Unpacking the Complexity of Patient Handoffs Through the Lens of Cognitive Load Theory

Abstract

Issue: The transfer of a patient from one clinician to another is a high-risk event. Errors are common and lead to patient harm. More effective methods for learning how to give and receive sign-out is an important public health priority. Evidence: Performing a handoff is a complex task. Trainees must simultaneously apply and integrate clinical, communication, and systems skills into one time-limited and highly constrained activity. The task demands can easily exceed the information-processing capacity of the trainee, resulting in impaired learning and performance. Appreciating the limits of working memory can help identify the challenges that instructional techniques and research must then address. Cognitive load theory (CLT) identifies three types of load that impact working memory: intrinsic (task-essential), extraneous (not essential to task), and germane (learning related). The authors generated a list of factors that affect a trainee's learning and performance of a handoff based on CLT. The list was revised based on feedback from experts in medical education and in handoffs. By consensus, the authors associated each factor with the type of cognitive load it primarily effects. The authors used this analysis to build a conceptual model of handoffs through the lens of CLT. Implications: The resulting conceptual model unpacks the complexity of handoffs and identifies testable hypotheses for educational research and instructional design. The model identifies features of a handoff that drive extraneous, intrinsic, and germane load for both the sender and the receiver. The model highlights the importance of reducing extraneous load, matching intrinsic load to the developmental stage of the learner and optimizing germane load. Specific CLT-informed instructional techniques for handoffs are explored. Intrinsic and germane load are especially important to address and include factors such as knowledge of the learner, number of patients, time constraints, clinical uncertainties, overall patient/panel complexity, interacting comorbidities or therapeutics, experience or specialty gradients between the sender and receiver, the maturity of the evidence base for the patient's disease, and the use of metacognitive techniques. Research that identifies which cognitive load factors most significantly affect the learning and performance of handoffs can lead to novel, contextually adapted instructional techniques and handoff protocols. The application of CLT to handoffs may also help with the further development of CLT as a learning theory.

Keywords:

• cognitive load theory
• handoffs
• instructional design