, especially simulation education. The Zone of Proximal Development is crucial for understanding how learners acquire new knowledge and can be defined as the space between what a learner can do without assistance and what a learner can do with adult guidance or in collaboration with more capable peers (Vygotsky, 1978, p. 86).
The Zone of Proximal Development highlights that learners are dynamic in their abilities and can grow when provided with the proper support and scaffolding. Educators must assess the learners’ current level of competence and understand what they can do independently and when they require additional resources and mentoring to learn. Scaffolding is provided through prompts, visual aids, kinesthetic opportunities, and facilitation to manage the cognitive load.
Cognitive Load Theory aims to optimize learning by managing the cognitive load on working memory, which has limited capacity. It involves three types of cognitive load: Intrinsic Load – The complexity inherent to the material; Extraneous Load – The unnecessary cognitive effort due to poor instructional design; and Germane Load – The cognitive effort used for learning and schema building (Sweller, 1988). By managing the intrinsic load (complexity) into smaller parts and a concrete experience, the learner can transfer the learning from short-term to long-term working memory. In healthcare simulation, the simulation educator can improve intrinsic load, minimize the extraneous load, and create a balanced germane load. This approach allows for more targeted learning to occur.
View the previous HealthySimulation.com CE Webinar Scaffolding Difficult Clinical Concepts into Healthcare Simulation Activities to learn more!
Application of Teaching Complex Concepts – Pneumothorax and Chest Tubes
One concept that undergraduate nursing students need help comprehending is the pathophysiology of a pneumothorax and how a chest tube works. As a didactic, clinical, and simulation educator, the struggle becomes how to identify the best way for a student to comprehend this information. The following case study will describe one approach used to address this situation.
At one university’s school of nursing, a needs assessment was conducted to identify concepts students consistently struggled with on standardized examinations. One of the items was pneumothorax with chest tube management. The clinical and simulation lab educators collaborated to determine how to provide the students with a scaffolding approach and a hands-on opportunity to manage the cognitive load of this concept to promote long-term and working memory.
During the didactic class, the chest tube and chest drainage system was taken into the classroom. A trifold poster board was developed to show the pneumothorax and where the chest tube would be placed to remove the leaking air. This poster board was displayed in the clinical/simulation lab for students to view after the didactic lecture. However, the grades on the standardized test did not improve with this intervention.
The perfect opportunity to collaborate with colleagues from multiple institutions through a four-hour pre-conference workshop at an INACSL Conference occurred which led to a potential solution. The workshop’s focus was to provide educators with opportunities to design simulation props to promote realism and teach ventilator use and gas exchange. A pig’s heart and lungs were purchased from a local meat packing facility for this. The educators were allowed to see how this could be used, when appropriate, at their facilities.
Within six months of the conference, I obtained a pig heart and lungs to practice. I discovered multiple concepts that could be taught. These were:
- Endotracheal tube cuff inflation – students could see what happens when the cuff is inflated and the consequences of overinflation
- Lungs drying out over time – not enough surfactant. So, the lungs were placed in a large plastic storage bag with spray cooking oil applied.
- Over time, the lungs dry out, and a pneumothorax or bleb occur
- Pneumothorax – students could see how limited space in the chest would cause heart displacement, trachea deviation, and less space for the functioning lung to inflate
- A chest tube was shown, and a discussion of where it would be placed and the results of the chest tube drainage systems with air leak
The students were very engaged and stated they could finally understand what was being discussed. By understanding what was happening, they would know what to assess the patient for. One of the adjunct clinical instructors with over 20 years of critical experience stated, “I understand a pneumothorax and chest tube on such a higher level now. That was impressive.” Additionally, the scoring on the pneumothorax and chest tube during the standard test improved.
The incorporation of a 3D-printed ribcage can enhance this experiential learning opportunity. This would elevate the experiential learning experience to demonstrate the restriction of the pneumothorax on the heart and functioning lungs. This is only one example of how to scaffold the learning.
Remember, simulation is only limited by the educator’s imagination and innovation. Simulation professionals are creative and love to push the envelope to enhance learning.
Learn More About Cognitive Load Management and Scaffolding in Clinical Simulation!
References:
- Sweller, J. (1988). Cognitive load during problem solving: Effects on learning. Cognitive science, 12(2), 257-285.
- Vygotsky, L. S. (1978). Mind in Society: The Development of Higher Psychological Processes.
- M. Cole, V. John-Steiner, S. Scribner, & E. Souberman (Eds.). Cambridge, MA: Harvard University Press.
