Cognitive Task Analysis Research Articles

Adapting Cognitive Task Analysis Methods for Use in a Large Sample Simulation Study of High-Risk Healthcare Events.

Cognitive task analysis (CTA) methods are traditionally used to conduct small-sample, in-depth studies. In this case study, CTA methods were adapted for a large multi-site study in which 102 anesthesiologists worked through four different high-fidelity simulated high-consequence incidents. Cognitive interviews were used to elicit decision processes following each simulated incident. In this paper, we highlight three practical challenges that arose: (1) standardizing the interview techniques for use across a large, distributed team of diverse backgrounds; (2) developing effective training; and (3) developing a strategy to analyze the resulting large amount of qualitative data. We reflect on how we addressed these challenges by increasing standardization, developing focused training, overcoming social norms that hindered interview effectiveness, and conducting a staged analysis. We share findings from a preliminary analysis that provides early validation of the strategy employed. Analysis of a subset of 64 interview transcripts using a decompositional analysis approach suggests that interviewers successfully elicited descriptions of decision processes that varied due to the different challenges presented by the four simulated incidents. A holistic analysis of the same 64 transcripts revealed individual differences in how anesthesiologists interpreted and managed the same case.

Naturalistic decision making and decision drivers in the front end of complex projects

Decision making plays a crucial role in the front end of projects which is a critical stage for maximising the performance of complex projects. Although it has been suggested that project managers rely more on analytical approaches to decision making as opposed to an intuitive mode, there is emerging evidence of project managers using intuitive decision processes. Yet, little is known about how this occurs during the front-end phase, with few attempts to study the underlying cognitive processes and what influences project decision making. This research gap is addressed by interviewing project managers experienced in front-end decision making (n = 16) of large-scale complex projects within the oil and gas industry. Adopting a naturalistic decision-making (NDM) methodology and using a form of cognitive task analysis, a thematic coding of their accounts of decision making during the front end of large complex projects identified key decision processes and influencing factors (drivers). Formal analytical processes (e.g., data-driven calculations, software rating tools) were favoured but, and in line with emerging findings, these experienced project managers also used intuitive decision-making processes, such as pattern recognition and feelings/associative memory. Decision drivers were grouped into 5 clusters - project external factors, project internal factors, social dimensions, individual differences, and time pressures. The findings suggest that project managers should be trained on how to recognise when intuitive decision making is occurring and how to use it while being aware of its strengths, weaknesses and influencing factors. A focus on building descriptive models of actual decision making in complex environments, for the training of project managers, by applying NDM methods will enhance the management of the front end of projects.

High performance coach cognition in the wild: using applied cognitive task analysis for practical insights-cognitive challenges and curriculum knowledge.

Despite significant empirical work in the sport coaching domain, there remains a paucity of evidence to inform practice in high-performance sport coaching. As a result, there are gaps in our understanding regarding coaching expertise at different levels of athlete performance. A significantly underutilized approach in coaching research is Cognitive Task Analysis and it's knowledge elicitation tools. Addressing these concerns, here we utilize applied Cognitive Task Analysis and a semi-structured interview protocol to elicit the cognitive challenges and use of knowledge by a group of N = 7 high-performance endurance sport coaches from a single national governing body. Analysis suggested prominent and ongoing challenges in day-to-day practice which, in turn require significant adaptive skill. In addition, results show how coaches used knowledge flexibly and conditionally to meet the demands of their role. A novel finding being the identification of the use of curriculum knowledge to mentally project the needs of athletes. The findings suggest opportunities for utilizing Cognitive Task Analysis to investigate the cognitive challenges of sport coaching and enhance coach development practice.

Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: an interview study

BackgroundSafety has been described as a dynamic non-event and as constantly present in professionals’ work processes. Investigating management of complex everyday situations may create an opportunity to elucidate safety management. Anaesthesia has been at the frontline of enhancing patient safety – testing and implementing knowledge from other high-reliability industries, such as aviation, in the complex, adaptive system of an operating room. The aim of this study was to explore factors supporting anaesthesia nurses and anaesthesiologists in managing complex everyday situations during intraoperative anaesthesia care processes.MethodsIndividual interviews with anaesthesia nurses (n = 9) and anaesthesiologists (n = 6) using cognitive task analysis (CTA) on case scenarios from previous prospective, structured observations. The interviews were analysed using the framework method.ResultsDuring intraoperative anaesthesia care, management of everyday complex situations is sustained through preparedness, support for mindful practices, and monitoring and noticing complex situations and managing them. The prerequisites are created at the organization level. Managers should ensure adequate resources in the form of trained personnel, equipment and time, team and personnel sustainability and early planning of work. Management of complex situations benefits from high-quality teamwork and non-technical skills (NTS), such as communication, leadership and shared situational awareness.ConclusionAdequate resources, stability in team compositions and safe boundaries for practice with shared baselines for reoccurring tasks where all viewed as important prerequisites for managing complex everyday work. When and how NTS are used in a specific clinical context depends on having the right organizational prerequisites and a deep expertise of the relevant clinical processes. Methods like CTA can reveal the tacit competence of experienced staff, guide contextualized training in specific contexts and inform the design of safe perioperative work practices, ensuring adequate capacity for adaptation.

COLLABORATIVE TEAM TRAINING IN IMMERSIVE VIRTUAL REALITY IS SUPERIOR TO INDIVIDUAL LEARNING FOR PERFORMING TOTAL HIP ARTHROPLASTY: A RANDOMIZED CONTROLLED TRIAL

Superior teamwork in the operating theatre is associated with improved technical performance and clinical outcomes. Yet modern rota patterns, workforce shortages, and increasing complexity of surgery, means that there is less familiarity between staff and the required choreography. Immersive Virtual Reality (iVR) can successfully train surgical staff individually, however iVR team training has yet to be investigated. We aimed to design a multiplayer iVR platform for anterior approach total hip arthroplasty (AA-THA) and assess if multiplayer iVR training was superior to single player training for acquisition of both technical and non-technical skills.An iVR platform with choreographed roles for the surgeon and scrub nurse was developed using Cognitive Task Analysis. Forty participants were randomised to individual or team iVR training. Individually- trained participants practiced alongside virtual avatar counterparts, whilst teams trained live in pairs. Both groups underwent five iVR training sessions over 6-weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated theatre. Teams performed together and individually trained participants were randomly paired up. Videos were marked by two blinded assessors recording the NOTSS, NOTECHS II and SPLINTS scores - validated technical and non-technical scores assessing surgeon and scrub nurse skills. Secondary outcomes were procedure time and number of technical errors.Teams outperformed individually trained participants for non-technical skills in the real-world assessment (NOTSS 13.1 ± 1.5 vs 10.6 ± 1.6, p =0.002, NOTECHS-II score 51.7 ± 5.5 vs 42.3 ± 5.6, p=0.001 and SPLINTS 10 ± 1.2 vs 7.9 ± 1.6, p = 0.004). They completed the assessment 28.1% faster (27.2 minutes ± 5.5 vs 41.8 ±8.9, p<0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, p<0.001).Multiplayer training leads to faster surgery with fewer technical errors and the development of superior non-technical skills for anterior approach total hip arthroplasty. The convention of surgeons and nurses training separately, but undertaking real complex surgery together, can be supplanted by team training, delivered through immersive virtual reality.

It’s about time: How to study intertemporal choice in systems design

Decision making pervades software and systems engineering. Intertemporal decisions involve trade-offs among outcomes at different points in time. They play a central role in systems design, as recognised since the inception of the software engineering (SE) field. They are also crucial for the sustainability of design decisions. However, temporal decision making is not adequately understood in SE. The field of Judgement and Decision Making (JDM) offers important empirical findings and research methods that could be utilised. This article establishes a baseline for studying how software professionals handle intertemporal choices. It examines how temporal distance affects choices in an example scenario, explores in what areas of software development such decisions can be found, and examines how systems design decisions can be characterised and studied as intertemporal. We developed a method to study intertemporal choice in SE, based on an initial set of psychological theory grounded in JDM. We instantiated the method in a study to elicit responses to an intertemporal choice task followed by a Cognitive Task Analysis (CTA) interview. We found that study participants overall tended to discount future outcomes, but individual participants varied wildly in how they valued present vs. future outcomes. They indicated several locations in which intertemporal choices occur in everyday software development. Based on these findings, and by reconciling our initial theory with existing JDM theory and results, we further developed and refined our theory and study method into a framework for studying intertemporal decision making in SE. To obtain a basis for more sustainable software systems design decisions, SE research should adopt a more comprehensive, detailed, and empirically consistent way of understanding and studying intertemporal choices. We provide suggestions for how future research could achieve practical methods that address essential characteristics of real-life systems design decisions.

"What brought you in today?": Modeling patient-provider clinic visits to characterize rural providers' antibiotic treatment decisions.

Designing clinical decision support (CDS) tools is challenging because clinical decision-making must account for an invisible task load: incorporating non-linear objective and subjective factors to make an assessment and treatment plan. This calls for a cognitive task analysis approach. The objectives of this study were to 1.) understand healthcare providers' decision making during a typical clinic visit, and 2.) explore how antibiotic treatment decisions are made when they arise. Two cognitive task analysis methods were applied - Hierarchical Task Analysis (HTA) and Operations Sequence Diagramming (OSD) - to 39h of observational data collected at family medicine, urgent care, and emergency medicine clinical sites. The resulting HTA models included a coding taxonomy detailing ten cognitive goals and associated sub-goals and demonstrated how the goals occur as interactions between the provider and electronic health record, the patient, and the physical clinic environment. Although the HTA detailed resources for antibiotic treatment decisions, antibiotics were a minority of drug classes ordered. The OSD shows the sequence of events and when decisions are made solely at the provider level and when shared decision making occurs with the patient. Qualitative data from the observations informed a constructed vignette case example portraying select tasks from the HTA. These findings emphasize that the scope of disease states presenting to a generalist clinical setting is broad and could include acute exacerbations of rare diseases within a time-pressured environment. CDS must be accessible, time efficient, and fit within the resource gathering task before treatment decisions are made.

A Video-Based Assessment Tool to Measure Intraoperative Laparoscopic Suturing Using a Modified Script Concordance Methodology

Laparoscopic suturing (LS) is a challenging laparoscopic skill to teach. Its complexity and nuances are not modeled or measured in current simulation and assessment platforms.The script concordance test (SCT) is used to assess clinical reasoning.The purpose of this study is to provide evidence for validity of this novel SCT based online assessment for LS skills. We designed a video-based online SCT for LS using a cognitive task analysis and expert panelists.The CTA yielded 4 LS domains: needle handling (NH), tissue handling (TH), knot tying techniques (KT) and operative ergonomics (OE). Five-point scales with anchoring descriptors from -2 to +2 were used. Scoring was based on a modified SCT methodology. The test was administrated to 37 subjects (18 experts and 19 novices). There was no time limit given. A different expert group from the minimal invasive surgery (MIS) panelist were recruited. Experts were defined as surgeons and fellows with LS experience of >25 cases annually. Validity was assessed by comparing SCT scores of experienced and inexperienced surgeons. Cronbach's alpha was used to assess the internal consistency of the test. The survey started off with 47 questions in each of the following domains: 13 NH, 4 TH, 20 KT and 10 OE. Thirty-seven surgeons (18 experts and 19 inexperienced surgeons). Questions that demonstrated a large discrepancy among experts and panelists with a weighted score difference more than 40 were discarded (n = 20). One question was discarded because it received a 100% score from all participants. This yielded 26 remaining questions in the following domains: 8 NH, 2 TH, 11 KT and 5 OE. The test reliability level (Cronbach a) was 0.80. The mean score was 72 ± 9% and 63 ± 15% (p = 0.02) for experts and inexperienced surgeons, respectively. The mean time to complete the test was 21 minutes. This study provides validity evidence for a novel intraoperative LS assessment. The variability of responses between experts and panelists suggests that SCT may capture the clinical differences/surgeon preferences in performing LS intraoperatively.

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models.

Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta. We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis. Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible. Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.

Defining Cognitive Competencies for Breast Augmentation Surgery

Breast augmentation is the most performed aesthetic procedure in the United States yet one that surgical trainees have limited exposure to. This creates a lack of confidence in performing this key procedure among graduates. It is imperative to develop novel curricula and objective measures to standardize acquiring competency. This qualitative study establishes various cognitive competencies and pitfalls in augmentation mammoplasty. Using a priori established task analysis, literary sources and operative observations, a total of 20 cognitive vignettes were developed to conduct cognitive task analyses (CTA) for breast augmentation through semistructured interviews of experts. Interviews were itemized, and verbal data were recorded, transcribed verbatim, and thematically analyzed by reviewers. Eight experts were interviewed (median age 39 years, 87.5% males, with a median of 7 years in practice). A conceptual framework for breast augmentation was developed and divided into 5 operative stages containing 208 competencies and 41 pitfalls. Pitfalls were mapped to deficits in shared decision making, proper informed consent, prospective hemostasis, and awareness of anatomical landmarks and markings. This work provided an inclusive framework of cognitive competencies in breast augmentation surgery to facilitate their assessment. This model guides the analysis of other procedures to transfer cognitive competencies to learners. In a transition toward competency-based education, this provides a primer to assessments that include all aspects of a surgeon's skill set.

Uncovering patient safety considerations in laparoscopic cholecystectomy using cognitive task analysis.

Educating residents on laparoscopic operations requires direct teaching and deliberate practice. Attending surgeons are often systematic when performing surgery, which creates a challenge when instructing surgery residents. The aim of this study was to use cognitive task analysis to expand laparoscopic cholecystectomy into microsteps reflecting expert surgeon cognition (perceptions, assessments, decisions, etc.) throughout the operation such that these could be better formalized and conveyed to residents in educational materials or assessments and to attending surgeons as teaching scripts. One surgeon, a surgical resident, and a human factors specialist conducted cognitive task analyses with three expert general surgeons and one hepatobiliary surgeon using semi-structured interviews. These interviews expanded an existing task model of laparoscopic cholecystectomy to specifically add patient safety aspects including injury prevention, risk management, and complication detection for each step. Interview analysis resulted in an expanded task diagram. Cognitive task analysis expanded the current laparoscopic cholecystectomy task model from 19 to 97 microsteps. In addition to microsteps, an additional major step was identified, the planning step or step zero. Steps with the greatest number of microsteps included dissection with 15 microsteps and intraoperative cholangiogram with 10 microsteps. Laparoscopic cholecystectomies are complex operations with multiple microsteps. Identification of these steps can lead to explicit strategies that can improve training of surgeons, with an end towards efficacy and safety. The identification of a planning step prior to beginning the operation is a significant finding that should arguably be included in all future cognitive task analyses regardless of operation or procedure, to emphasize to trainees what senior surgeons have learned through experience. These findings inform the development of interventions for surgical training and evaluation of competency.

‘They didn’t do anything wrong! What will I talk about?’

Simulation educators are often unsure of how to conduct a debriefing when learner performance meets or exceeds the expected standard and no significant errors have occurred. Similar to patient safety practices in clinical settings, simulation educators frequently focus on debriefing errors. Indeed, much debriefing training focuses on developing skills needed to conduct the “difficult conversations” that involve giving feedback on errors that occurred. Many simulation educators have not been taught an approach to debriefing positive performance. This manuscript provides such an approach. The approach applies the principles of Cognitive Task Analysis, a technique used in human factors research, to debriefing positive performance. The steps of knowledge elicitation, knowledge representation, and data analysis and synthesis can guide debriefers as they help learners discuss their positive performance, with the goal that the same positive practices will be repeated in future clinical practice.

Development and validation of a task load index for process control room operators (PCRO-TLX)

Process control room operators (PCRO) perform a range of complex cognitive safety-critical tasks. The aim of this exploratory sequential mixed methods study was to develop an occupation specific tool to measure the task load of PCRO using NASA Task Load Index (TLX) methodology. Participants were 30 human factors experts and 146 PCRO at two refinery complexes in Iran. Dimensions were developed via a cognitive task analysis, a research review, and three expert panels. Six dimensions were identified: perceptual demand, performance, mental demand, time pressure, effort, and stress. Data from 120 PCRO confirmed that the developed PCRO-TLX has acceptable psychometric properties, and a comparison with the NASA-TLX confirmed that perceptual, not physical, demand was relevant for measuring workload in PCRO. There was a positive convergence of scores of the Subjective Workload Assessment Technique and the PCRO-TLX. This reliable tool (α = 0.83) is recommended for risk assessing the task load of PCRO. Practitioner summary: There are benefits of having a specific tool to measure task load in safety critical roles. Thus, we developed and validated an easy-to-use targeted tool, the PCRO-TLX, for process control room operatives. Timely use and response will assure optimal production alongside health and safety in an organisation. Abbreviations: PCRO: process control room operator; TLX: task load index; PCRO-TLX: process control room operator task load index; NASA-TLX: National Aeronautics and Space Administration task load index; SWAT: subjective workload assessment technique; DALI: driving activity load index; SURG-TLX: surgery task load index; SIM-TLX: virtual reality simulation task load index; VACP: visual, auditory, cognitive and psychomotor; CVI: content validity index; CVR: content validity ratio; RMSEA: root mean square of error approximation; GFI: goodness of fit index; AGFI: adjusted goodness of fit index; CFI: comparative fit index; ANOVA: analysis of variance; CI: confidence interval

Critical design choices in healthcare simulation education: a 4C/ID perspective on design that leads to transfer

BackgroundHealthcare simulation education often aims to promote transfer of learning: the application of knowledge, skills, and attitudes acquired during simulations to new situations in the workplace. Although achieving transfer is challenging, existing theories and models can provide guidance.RecommendationsThis paper provides five general recommendations to design simulations that foster transfer: (1) emphasize whole-task practice, (2) consider a cognitive task analysis, (3) embed simulations within more comprehensive programs, (4) strategically combine and align simulation formats, and (5) optimize cognitive load. We illustrate the application of these five recommendations with a blueprint for an educational program focusing on simulation activities.ConclusionsMore evidence-informed approaches to healthcare simulation might require a paradigm shift. We must accept that a limited number of simulations is not enough to develop complex skills. It requires comprehensive programs that combine simulation sessions with workplace learning.

Applying cognitive task analysis to health services research.

Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study. Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration. Qualitative study of discharge planning using CTA. Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis. We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task. A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research.

Assessing antibiotic prescribing in nurse practitioners: Applied cognitive task analysis.

Prescribing antibiotics is a demanding and complex task where decision-making skills are of critical importance to minimize the risk of antimicrobial resistance. Despite its importance, little is known about the decision-making skills and cognitive strategies new Nurse Practitioners (NPs) use when prescribing antibiotics. To identify the cognitive demands of antibiotic prescribing complexity and to explore the cognitive strategies that new NPs in New Zealand use when prescribing antibiotics. A qualitative approach using Applied Cognitive Task Analysis (ACTA) methodology. A purposive sample was recruited consisting of five NPs who had been registered within the last five years and were prescribing antibiotics as part of their scope of practice. In-depth face-to-face interviews consisting of a task diagram interview and a knowledge audit were conducted and analyzed following the ACTA protocol. Four cognitive elements were identified from the data which showed the cognitive demands of prescribing antibiotics, and the cues and strategies NPs use for safe practice. These were: 1 prescribing in the face of uncertainty (complex patients and diagnostic uncertainty); 2 making clinical decisions with insufficient/poor guidance (lack of guidelines, conflicting information); 3 producing an individualized treatment plan in view of clinical and non-clinical patient factors (patient demand/expectation, inadequate patient education, risks versus benefits of antibiotic treatment); 4 ensuring treatment efficacy and continuity of care (ineffective treatment, patient care follow up). The ACTA framework has given insight into the current antibiotic prescribing practice of new NPs, identifying areas where professional development courses and treatment resources can be targeted to support antibiotic prescribing. NPs are likely to benefit from resources that are freely available and reflect national or local antimicrobial data. Further work is also warranted to determine whether targeted education resources and clinical pathways will help with diagnostic uncertainty, and how this could be embedded into existing curricula.

The Hidden Burden of Equipment Failure in Endoscopy: Uncovered and Improved With Digital Technology.

Objective A growing and ageing population combined with severe disruptions across endoscopy services throughout the United Kingdom (UK) during the recent pandemic has accelerated the backlog of patients awaiting endoscopic procedures. This places increased pressure to improve service efficiencies in an attempt to reduce this growing burden. Moreover, beyond repair costs, the full impact of faulty endoscopes on services is not well documented. This study aimed to outline tasks performed to traditionally report a broken endoscope; measure the impact on staff time, efficiency costs and staff morale; and report outcomes of staff experience and productivity when replacing traditional reporting with a digital reporting tool. Methods This study was conducted over six months at three endoscopy units. Cognitive-task analysis (CTA) and a time-motion study (TMS) were performed to process map all traditional tasks when an endoscope breaks, and again after a digital reporting tool was implemented. Two staff surveys were conducted. Data was aggregated to determine the overall impact and model efficiency costs. Results With traditional processes, on average one faulty endoscope generated 54 tasks, consuming 8 hours 53 minutes of staff time or £325 in efficiency costs, with 60% of staff reporting a negative effect on morale. In comparison, digital reporting generated 41 tasks, consuming 4 hours 31 minutes of time or £147 in efficiency costs, resulting in £45,468 saved annually. Furthermore, 95% of staff said their morale improved, and environmentally all paper-based processes were removed. Conclusion This study demonstrated the immense hidden burden of faulty endoscopes. Given the current challenges to endoscopy recovery,digital reporting tools may present an attractive means to minimise disruption to endoscopy services driven through improved equipment maintenance.

Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure.

The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. Hierarchical and cognitive task analyses for a TAR procedure were performed using semi-structured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts (median 66 minutes [44-78]). Subject matter experts practiced a median of 6.5 years [1.5-16] and have completed a median of 300 [60-500] TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure; ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.

A Mixed Assessment for the Science Learning via a Bayesian Network Representation

This study explored an alternative assessment model to examine Chemistry learners’ progress. “The Assessment of Problem-Solving in Chemistry Learning” as a model represented students’ mastery of chemistry study. The data were from journaling narratives and analyzed through cognitive task analysis. Based on the analyses, a student model was established, which represents the qualitative information in a structure, and provides a potential framework of the assessment model for the quantitative representation—a Bayesian network assessment model. The student’s performance was assessed via the Bayesian network assessment model, and classified into three categories: low level, middle level, and high level. The mastery level should be at least scored at and above 90.51/100 for Declarative, Procedural, and Strategic Knowledge respectively.

Enhancing surgical education for resource-limited settings: open appendectomy cognitive task analysis

Open appendectomy is one of the most common procedures performed globally, especially in low- and middle-income countries (LMICs). In many LMICs, surgical education is limited by personnel shortages. Developing effective teaching methods for resource-limited environments may enhance the availability of a trained workforce. Cognitive task analysis (CTA) is an effective method to obtain expert input to define operative steps and cognitive processes in complex procedures. The aim of this study was to perform the first CTA for open appendectomy in an effort to develop a teaching module for practitioners in LMICs. Twelve expert general surgeons completed semi-structured interviews which were recorded via Zoom. Each expert had previously performed > 100 open appendectomies. Each interviewee described the entire procedure and then answered specific questions to inform surgical decision making, anatomic landmarks, and error recognition/avoidance. The responses were collated by two independent reviewers into a CTA model which then underwent review through a multi-disciplinary surgical education team. Final steps were presented back to the experts for feedback and modifications and tested on a simulator. Completeness of each expert’s interview was determined by two metrics: time and percentage of steps on the compiled model that the expert surgeon described. The CTA identified five main steps: preoperative patient preparation, safe entry into the abdomen, identify the appendix, appendectomy, and abdominal closure. Each step had additional sub-steps for a total of 24 procedural steps. Available equipment/supplies and critical decision point descriptions provided the most variability. The median completeness score for the unstructured portion of the interview was 76% (IQR 68–80). Using CTA, we defined the essential operative steps, decision points, and areas of potential error with performing an open appendectomy. These results provide a framework that can guide intraoperative instruction and the development of a teaching module for open appendectomy that can be implemented in LMIC to enhance surgical education.