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Technology-enhanced learning
in anaesthesia and educational theory
Katherine Kirkpatrick MBChB FRCA
Ralph James MacKinnon BSc MBChB FRCA
Technology-enhanced learning (TEL) is a spec-
trum of educational modalities within which a
real-life task, event, or experience is recreated
with the aim of providing a safe learning environ-
ment, for the acquisition of skills, knowledge, and
behaviours. Innovative features of TEL include
an emphasis on patient safety and collaborative,
inter-professional team working, with a focus
upon evidence-based, cost-effective equality of
provision to achieve clear learning objectives.
Anaesthetic teaching includes ‘hands on’
teaching in addition to the other traditional modal-
ities of lectures, workshops, scenario training and
role-playing. There is considerable evidence that
feedback is a key part of the learning experience,
in particular with respect to behavioural/human
factor training.
1
Human factors undoubtedly play
an important contributory role in the majority of
anaesthesia-related critical incidents and deaths.
One of the significant strengths of TEL is that it
allows us to evolve further upon the traditional
teaching modalities, particularly with respect to
feedback and reflective learning.
TEL modalities in anaesthesia
E-learning
E-learning usually refers to web-based inter-
active learning. E-learning allows learning at a
pace, time, and place desired by the learner and
has become increasingly widespread. This can
be used to develop knowledge before experi-
ence of new skills which can be applied
across the anaesthesia curriculum. E-learning
packages often contain self-assessment tools,
enabling learners to confirm understanding and
monitor progress. E-learning anaesthesia is a
joint initiative by the Royal College of
Anaesthesia and e-Learning for Healthcare. It
contains more than 750 curriculum-based
topics, catalogued by subject, in addition to
other useful learning resources. E-learning is
increasingly being used for mandatory training
and CME acquisition.
Video gaming and virtual immersive
worlds
Evidence exists for the use of video game tech-
nology to improve patient fitness, coordination,
anxiety and compliance with treatments since the
1980s.
2
It is also plausible that video game play
may improve practitioner skill by improvement of
hand–eye co-ordination. A virtual world is a
usually web-based computer system which allows
participants to explore a multimedia environment
using a graphic representation of themselves.
Second Life is one such system and contains edu-
cational packages applicable to anaesthesia.
3
Such
systems have relatively low running costs after the
initial outlay and application is virtually unlimit-
ed. Within the anaesthesia curriculum, such
systems could be used for scenario-based teach-
ing, allowing users to develop decision-making
and critical incident skills without the real-life
consequences.
Part-task trainers
There are a variety of simulators available to
learn dextrous tasks, such as fibreoptic intubation
and regional anaesthesia, allowing hands-on
training without the need for direct patient
contact and therefore improving safety. Part-task
trainers may have a particular application to
anaesthesia as there is a large skill base that the
anaesthetist in training must develop. A current
development of interest are haptic devices, that
feedback touch sensation, for example, the loss
of resistance experienced when one passes a
needle through a tissue plane, such as the liga-
mentum flavum.
Standardized patients and actors
The use of standardized patients has been a
part of undergraduate and postgraduate teaching
assessment for decades. Such simulations not
only assess clinical skills and decision-making
but also communication and interpersonal skills
Key points
Technology-enhanced
learning (TEL) is an effective
educational tool.
The added value of TEL
must be clearly mapped to
learning objectives.
Reflective learning is
integral to TEL.
Debriefing is a key
educational step to translate
learning into the clinical
arena.
Robust education design
and expert facilitation skills
are paramount.
Katherine Kirkpatrick MBChB FRCA
Specialist Registrar in Anaesthesia
Royal Manchester Children’s Hospital
Manchester
UK
Ralph James MacKinnon BSc MBChB
FRCA
Consultant Paediatric Anaesthetist
Department of Paediatric Anaesthesia
Royal Manchester Children’s Hospital
Central Manchester Foundation Trust
Hathersage Road
Manchester M13 9WL
UK
Tel: þ44 161 701 1263/þ44 161 701
1264
Fax: þ44 161 701 4875
E-mail: ralph.mackinnon@cmft.nhs.uk
(for correspondence)
263
doi:10.1093/bjaceaccp/mks027 Advance Access publication 21 May, 2012
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 12 Number 5 2012
&The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
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mapped to meet specific educational goals. The University of
Dundee have developed an Inter-professional Ward Simulation
Exercise
4
for use in junior doctor training. It is carried out in a
highly realistic ward setting and has remote viewing facilities,
allowing assessment of clinical ability and multidisciplinary col-
laborative practice, providing the opportunity for feedback and re-
flection on performance. Standardized patients are currently used
in the Fellowship examinations and enable development of com-
munication skills and multi-disciplinary team working.
Human patient simulation
There is evidence to support human patient simulators as effective
learning tools for the acquisition of new skills.
5
New high-fidelity
simulators use advanced technology, making the scenario more
true to life. Simulation is ideal for training for critical incidents
and emergency drills of both common and rare clinical scenarios,
with no risk to the patient or the learner. During simulated scen-
arios, there is the opportunity to freeze a situation, gain expert
advice, and rerun scenarios. There is also the opportunity of
instant feedback enriching simulation as a highly educationally
beneficial tool. The benefits are not only confined to clinical skill
development, but also the ability to work as part of a multi-
disciplinary team and develop non-technical skills or human
factors.
Learning theory
A core educational principle of TEL is the provision of a safe
learning environment rich in reflective learning where one can
scrutinize one’s own practice and further develop our taken for
granted assumptions/mental routines by learning through experience.
This is termed experiential learning. The educational model is self-
directed learning with the learner triggering meta-cognitional events
that by self-reflection may modulate changes in practice.
Key education and training drivers for TEL
Patient safety is the cornerstone of anaesthetic practice. A second
driver has been the decreasing exposure of anaesthetists to cases
due to recent working pattern changes and concerns regarding a
possible effect on competency in terms of both the acquisition and
retention of core skills. There are four stages of competency. Stage 1
is unconscious incompetence, when an individual neither knows
how to do something nor recognizes his/her deficit or has a desire
to address it. Stage 2 is conscious incompetence where the individ-
ual recognizes that he/she does not understand or know how to do
something but is yet to address the deficit. The third stage is con-
scious competence where the individual knows how to do some-
thing; however, demonstration of the knowledge requires a great
deal of conscious thought. Unconscious competence, the fourth
stage, is when an individual can perform a task without concentrat-
ing deeply. This stage can also be subdivided into the ability to
perform and not teach (kinesthetic competence) and ability to
perform and teach (theoretic competence). Competency is a key
stage of anaesthetic training; however, it is only a learning mile-
stone en route to becoming an expert, as shown in Figure 1.
6
Educational principles of TEL
A full discussion of all the aspects of educational theory behind
TEL is beyond the scope of this article. TEL educational interven-
tions are constructive; new experiences build upon previous knowl-
edge. Mallot and colleagues
7
re-emphasized that there is a ‘long
tradition of learning new generalisable clinical knowledge from the
patient at the bedside’. Moreover, the bedside is a common envir-
onment where mistakes are made in both the evaluation and man-
agement of clinical problems. Similarly, in theatre, patient’s
physiology provides the continual triggers for clinical cognition for
anaesthetists. Mallot and colleagues
7
identified bedside mistakes as
triggers for metacognition. Metacognition was defined by
Livingston
8
as ‘knowledge monitoring and strategic control over
cognitive processes by an executive level in intellect’. Mallot and
colleagues
7
highlighted patients and by extension human patient
simulators as heuristic entities, that aid in clinical discovery pro-
cesses and problem solving by experimentation.
The real-time responses of human patient simulators to inter-
ventions or lack of intervention, is a key asset to explore deficits in
knowledge by invoking metacognition. This facilitates the develop-
ment of management strategies by reflecting on the thought pro-
cesses and mental subroutines behind participant’s performances.
In this context, TEL can be effectively utilized in motivation-
dependent goal-based reflective learning. The underlying principles
include (i) goal-based learning, (ii) role-play, (iii) reflective
debriefing, and (iv) strategy formation. Motivation is a key compo-
nent of learning with human patient simulators; the optimal educa-
tional experiences will aim to build the self-motivation of the
participants to explore their knowledge, skills, behaviours, and
attitudes.
Educational experiences, usually in the format of simulation
courses (human patient simulators or part task trainers), use both
pedagogic and andragogic characteristics, as shown in Table 1,to
differing degrees. The aviation industry has evolved from didactic
pedagogic teaching practices to a simulator-based, highly reflective
andragogic approach. In addition, Helmreich and Foushee
9
demon-
strated that such an approach reduced risks markedly. TEL is an in-
nately social educational experience; many simulation courses
revolve around learning in groups of five, individually, or in teams
meeting new problems, solving them, and understanding how in a
social setting. This has particular resonance with respect to inter-
professional team training.
Role-play
For generations we have appreciated that situated learning, of
which role-play with simulators is only a modern-day example, is
a highly effective learning strategy that promotes memory
Technology-enhanced learning in anaesthesia
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retention. Anaesthetists are very well versed with role-play, the
advanced life support courses are an example of this. The role-play
component of TEL can be both strongly experiential and challen-
ging. Challenging in that it arouses but not threatens and challen-
ging in terms of logically solving problems, emotionally in
remaining calm and collected, and socially within a theatre team
construct. The high-fidelity theatre simulations can be extremely
realistic rehearsals of practitioner contexts that can stimulate learn-
ing. Moreover, the course scenarios are not constraint, but in a
state of free flux, there is no limit to how the participants respond
Fig 1 Dreyfus model of skill acquisition.
6
Table 1 The pedagogic and andragogic characteristics of simulation courses, modified from Mallot and colleagues
7
Pedagogic Andragogic
Facilitator directs learning—as a guide to learning Self-direction of learner is essential
Learner motivated by external pressures of reduced caseload exposure and
training and fears of consequences of failure
Learner motivated internally by self-awareness, self-confidence, and self-recognition. The
learning experience itself provides the opportunity to develop all of these further
Learning rigidly follows clearly signposted stages Learning is flexible and evolves following the actions or inactions of the learner, in real time
Learner advances along pre-formatted sequential events to reach a level that
he or she was informed about beforehand with course material
Learner continually triggers metacognitional events that by self-reflection, modulates changes in
practice
There is continual self-evaluation
Experience of the instructor drives the learning The learner drives the learning, the experienced facilitator guides
The learning experience is potentially so authentic that in itself it becomes a clinical experience
that promotes further self-confidence and self-actualization
Technology-enhanced learning in anaesthesia
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to the immediate physiological feedback from the simulators.
Safety cannot be overstated. The safety of the patient is obvious;
however, it is the safety of the participant that is paramount. The
participant must feel safe to make decisions and observe them
unfold clinically without the fear of harming the patient or feeling
self-inhibited in front of their peers or tutors. The importance of
trust to ensure such safety is vital if one is aspiring to transformative
learning by engaging both cognitive and affective cerebral domains.
The participant by virtue of being in a simulation training
session will be anticipating an impending crisis, with senses heigh-
tened. As the simulated patient clinically deteriorates, the learner
will experience initial stimuli as physiological parameters change
and alarms sound, then dependent on management strategies,
further stimuli both positive and negative.
The previously discussed clinical discovery and disease per-
spective mapping of Mallot and colleagues
7
is perhaps too simplis-
tic to explain a myriad of rapidly changing stimuli, of which many
can be deeply negative until interventions improve the situation.
The situated learning and constructivist theories described by Spiro
and colleagues
10
may provide a more in-depth understanding of
how the transformative learning occurs. It is conceivable that pre-
existing factual knowledge and experience could be reconstructed
rapidly by the course participants, after they have constructed an
understanding of what is evolving in front of them; however, one
must ask if this is the complete picture?
Reflective learning
Where is the reflection in TEL? One answer is within the group
debrief session that occurs after each simulation session. Rudolph
and colleagues
11
consider this the crucial step in the experiential
learning process, where participants integrate insights from direct
experience into behavioural changes in future actions. Debriefing
can be defined as ‘facilitator-led participant discussion of events,
reflection, and assimilation of activities into their cognitions produ-
cing long lasting learning’.
12
The underlying principle is for parti-
cipants to discuss with each other and discover as much on their
own as possible, guided by an appropriately trained and experi-
enced tutor. Central to a reflective debrief is the gathering of infor-
mation, analysis and evaluation of what happened, with synthesis
and construction of future strategies followed by active experimen-
tation once more. This concrete experiencing, reflective observa-
tion, abstract conceptualization, and active experimentation is
termed a Kolbian cycle.
13
Kolb
13
also emphasized that the com-
bination of actively experiencing, accompanied by intense emotion
promotes long-lasting learning. Emotion is a key element during
simulations and debriefs.
The creation of a bubble of safety, in which participants are
trusting of their environment and are able to express their thoughts,
is a key objective, for debrief facilitators. The level of facilitation
required to achieve self-awareness, self-reflection, and ultimately
self-confidence by debriefing is dependent on the facilitator recog-
nizing the level required for different participants. A number of
adaptations of the Kolbian reflective cycle exist. The Gibbs cycle
14
(Fig. 2) allows facilitated exploration by reflection on the individ-
ual thought processes that have determined whether to act or not
on specific triggers. Cowan
15
described reflection as ‘the bridge
from practical experiences to a potentially useful abstract general-
isation’. Building upon Schon’s
16
principles of reflection-in-action
and reflection-on-action, Cowan
15
added an anticipatory or
reflection-for-action and provided the following definitions.
Reflection-on-action: ‘the questioning and answering about learn-
ing development or experiences which occur once the event which
occasioned learning is complete’. Reflection-in-action: ‘is to de-
scribe relevant questioning and answering which occur in the midst
of action—very briefly or in a brief withdrawal from the process’.
Reflection-for-action: ‘to describe the questioning and answer-
ing about desired learning which occurs before the action in which
it is expected or hoped that such learning or development may
occur’. The use of reflection techniques exploring participant’s
frames (mental models based on previous experiences and learn-
ing) and emotions to close a performance gap related to predeter-
mined learning objectives is now well established in the healthcare
simulation arena.
Translation into the clinical arena
Ultimately, it is not what technology you use that counts, but what
the learner takes from it. TEL will at minimum allow self-
reflection and give the learner self-awareness and self-confidence.
There is evidence to support translation of learning into the clinical
area. A recent case– control study revealed that residents trained in
advanced cardiac life support using human simulation gave better
Fig 2 The Gibbs reflective cycle.
14
Technology-enhanced learning in anaesthesia
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clinical care during real-life emergencies than residents with no
simulation training.
17
Curricula mapping the value of TEL to anaesthesia
Modalities of TEL that provide an added value compared with
traditional teaching methodology can be ‘mapped’ against desired
learning objectives, for example:
- Knowledge acquisition
†E-learning
†Virtual immersive worlds
- Abstract skills acquisition
†Part-task trainer in an abstract setting
†Replication task of required psychomotor skills
- Contextualized skills acquisition
†Part-task trainer in a contextualized setting
- High-fidelity replication of real-life task/process
†Highest fidelity full-body simulator placed in highest fidelity
environment possible
The key will be to collaborate at a regional or national level to
produce high-quality evidence-based peer-reviewed educational
material, without re-inventing the wheel many times over.
Future of TEL in anaesthesia
There is already a diverse array of TEL modalities available, and
with future advances in technology, there will be increasingly
human-like simulators. TEL currently has an important role in
training. With clearly defined learning objectives, rigorous
evidence-based educational design and strong emphasis on the
expert facilitation, anaesthesia remains at the forefront of TEL
development.
Declaration of interest
None declared.
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