Elucidating cognitive processes in cardiac arrest team leaders: a virtual reality-based cued-recall study of experts and novices

Abstract

Background

Team leadership during medical emergencies like cardiac arrest resuscitation is cognitively demanding, especially for trainees. These cognitive processes remain poorly characterized due to measurement challenges. Using virtual reality simulation, this study aimed to elucidate and compare communication and cognitive processes-such as decision-making, cognitive load, perceived pitfalls, and strategies-between expert and novice code team leaders to inform strategies for accelerating proficiency development.

Methods

A simulation-based mixed methods approach was utilized within a single large academic medical center, involving twelve standardized virtual reality cardiac arrest simulations. These 10- to 15-minutes simulation sessions were performed by seven experts and five novices. Following the simulations, a cognitive task analysis was conducted using a cued-recall protocol to identify the challenges, decision-making processes, and cognitive load experienced across the seven stages of each simulation.

Results

The analysis revealed 250 unique cognitive processes. In terms of reasoning patterns, experts used inductive reasoning, while novices tended to use deductive reasoning, considering treatments before assessments. Experts also demonstrated earlier consideration of potential reversible causes of cardiac arrest. Regarding team communication, experts reported more critical communications, with no shared subthemes between groups. Experts identified more teamwork pitfalls, and suggested more strategies compared to novices. For cognitive load, experts reported lower median cognitive load (53) compared to novices (80) across all stages, with the exception of the initial presentation phase.

Conclusions

The identified patterns of expert performance — superior teamwork skills, inductive clinical reasoning, and distributed cognitive strategiesn — can inform training programs aimed at accelerating expertise development.

KEY MESSAGES

1. Novel combination of virtual reality simulation and cognitive task analysis provides a promising educational tool for identifying and addressing gaps in resuscitation team leadership skills, offering a valuable approach to competency-based medical education in critical care scenarios.

2. The consistently high cognitive load reported by team leaders, regardless of experience level, suggests a need for guidance on strategies to better distribute cognitive demands among team members during cardiac arrest resuscitations.

3. Experts demonstrate more advanced teamwork skills, inductive reasoning, and distributed cognition during cardiac arrest management, highlighting areas for focused skill development in novice leaders.