Home > Research > Project 12

The Deteriorating Patient Smartphone-based TRE: How can learners’ achievement emotions guide the design of a new technology-rich learning environment?



  • Jeff Wiseman (McGill U., Theme 1)
  • Susanne P. Lajoie (McGill U., Theme 1)

Research Assistant:

  • Tara Tressel (McGill U.)


Today’s medical students are digital natives who comfortably use online social media and smartphones to exchange their own and others’ narratives and media as a part of their daily lives. (Zickuhr, 2011). Preparing medical students to approach an emergency or other emotionally challenging clinical situation is an important educational goal: Deliberate practice with multiple examples and feedback (Ericcson, 2004) are essential for learning. Changes in learners’ call schedules and demands on clinicians’ time impose increasing constraints on students’ opportunities to safely practice these skills with feedback in clinical environments (Gordon, 2000). High-fidelity simulations are available in many schools however they are expensive, can accommodate limited numbers of learners at a given time, are logistically complex to set up and are thus not readily available for learners’ deliberate practice with feedback. The universally used “ABCDEFG” emergency care mnemonic (Thim, 2012) is a hierarchical list of the treatable medical problems that can cause a patient to die within 5-10 minutes – too rapidly to permit a clinician the time needed for iterative hypothesis testing. Properly used, this mnemonic may help learners deal with some of the challenges of an emergency situation.

Instructional design in medicine is largely based upon the traditional 4-part cycle of learning objectives, instructional strategies and evaluation methods for a given context. (Amundsen, 2004) (Mayer, 2010). Emotions in the domain of medical education have been poorly defined and explored (Fraser, 2012) and many investigators see emotion as an essential but too often ignored fifth part of the educational cycle. (Pekrun R. , Emotions as Drivers of Learning and Cognitive Development, 2011) (Boekaerts, 2010).

The Deteriorating Patient Activity (DPA) (Wiseman, 2008) (Lu, 2009) (McGillion, 2011) is an inexpensive, logistically simple and rapidly deployable low-fidelity simulation that reproduces learners’ emotions engendered by an emergency and provides opportunities for deliberate practice and feedback within a safe classroom environment. The objective of this activity is to help students learn how to gain control of an unstable clinical scenario. The clinical teacher takes on and moves between the roles of a patient with deteriorating clinical signs, vital sign recorder and nurse. Students have to apply the ABCDEFG framework to decide what steps to take in treating or stabilizing the situation, which evolves in response to their actions. The tutor can provide students with hints in the form of negative or positive emotional as well as cognitive stimuli. Throughout the activity, students get the opportunity to compare their thinking to that of an expert as well as to more senior students. During debriefing, students are supported by the teacher in reflection on their actions during the scenario.  Students perceive that this activity is effective in improving their decision making, motivating and stressful since the “patient” can “die”.

Although clinical teachers can readily learn how to teach using a DPA, they must be present and have the time to provide this simulation and afford students deliberate repeated practice with feedback. The Digital Deteriorating Patient Activity (DDPA) project (Blanchard, The online deteriorating patient: An adaptive simulation to foster expertise in emergency decision-making, 2010) (Blanchard, A realistic digital deteriorating patient to foster emergency decision-making skills in medical students, 2012) aimed at overcoming these issues by offering an online computer-supported version of the DPA to much larger numbers of learners. Teachers and students from McGill University Faculty of Medicine used a preliminary version of the DDPA to validate core technological design decisions. This pilot project confirmed that the software reacted according to medical knowledge built into the system by the expert.

The current project aims to use learners’ achievement emotions to guide the development of a set of software applications that will build on lessons learned from the pilot version – a Deteriorating Patient smartphone “app” (DPSA) that is portable, accessible anywhere and at any time, can be reviewed as many times as needed and that does not need a live tutor. It would permit case developers to insert changes in the “patient’s” clinical condition in response to learners’ actions or independent of them, thus varying learners’ perceptions of control and eliciting learners’ achievement emotions of varying valence and activation. It would leverage the skills of today’s digital natives to support online feedback and debriefing among learners and tutors, thus supporting the creation of a community of live and digital learners and tutors.