By Todd Maddox, PhD and Tim Fitzpatrick
The ideal kidney care education and training solution speeds initial learning, enhances long-term retention and builds strong behavioral repertoires and situational awareness. Unfortunately, no single education and training solution can achieve this goal in all situations. Fortunately, there is a method for determining which learning solution is optimal in a given situation. This method relies critically on an understanding of the psychology and neuroscience of learning.
In this report, we outline a neuroscience framework for determining which learning solution is optimal for each of many kidney education and training problems. The framework requires that three steps be followed.
Figure 1: Three Steps to Evaluating the Effectiveness of L&D Solutions
First, one must identify the education and training problem at hand. For example, the goal might be to learn to name the structures and to identify the functions of the kidney, or to familiarize a potential home dialysis technician with the technical and people skills necessary to excel at the job, or to care and maintain a peritoneal dialysis machine.
Second, one must identify the learning system(s) in the brain that must be engaged to optimally gain the knowledge or skill. This requires an understanding of the neuroscience of learning and the processing characteristics of distinct learning systems in the brain.
Finally, one must identify the learning solution that optimally engages the learning systems identified in Step 2 in order to optimally address the education and training problem identified in Step 1.
Identify the Learning Task
The first step in the neuroscience framework is to identify the learning task at hand. A good starting point is to determine whether the task is to learn (or memorize) information or facts and figures, to familiarize a patient or provider with a situation that is hard to verbalize, or to learn some technical or motor skill. For example, learning a set of facts or figures might include learning the number and size of the kidneys, the eGFR and kidney function percentages associated with each stage of chronic kidney disease, or the pros and cons of in center vs. home dialysis. Familiarization learning might involve experiencing a “day in the life” of a home dialysis nurse to help a new hire determine whether home dialysis is a good fit for their career, or experiencing a “day in the life” of a peritoneal dialysis patient to help an in-clinic dialysis patient determine whether home dialysis is right for their lifestyle. Finally, technical or motor skills learning might involve a home dialysis nurse or patient learning the skills needed to care and maintain a broad range of home dialysis machines (in the case of the nurse) or a particular peritoneal dialysis machine (in the case of the PD patient).
The distinction between a learning task that requires information (knowledge) acquisition, familiarization, or technical/motor skills development is critical because the neural systems that underlie each of these learning tasks is different.
Many tasks require more than one type of learning. For example, knowing how to care and maintain a home dialysis machine (technical/motor skill) is important, but it is also important to know and identify each part of the machine and to be able to describe it to others (information). The need to engage multiple learning systems in synchrony is one reason why innovative immersive learning technologies are growing in prevalence in healthcare learning, and need to be expanded to kidney education and training. We address this in greater detail below.
Learning Systems in the Brain
The second step in the neuroscience framework is to determine the relevant brain regions for solving the identified task.
The brain is comprised of at least four learning systems: the cognitive, experiential, behavioral, and emotional learning systems (see below).
Figure 2: Learning Systems in the Brain
The cognitive skills learning system is the primary system in the brain for learning fact-based knowledge and information. The cognitive system relies on the prefrontal cortex and its learning efficiency is limited by working memory and attentional processes. Initial learning occurs in the prefrontal cortex and then with mental repetition that learning is transferred to long-term memory in the hippocampus to facilitate long-term information retention.
The experiential learning system encodes the rich context associated with learning; specifically, the sights, sounds, smells, and touches of every learning episode. The relevant brain regions are the occipital lobes (sight), temporal lobes (sound), and parietal lobes (touch/smell). Experience provides the context and scaffolding that grounds and contextualizes all learning and provides the foundation for situational awareness.
The behavioral skills learning system in the brain has evolved to learn technical and motor skills. The behavioral system links environmental contexts with actions and behaviors and does not rely on working memory and attention. In fact, there is strong scientific evidence that overthinking it hinders behavioral skills learning. Behavioral skills learning is mediated by the striatum and involves gradual, incremental dopamine-mediated changes in behavior. Processing in this system is optimized when behavior is interactive and is followed in real-time (literally within milliseconds) by corrective feedback. Behaviors that are rewarded lead to dopamine release into the striatum that incrementally increases the likelihood of eliciting that behavior again in the same context. Behaviors that are punished do not lead to dopamine release into the striatum, thus incrementally decreasing the likelihood of eliciting that behavior again in the same context. Behavioral skill learning is optimized when the learner trains on multiple behaviors across multiple settings. This enhances generalization, transfer and long-run behavior change.
Finally, the emotional learning system relies on the amygdala and other limbic structures. The detailed processing characteristics of this system are less understood than the cognitive and behavioral skills learning systems, but emotional learning strongly affects both cognitive and behavioral skills learning. Emotional learning encodes so much of the personal nuance of learning situations and is critical to the development of situational awareness.
Determine the Learning Technology that Optimally Engages the Relevant Brain System(s)
The third step in the neuroscience framework is to determine which learning technology optimally engages the relevant brain systems in the interest of achieving the learning goal.
Optimizing Information Learning: Suppose you want to train fact-based information such as the number and size of the kidneys, the eGFR and kidney function percentages associated with each stage of chronic kidney disease, or the pros and cons of in center vs. home dialysis. Given the neuroscience of learning, these tasks would be mediated by the cognitive learning system in the brain. Because this system relies on working memory and attention, both of which are limited resources, an effective education solution will be one that limits the cognitive load. The use of microlearning, an approach to training that focuses on conveying information about a single idea within a short (3 – 5 minute) span, minimizes the load placed on working memory and attention and is highly effective for initial learning of information. Combine this concept with spaced microlearning and periodic testing strategies and you have a learning tool that will speed the transition to long-term memory stores.
A Learning Management System (LMS) can be used effectively to solve these kidney education problems as long as spaced microlearning training and periodic testing are incorporated. This is a simple and effective way to instill large amounts of important information on kidney patients and providers and should be utilized broadly in the kidney education sector.
Optimizing Familiarization Learning: Suppose you are faced with a very different learning problem where you need to help candidates interested in the growing field of home dialysis understand what a particular role is like day-to-day. You can provide vast amounts of “information” describing the job, and even use spaced microlearning approaches to make sure they really understand, but as any home dialysis team member will tell you, there is much more to the job than a list of facts and figures. In this case, what you strive for is a learning technology that provides a rich experience for the candidate. You want the candidate to “walk a mile in the shoes” of a current home dialysis nurse. You want the candidate to experience what it is like to interact with a variety of patients, some easy and some challenging. You want a tool that provides a rich, realistic context to familiarize them. In this case, you want experiential centers in the brain to be activated, but also emotional centers and cognitive centers. In this case, virtual reality technology that utilizes 360-degree video offers the ideal solution. With 360 virtual reality you can be immersed in the home dialysis nurse’s daily environment. You can experience and feel what they feel. With voiceover you can hear first-person how they address specific situations, support patients and achieve their overall aims.
An analogous learning problem is that of familiarizing in-clinic dialysis patients with their way of life should they decide to pursue a home dialysis treatment option. This is an especially important problem to address given the 2019 Presidential Executive Order on Advancing American Kidney Health which mandates a significant increase in patients using home dialysis modalities. As with the home hemodialysis patient, one can provide huge amounts of “information” describing the pros and cons of home hemodialysis or peritoneal dialysis relative to in-clinic dialysis, and even use spaced microlearning approaches to make sure the patient retains the information. But as any home dialysis patient will tell you, a true understanding requires a context-rich experience. You want the patient to “walk a mile in the shoes” of a current home dialysis patient and to hear their story. In this case, you want experiential centers in the brain to be activated, but also emotional centers and cognitive centers. In this case, virtual reality technology that utilizes 360-degree video offers the ideal solution. With 360 virtual reality you can immersed an in-clinic patient in the life of a home dialysis patient. The in-clinic patient can experience and feel what home dialysis is like and how it will change their daily life.
Optimizing Technical and Motor Skills Learning: Once a home hemodialysis technician is hired, or an in-clinic dialysis patient chooses peritoneal dialysis, now they must be trained on the technical and motor skills needed to care and maintain the home dialysis machine. You can provide huge amounts of “information” such as the steps needed to follow, and you can summarize some of the common problems. You can even use spaced microlearning approaches to make sure they really understand, but as any home dialysis technician or peritoneal dialysis will tell you,
it is one thing to know 'what' to do, and something completely different to know how to do it. Knowing 'what' is information, knowing 'how' is behavior.
To learn “how” to care and maintain a home dialysis machine and to have the situational awareness to troubleshoot and solve common and uncommon problems, you need all four learning centers in the brain to be active. These include experiential, behavioral, emotional and cognitive centers. In this case, interactive virtual reality technology or augmented reality technology offers the ideal solution. The critical requirement is that the user must be able to generate motor behaviors and receive feedback in real time.
(Image credit: Zgoura et al, "Virtual Reality Simulation in Peritoneal Dialysis Training: The Beginning of a New Era", Advances in CKD, 2019, https://doi.org/10.1159/000494595)
For example, with interactive virtual reality, a computer graphics rendered home hemodialysis machine might be present in the visual display. Step by step instructions are provided and, using haptics or hand tracking, the user might follow those steps to care and maintain the machine. Correct motor behaviors will be rewarded and incorrect behaviors will be punished. An augmented reality solution would follow the same logic, but in this case a real home hemodialysis machine will be present and visual and auditory assets will be overlaid on the visual field to provide step by step instructions. The user can be presented with common or rare problems to solve all in a safe environment, and as many times as necessary.
To advance the important charge of educating and training kidney disease patients and providers, one must understand how the brain learns and use the learning technology that is optimal for each training problem. This requires the application of learning science. A three-step process should be followed to determine the ideal learning tool to solve the specific learning problem. If information, such as the number and size of the kidneys, the eGFR and kidney function percentages associated with each stage of chronic kidney disease, or the pros and cons of in center vs. home dialysis, must be learned, then a LMS that incorporates spaced microlearning and periodic testing will be effective.
If context-rich familiarization, such as experiencing a “day in the life” of a home dialysis nurse or peritoneal dialysis patient to help determine whether home dialysis is the right fit, then virtual reality with 360 video is necessary. If technical or motor skills learning is required, such as learning the skills needed to care and maintain a broad range of home dialysis machines and devices, then interactive virtual reality or augmented reality is necessary.