Best Practices and Theoretical Foundations for Simulation Instruction Using Rapid-Cycle Deliberate Practice

Abstract

Summary Statement 

Rapid-cycle deliberate practice (RCDP) is a learner-centered simulation instructional strategy that identifies performance gaps and targets feedback to improve individual or team deficiencies. Learners have multiple opportunities to practice observational, deductive, decision-making, psychomotor, and crisis resource management skills. As its implementation grows, simulationists need to have a shared mental model of RCDP to build high-quality RCDP-based initiatives. To compare and make general inferences from RCDP data, each training needs to follow a similar structure. This article seeks to describe the fundamentals of RCDP, including essential components and potential variants. We also summarize the current published evidence regarding RCDP's effectiveness. This article serves to create a shared understanding of RCDP, provide clear definitions and classifications for RCDP research, and provide options for future RCDP investigation.

More than 425 institutions in the United States alone provide simulation as experiential training for their clinicians.^1–5 Simulation training used to change clinical behaviors and impact patient outcomes has been successful.^6–11 As with all instructional tools, educators must learn how to effectively incorporate simulation to improve learner performance. One simulation instructional method that has been successful is rapid-cycle deliberate practice (RCDP).¹²

Rapid-cycle deliberate practice (RCDP) is a learner-centered simulation instructional strategy that identifies performance gaps and targets feedback to improve individual or team deficiencies. Learners have multiple opportunities to practice observational, deductive, decision-making, psychomotor, and crisis resource management skills. Instructor feedback gives learners-specific solutions (“prescriptions”) to provide faster, safer, and better-coordinated patient care.¹²

As its implementation grows, simulationists need to have a shared mental model of the conceptual underpinnings of RCDP to build high-quality RCDP-based initiatives. To make general inferences from RCDP-derived data, each training needs to adhere to comparable design requirements. This article seeks to describe RCDP fundamentals, including essential components and potential variants. We aim to also identify lingering questions and future RCDP research opportunities. Our goal is that this article serves to create a shared understanding of RCDP, provide clear definitions and classifications for RCDP research, and provide options for future RCDP investigation.

Rapid Cycle Deliberate Practice CURRENT EVIDENCE

First coined by Hunt et al¹² in 2014, RCDP built on the deliberate practice work of K. Anders Erricson. In 2017, Taras and Everett¹³ completed a systematic review on RCDP and found 15 resources that met their inclusion criteria, with only two being published articles. Since that review, 11 articles have been published describing the use of RCDP in simulation education, with continued proliferation of oral and research presentations at scientific meetings. This is evidence of the increased application of RCDP and the simulation community's interest in its use to improve clinician performance.

Of the 11 articles published on RCDP, at least 8 have offered evidence to support RCDP's effectiveness in healthcare simulation training:

• Hunt et al¹² and Lemke et al¹⁴: teams improved performance during simulated pediatric resuscitations when members were trained using RCDP.
• Hunt et al¹⁵: RCDP training resulted in higher chest compression fractions and faster time to start compressions and defibrillate in novice providers when compared with a traditional American Heart Association resuscitation course; learners also improved chest compression quality, airway management, and team communication.
• Sullivan et al¹⁶: teaching using RCDP improved time to starting compressions and time to defibrillation in licensed nurses on general care units compared with nurses who only completed AHA standard training; nurses achieved and sustained the standards without significant decay when training was repeated in 3-month intervals.
• Brown et al¹⁷: improvement in time to task in high-complexity postoperative congenital heart disease–simulated events when pediatric nurse practitioners were trained using RCDP.
• Magee et al¹⁸: immediate improvement in pediatric interns' abilities and decreased time to perform critical interventions in neonatal resuscitation when taught using RCDP.
• Cory et al¹⁹: improvement in performance scores of pediatric residents trained with RCDP in septic shock management immediately after training compared with residents who learned using reflective debriefing.
• Gross et al²⁰: pediatric residents receiving RCDP training in intubation choreography achieved a significantly higher score on an intubation checklist than those who received postscenario feedback.

A qualitative analysis of learner perspectives of RCDP training identified 3 major themes. Rapid cycle deliberate practice (a) creates “real-time” interruptions for timely correction of “bad habits/mistakes” and creates new skills through repetition and practice, (b) instills confidence through a sense of security, decreased anxiety, open communication, and elimination of doubt, thus creating a safe learning environment, and (c) maximizes learning by introducing new information in smaller chunks and reinforcing learning in real time, while emphasizing teamwork.²¹

CONCEPTUAL UNDERPINNINGS OF RCDP

When our team was able to quantify improved performance¹² with RCDP, we sought to understand why this approach was measurably more effective than our previously used methods of simulation training. We found that certain epistemological theories are emphasized in RCDP, thus enhancing learner performance. These include contextual learning, constructivism and behaviorism, situated cognition, and social learning.

Contextual Learning

Learners are more motivated to learn when instructional content is related closely with contexts specific to their own careers.²² This is particularly true in health care, where slight changes in environment can cause disorienting dilemmas that cause delays in vital interventions that can be the difference between a patient's life and death.¹⁵ This requires instructional design based on contextual learning and deeply rooted in concepts of constructivist theory and situated cognition. Contextual learning emphasizes problem-solving, allows learning to occur in diverse life contexts, and assists learners in monitoring their own learning, so they can become more self-regulated.²³ It provides instruction directly related to the life experiences or functional contexts of adult learners²³ and grows out of constructivism. Constructivist theorists believe that individuals learn by constructing meaning through interacting with and interpreting their environments.²⁴ Theories of situated cognition assume that knowledge is inseparable from the contexts and activities within which it develops.²⁵ We used these as a foundation for recreating, for instance, the environment and anxiety of a real cardiac arrest during training.

Constructivism Versus Behaviorism

Although RCDP curriculum is designed based on constructivism, we functionally applied portions of behaviorist learning theory, where learning is manifested by a change in behavior. Rapid cycle deliberate practice applies Edward Thorndike's Laws of Exercise and Effect, which state that repetition with positive reinforcement results in substantial learning.²⁶ This repetition, or practice, can change neural pathways in the brain by thickening myelin sheaths of axons in the affected neurons (myelination). Thicker myelin sheaths increases neural signal speeds, which increases speed of recall and enhance performance.^27,28

Social Learning Theory

Rapid cycle deliberate practice teaching methods are also rooted deeply in social learning theories, which suggest that people learn from observing others.²⁹ We take it a step further, agreeing with Miller and Dollard³⁰ that people do not learn from observation alone; they must imitate and reinforce what they observe.

Practice, Errors, and Learning

Practice is necessary to reach high levels of performance.³¹ When learning a new skill, novice learners focus on understanding the activity and avoiding mistakes.³² To achieve consistent, gradual improvement, Ericsson et al³³ found that participants need 3 conditions met. Learners need to do the following:

• 1) be aware of what aspects of their performance require improvement;
• 2) receive detailed, immediate feedback on their performance; and
• 3) have ample opportunities to improve performance by practicing the same or similar tasks repeatedly.³³

Deliberate practice gives multiple chances to perform a task correctly, with opportunities for purposeful overtraining and automatization.³⁴ More accomplished individuals in the domain are essential to guide participants to superior performance in a safe and effective manner.²⁴ Without consistent feedback from a coach, repeated practice can lead to arrested development or incorrect skill performance. Performers may lose conscious control over skill execution, which can make further performance modification difficult.³⁵ The chance for instructors to observe an entire performance allows for a more insightful prescription, which will improve subsequent performances. Allowing learners to perform a mistake through without interruption is important for long-term memory consolidation.^28,36 Instructors have observed that learners are engaged in solution finding when they have just made an error. Evidence also suggests that motor task improvement is “partly because the brain recognizes the errors it experienced before.”²⁷

INDICATIONS FOR RCDP

Patient care is complex, so it is reasonable to expect that learners will need multiple opportunities to practice new skills before becoming measurably better. Often, that means having content presented longitudinally. Evidence shows that this is beneficial, particularly in the integration of simulation into curricula.⁸ Unfortunately, there are times when urgent performance improvement is needed, without the luxury of extended timelines. This need to positively impact team performance during pediatric cardiac arrests despite limited opportunities for focused teaching time was a major motivation for initially developing RCDP.^12,37

We have identified opportunities when RCDP may be leveraged to impact clinical performance. These include educational opportunities with the following:

• Existing, well-established performance guidelines: The Institute of Medicine recommends establishing performance standards to minimize risk of harm to patients.³⁸ These can originate from national guidelines, institutional protocols, or expert consensus. Using standards provides an objective way to measure learner performance and an ability to build prescriptive feedback.
• A need for learners to master key behaviors: RCDP continuously provides formative testing of learner performance against established standards. Instructors will not advance to the next learning objective until learners achieve the current objective. This describes several of the complementary features of mastery learning incorporated into RCDP.⁵
• Limited teaching time: Published RCDP studies show that it allows learners to master a large amount of content within one standard time frame,^12–20,39 making it a good option when learners have a short time to master a topic, or if it is a stand-alone or self-sustaining course.
• Low-volume, high-risk, time-sensitive events: RCDP has been associated with improvement in team performance during simulated low-volume, high-risk, time-sensitive events.^12–20,39
• Team situations requiring or benefitting from specific scripting and/or choreography: RCDP can facilitate utilization of shared mental models for patient assessment, explicit choreography for patient management, role delineation, shared language, and interdisciplinary procedural training.

RELATIVE CONTRAINDICATIONS TO RCDP

Because RCDP scholarship is still in its early stages, we are hesitant to disregard its use in specific situations; recommendations regarding its use will likely evolve as its use becomes more widespread. However, there are times when RCDP may not be the most beneficial educational strategy. These may include:

• Training that does not have a clear approach to solve clinical problems. As noted by Magee et al,¹⁸ algorithms provide clear stopping points and lend themselves to clear prescriptions. The lack of an established “right answer” makes it difficult to determine which the most essential performance objectives are.
• When no prescriptions exist. Although it may be possible to design an RCDP course without standard guidelines or protocols, developing prescriptions may be impaired and learning may be inadequate. Because prescriptions give the students a framework for a “right answer,” instructors' inability to provide prescriptions will hinder performance improvement.
• When there is clear disagreement regarding the “right answer.” Similar to the previous point, when experts disagree about appropriate intervention, instructors are limited in their ability to confidently provide learners with a new approach. Example: when providers disagree on the timing of <insert medication> delivery, the interdisciplinary team cannot be taught a shared mental model of when <medication> should be given.
• If there is a significant existing knowledge gap. Rapid cycle deliberate practice microdebriefs are meant to provide quick feedback about current performance, provide an opportunity to quickly understand learners' current framework, and provide a practical solution to improve performance. The efficiency of this model requires that knowledge gaps be addressed outside of the simulation setting, using a more appropriate instructional strategy. Example: Learners who are unfamiliar with the signs and symptoms of anaphylaxis should be provided with prereading before attending an RCDP simulation teaching how to manage anaphylaxis.
• If there is no access to contextually relevant training resources. Example: difficult airway training without a fiberoptic scope will not allow teams to understand the team choreography of how to incorporate that aspect of the algorithm in that training.

WHAT DOES AN RCDP COURSE LOOK LIKE?

Rapid cycle deliberate practice's design process is similar to other simulation strategies, but its implementation is a very different experience for the instructor and the participants. A comparison of traditional simulation and RCDP is found in Table 1 Supplement 1. Figure 1 illustrates the process of the “Feedback-replay loop,” which is unique to RCDP.

TABLE 1 - Comparison of Traditional Simulation Design and RCDP Simulation Design

Traditional Simulation40	RCDP12
Pre-event curricular design with needs assessment to establish the session's goals and learning objectives	Pre-event curricular design with needs assessment to establish the session's goals and learning objectives. Identify performance metrics for learning objectives
Learner orientation to the simulation,41 including: • Introduction to environment • Expectations during simulation • Confidentiality • Strengths and weaknesses • Logistics • Solicitation of thoughts • Psychological safety	learner orientation, which includes content from traditional simulation orientation as well as specific information about RCDP training, including the following: • Description of the “instructor-as-coach” paradigm • Explanation of the feedback-replay loop • Explanation of feedback prescriptions • Acknowledgment of the natural tendency to become defensive • Request for commitment to receive feedback from their coach
Simulated patient event	Gap analysis simulation
Postscenario debriefing (identification of knowledge and performance gaps and learner self-reflection), with the goal of developing a plan for improved performance in future events42	Initial debriefing,43 which evaluate the learners' understanding of performance goals, compare performance to established standards, and create baseline performance levels for use during the rapid cycle process.
(Optional) Repeat of the same or similar patient scenario7	Feedback-Replay Loop Uses pauses for expert coaches to provide timely and specific feedback to improve an underperformed skill by providing specific solutions, which we call “performance prescriptions.” Scenarios are rewound so an entire scenario or a portion of a scenario is repeated, allowing learners to practice until they achieve the established objective.
	(Optional) Final, uninterrupted scenario

FIGURE 1: Elements of the feedback-replay loop (pause-prescribe-perform).

CORE COMPONENTS OF RCDP

Embedded within the model of RCDP are several well-established instructional strategies, educational concepts, and core components. These include deliberate practice, mastery learning, contextualization, observable learning objectives, formative assessment, debriefing, feedback-replay loop, solution-sharing, and scaffolding. A description of each and how they are incorporated in RCDP are included in Table 2.

TABLE 2 - Core Components of RCDP

Instructional Technique	Definition	How It Is Applied in RCDP
Deliberate practice	A model of training activities that involve repetitive performance in a focused domain, coupled with rigorous skills assessment and specific and progressive formative feedback by an expert trainer or “coach.”32 This model has been proven to lead to progressively improved performance in a controlled setting.44	Allow the learner to repeat specific aspects of their performance (ie, quality of chest compressions), using the facilitator to provide immediate and specific feedback between attempts.
Mastery learning	Partners repetitive deliberate practice and robust feedback and measures performance against a predetermined standard.45 In mastery learning the curriculum and learner performance is fixed, and the time each learner takes to achieve mastery performance varies. There is increasing evidence of mastery learning's effectiveness in improving clinician performance.9,43,45,46	Though the entire course time is usually not variable, the number of repetitions, timing of interruption, and feedback provided varies with learner performance.
Contextualization	When learners are challenged by things that interest them, their intrinsic motivation increases and the knowledge and skills are more likely to be embedded in long-term memory.47 We found it to be important to translate skills into the context in which they will be used.	Contextually relevant basic life support skills for our medical students included performing on full-body manikins in beds (rather than the traditional course, using a torso on the floor).15
Specific, observable learning objectives (including measurable metrics)	RCDP is most effective when instructors are clear about which performance behaviors are the training focus. Learners are then aware of which objectives are essential and will get the most repetition. Performance metrics provide clarity regarding how instructors measure and evaluate when objectives are met.
Formative assessment	RCDP should target instruction at skills that are just beyond learners' current ability level.48,49 Learners need honest and frequent feedback on what they know and what they do not know (their currently level of expertise). Timely feedback has been shown to deepen one's memory for the assessed content.50	Instructors pause when an error is made, then describe current performance and expected performance. Debriefing and prescriptions are provided to improve next practice cycle.
Debriefing (initial, debriefing styles)	Initial debriefing allows learners to offer their initial reactions. The initial debrief takes longer than subsequent microdebriefings, and instructors may use any method of debriefing necessary to investigate learners' current understanding.14 Initial debriefing includes sharing evidence-based goals and performance metrics. Instructors do not need to address all aspects of the learners' performance because there will be ample opportunities in subsequent RCDP microdebriefings.	Time reserved to investigate learner performance and share protocols, algorithms, and team performance.
Feedback-replay loop and Microdebriefing	Instructors will pause when observing errors that breach the identified performance standards, supporting immediate reflection and correction.51 There should be enough scenarios to allow learners to achieve the essential learning objectives. Feedback should include sharing performance data, quantifying any breached standards and then provide a prescription to improve performance. Subsequent scenarios progressively raise expectations of learner performance.	Expert coach observes the team delivering IM epinephrine >5 minutes after the beginning of anaphylaxis. Coach pauses the team. Coach shares the standard breached, how long the team took and what the standard is. Elicit feedback from learners as appropriate. Provide feedback on inefficiencies in team performance; specific performance changes to make.
Solution-sharing (prescriptions)	offering solution-oriented feedback, with coaches providing specific evidence-based or expert-derived solutions, known as prescriptions	providing scripted language, such as the use of “action-linked phrases,”52 narrowing performance gaps and promoting a shared mental model of patient care
Scaffolding	Involves instructor assistance to support learner mastery of tasks or concepts just beyond his/her current capability.48 Learners are allowed to complete as much of a task as possible, unassisted. Errors are expected, and with feedback, prompting, and other educational supports the learner is able to achieve his/her goal. Provides support during the learning process that would not usually be available clinically, then gradually removed (“faded”), allowing the learner to perform with only tools that would be available in the real environment.	Breaking a task into smaller parts Poster of algorithm in room during the beginning of an RCDP session, removed by the end of training. Cue cards or verbal reminder from expert coach during simulation.

VARIABLE COMPONENTS OF RCDP

There are some components of RCDP that have been described in the literature that may fluctuate or not always be present. These include gap analysis scenarios, learner group size, learner role variation, subsequent scenario difficulty, and types of expert coach interventions.

Gap Analysis Scenario

The first RCDP scenario should proceed uninterrupted, acting as a gap analysis and providing the data for use in debriefing. This is an opportunity for the instructor to complete a formative assessment, as it provides insight into the learners' current performance level. The gap analysis is also part of the learning process, because trying to recall previously known information can actually aid in long-term memory storage and recovery.⁴⁷

The gap analysis simulation varies in length depending on the total teaching time but should last long enough for the instructor to evaluate the learners' ability to meet course objectives. For a typical resuscitation-focused scenario, this phase tends to range from 3 to 12 minutes.

There may be times when a gap analysis simulation can be foregone or truncated. One example may be if the needs assessment identifies that learners have no experience with the topic, and thus, current performance can be assumed to be poor. Alternatively, a video example of model performance can be shown to learner groups in lieu of a gap analysis simulation. This primes learners with an example of perfect performance and allows coaches to spend more time in feedback replay.

Learning Group Size

Determining the size of the learning group is part of the needs assessment and initial course design. Our general guideline suggests having learner sizes that approximate what is present clinically and include the roles that would typically exist. Generally speaking, learners are not able to consistently engage in groups larger than 8 to 10 people, so we may divide into smaller groups, with one group observing. Groups can switch between feedback-replay loops.

Learner Role Variation

Our goal is to have learners successfully complete the psychomotor skills necessary for their clinical role. For instance, when teaching a cardiac arrest scenario, all learners should place defibrillator pads and perform chest compressions, because those are skills anyone could perform. By contrast, only those who are expected to intubate would perform that role in a difficult airway scenario.

Subsequent Scenario Difficulty

Lemke et al¹⁴ defined RCDP specifically as including “progressive difficulty.” Hunt et al¹² described a progression of pediatric rapid response scenarios, beginning with respiratory distress and ending with cardiac arrest requiring defibrillation. Successive scenarios should raise performance expectations, but many clinical situations do not require more complex cases to build on previous learning objectives. Progressing in the case may be sufficient, such as a case that starts with respiratory distress and progresses to respiratory arrest, then cardiac arrest. The same case is used, with learning objectives building as the case continues along the same trajectory.

Types of Instructor Interventions

Whenever possible, instructors should use objective metrics when providing feedback. Although the term metrics often assumes specific data, there are many options available to instructors. The key is that metrics should be relevant to the learning objective. We have listed examples hereinafter:

• Time to completion (eg, medication delivery, equipment to bedside, defibrillation, etc)
• Medication dosage
• Quality of performance (eg, compression depth, rate, recoil)
• Language used (eg, verbalize diagnosis, using team members' names, closed-loop communication, action-linked phrases)

The type of prescriptions, supports, and scaffolding that instructors provide can also vary. Examples of scaffolding tools that can be provided for learners include the following:

• Action-linked phrases (eg, “There's no pulse, I'm starting compressions.”)⁵²
• Think-aloud(s)
• Demonstration of ideal performance
• Visual aids (eg, copy of algorithm on a poster or answers written on board)
• Metronome

Specific RCDP feedback and debriefing techniques used are at instructor's discretion. Although they are generally more directive than in traditional postevent debriefings,¹⁴ learner engagement should be solicited throughout, and debriefing/feedback techniques and time allotted depend on learner need and instructor preference.

Rapid Cycle Deliberate Practice FUTURE DIRECTIONS

Because we are in the beginning stages of studying the RCDP instructional method, there are many exciting questions to explore, which may include long-term performance, ideal placement and spacing of RCDP programs, learner and instructor fatigue, and debriefing style used.

Long-Term Memory Consolidation

We have evidence that RCDP helps with initial skills acquisition, but less clear on its impact to long-term memory. Magee et al¹⁸ found improvement in neonatal resuscitation performance, which was not sustained at a 4-month follow-up. It is unclear whether RCDP can improve long-term performance, and this is an area requiring more investigation.

Rapid cycle deliberate practice attempts to work within the limits of short-term and working memory⁵³ and uses strategies to break important concepts into smaller chunks⁵⁴ and repeat important concepts throughout the training.⁵⁵ Cognitive psychology studies how best to support long-term memory consolidation, and the results from this field will help better inform RCDP implementation.

Spaced Learning

Rapid cycle deliberate practice is a massed learning technique, meaning that all learning occurs in a single session. Studies in cognitive psychology have suggested that spaced learning can aid in long-term memory consolidation,^47,56 Sullivan et al¹⁶ showed positive performance outcome using RCDP in learning activities spaced at 3-month intervals, and this deserves additional study.

Fatigue

Ericsson and his team suggested that deliberate practice be provided in short sessions, which maximizes learner concentration to sustain active efforts to improve.³² Feedback from a pilot research study noted instructor and learner fatigue as a byproduct of RCDP training.¹⁴ Thus, consideration of either shorter training sessions (less than 2 hours) and/or breaks for learners and instructors may be important.

Debriefing Versus Feedback

Deliberate practice assumes a focus on correcting observable behaviors (what learners do) while de-emphasizing learner rationale (why they are doing it). Because postevent debriefing techniques focus on the rationale, RCDP can seem to live “at odds” with traditional simulation debriefing strategies.^43,57 Learner rationale should be carefully considered and be part of the microdebriefing process and selection of prescriptions. Rather than being at odds with reflective debriefing, RCDP is another teaching tool to be used when appropriate.

CONCLUSIONS

Rapid cycle deliberate practice evidence strongly suggests that its use can positively impact clinician performance. A shared cognition and established rigor are needed to assure that all RCDP courses and research share consistent foundations, and definitive conclusions can be made, which will iteratively improve the future of RCDP.