Cognitive Load and Self-Determination Theories Applied to E-Learning: Impact on Students' Participation and Academic Performance

Background
Emergency clerkships expose students to a stressful environment that require multiple tasks, which may have a direct impact on cognitive load and motivation for learning. To address this challenge, Cognitive Load Theory and Self Determination Theory provided the conceptual frameworks to the development of a Moodle-based online Emergency Medicine course, inspired by real clinical cases.
Methods
Three consecutive classes (2013–2015) of sixth-year medical students (n = 304) participated in the course, during a curricular and essentially practical emergency rotation. “Virtual Rounds” provided weekly virtual patients in narrative format and meaningful schemata to chief complaints, in order to simulate real rounds at Emergency Unit. Additional activities such as Extreme Decisions, Emergency Quiz and Electrocardiographic challenge offered different views of emergency care. Authors assessed student´s participation and its correlation with their academic performance. A survey evaluated students´ opinions. Students graduating in 2015 answered an online questionnaire to investigate cognitive load and motivation.
Results
Each student produced 1965 pageviews and spent 72 hours logged on. Although Clinical Emergency rotation has two months long, students accessed the online course during an average of 5.3 months. Virtual Rounds was the most accessed activity, and there was positive correlations between the number of hours logged on the platform and final grades on Emergency Medicine. Over 90% of students felt an improvement in their clinical reasoning and considered themselves better prepared for rendering Emergency care. Considering a Likert scale from 1 (minimum load) to 7 (maximum load), the scores for total cognitive load were 4.79±2.2 for Virtual Rounds and 5.56±1.96 for real medical rounds(p<0,01).
Conclusions
A real-world inspired online course, based on cognitive and motivational conceptual frameworks, seems to be a strong tool to engage students in learning. It may support them to manage the cognitive challenges involved in clinical care and increase their motivation for learning.

背景
急诊临床见习会让学生置身于需同时处理多项任务的高压临床环境，这会直接影响其认知负荷与学习动机。为应对这一挑战，研究团队以认知负荷理论（Cognitive Load Theory）和自我决定理论（Self Determination Theory）为概念框架，开发了一款基于Moodle平台的急诊医学在线课程，课程内容取材于真实临床病例。

方法
本研究纳入2013至2015年连续三届六年级医学生（总样本量n=304），所有受试者均参与了基于急诊轮转必修实践阶段开设的本课程。“虚拟查房（Virtual Rounds）”模块每周推送叙事性格式的虚拟病例，并针对患者主诉提供结构化梳理框架，以此模拟急诊科室的真实查房流程。此外，“极端决策”“急诊测验”与“心电图挑战（Electrocardiographic challenge）”等拓展活动，从多维度呈现急诊诊疗场景。研究者对学生的课程参与度及其与学业成绩的相关性进行了分析，并通过问卷调查收集学生的反馈意见。其中，2015届毕业生需完成线上问卷，以评估其认知负荷与学习动机水平。

结果
全体学生的人均页面浏览量为1965次，平均在线登录时长为72小时。尽管急诊临床轮转的官方时长为2个月，但学生们平均耗时5.3个月完成本在线课程的学习。虚拟查房模块的访问量最高，平台登录时长与急诊医学最终课程成绩呈显著正相关。超过90%的学生认为自身临床思维能力得到提升，且自认为能更熟练地开展急诊诊疗工作。采用1分（负荷最低）至7分（负荷最高）的李克特量表（Likert scale）进行评分，虚拟查房模块的总认知负荷得分为4.79±2.2，真实临床查房的总认知负荷得分为5.56±1.96，两组差异具有统计学意义（p<0.01）。

结论
基于认知与动机理论框架开发、取材于真实临床场景的在线课程，可有效激发学生的学习积极性，是一款极具应用价值的教学辅助工具。该课程能够帮助学生应对临床诊疗中的认知挑战，同时提升其学习动机。