Making Concepts Material A Randomized Trial Exploring Simulation as a Medium to Enhance Cognitive Integration and Transfer of Learning

Background: Simulation affords opportunities to represent functional relationships between conceptual (eg, anatomy) and procedural knowledge (eg, needle insertion technique) in ways that make them accessible to our many senses. Despite deprioritizing realism, such simulations may encourage trainees to create cognitive connections between these knowledge (ie, cognitive integration), which may improve transfer of learning. However, the impact of such "integrated instruction" has not been examined in simulation-based training. We developed integrated video- and simulator-based instructional modules for lumbar puncture training and compared their impacts on participants' retention, transfer, and conceptual knowledge. Methods: During 1 hour of simulation-based training, we randomized 66 medical students to receive either (a) video-based procedural-only instruction, (b) integrated video-based instruction, or (c) integrated simulator-based instruction. One week later, we tested participants' retention and transfer performances and their conceptual knowledge on a written test. Results: Simple mediation analyses revealed that compared with participants receiving procedural-only instruction, participants receiving integrated instruction had superior retention and transfer outcomes, mediated by gains in conceptual knowledge (all P < 0.01). We found no significant differences between the integrated groups for retention, transfer, or conceptual knowledge (all P > 0.01). Conclusions: We extended previous findings, showing integrated instruction (video- or simulator-based) improved trainees' conceptual knowledge, which mediated their improved retention and transfer. As an innovation, we demonstrated how simulators can facilitate cognitive integration by making abstract conceptual-procedural relationships material. In suggesting how researchers might capitalize further on simulator-based integration, we offer an alternative framework for designing simulations that emphasizes cognitive processes rather than simulator fidelity.