What is integrated cognitive simulation? How is it changing the face of teaching and learning in the healthcare sector?

For many of us, the best way to learn is to have a go: to take as many turns as we need to get it right. Practice makes perfect. But what if having a go has consequences? What if getting it wrong has higher stakes that can’t be resolved by simply pressing the restart button?

When it comes to healthcare education, mistakes have consequences. Consequences for patients, for students, their teachers, and their teaching institutions. These concerns motivated Professor John Windsor at the University of Auckland’s School of Medicine to help create a new way of training healthcare professionals. John’s innovation, along with his colleagues, was to develop the concept of cognitive simulation for learning clinical and operative procedures. The key was for students to learn in a risk-free environment. We asked John to tell us about his approach to teaching and learning and what the implications are for training healthcare professionals now and in the future.

Tell us about “integrated cognitive simulation”.

I coined the term “integrated cognitive simulation” to describe my approach because it makes use of the fact that doing a procedure involves two aspects: cognitive and technical.

The cognitive aspect of a procedure is understanding what to do, which instruments to use, in the proper order. Healthcare professionals need to make a lot of correct decisions to achieve the best outcome. You don’t have to perform a procedure in real life to master the cognitive aspect. In fact, learning online allows the cognitive aspect to be embedded before the distraction of the technical aspect of a procedure. The technical aspect is the hands-on part, where the procedural knowledge is put into practice in a physical setting with real instruments and models.

The integrated part of integrated cognitive simulation is important too. Students learn in different ways and through different media, which trigger different parts of the learner’s brain. From the outset, our concept was to bring different media together in one place, to link them and to allow the learner to have a rich, flexible and multi-dimensional learning experience. The media are integrated into a single learning package which includes illustrated instructional text, videos of experts performing procedures to demonstrate best practice, quizzes, and interactive 2D and 3D anatomy models for each procedure. The final and most important learning media is the simulation and this has different modes:  learning (with prompts and reinforcements), practice (a mock test) and testing (to allow determination of mastery).

The simulation takes on-line learning to a deeper level than conventional e-learning methods or common teaching techniques. It allows students to go step by step through the procedures by making a series of decisions. If the correct decision is made the procedure will progress. If the wrong decision is made, it is logged and must be corrected. Learning mode provides assistance so that the learner receives immediate feedback, making the learning interactive. In the practice and testing modes, there is no assistance.

The web-based simulations are an integral part of the cognitive learning. They allow students to master the steps and decisions in a procedure before they use a lab, practice on each other, or enter the clinical environment. Where the stakes are high, students will also be advised to use hands-on time to concentrate on their technical performance, having already mastered the cognitive knowledge required to successfully complete a procedure.

What does this way of learning mean for healthcare education now?

The web is democratizing learning. Students who don’t live close to their institution can still learn and practice their cognitive procedural skills. Students now have access to learning support and feedback whenever and wherever they choose. Web-based learning extends the reach of healthcare education to anyone with an internet connection, anywhere in the world, whether it’s a novice medical assistant on a remote island in Alaska, or a young doctor learning ultrasound in Nepal.

For healthcare students, integrated cognitive simulations allow them to learn at their own pace with limitless opportunities to practice and gain feedback. Confidence is gained without the anxiety of being observed by peers or instructors.  Further, this approach to learning allows the learner to identify the areas that require additional effort which means that their interaction with instructors can be more focused and targeted.

For instructors, the ability to monitor learning is an important aspect of the simulation platform.   Students who are struggling or not engaged are easily identified through the summary and detailed reports. The parts of procedures that present the most challenge to the students are also apparent. This means that in-person classroom and lab time time can be focused on needs of individual students. More time is also available for complex questions and informed discussions about procedures.  So, prior online simulation experience optimizes the time with instructors in the laboratory.

Because integrated cognitive simulation is web-based, resources can be kept current with evidenced-based guidelines. Textbooks often date quickly, but in the online environment, text, the teaching videos and the simulations can easily be modified to keep pace with innovations in the field.

What does this way of learning mean for healthcare education in the future?

With students increasingly using digital environments in their social worlds, starting their healthcare careers with digital resources like online-simulation gives them tools they are comfortable with. Simulation technology is leading the way for the training of future health care workers. This approach is a low cost, flexible and effective new way to teach healthcare students.

The future for IT in healthcare is very exciting, and the educational space is part of that.  One of the exciting and natural developments for online simulation is in support of personalized medicine. When learning simulations can be integrated with artificial intelligence that draws on patient-specific data, treatment for an individual patient could be modelled with greater accuracy than ever possible before. Healthcare professionals will be able to practice the relevant procedure with specific patient parameters.

And even further out, teaching clinical and medical procedures will likely move into total immersive learning environments using virtual and augmented reality. With this type of technology readily available, this development will become important in procedural learning.


It’s hard not to be excited about this vision for healthcare training and provision in the future. But for now, it’s good to know healthcare professionals like John are pushing the boundaries for teaching and learning, developing tools like integrated cognitive simulation to create powerful learning experiences for the healthcare professionals of tomorrow.


We’d like to thank Professor John A. Windsor for assistance with this article.

Professor Windsor has a personal Chair in Surgery at the University of Auckland and is a Consultant Surgeon at Auckland City Hospital.  Following training in General Surgery in New Zealand, he completed Fellowships in HBP/Upper GI, Vascular and Colorectal Surgery during a 2-year period in Edinburgh, Scotland. Returning to NZ in 1992 he established a specialty practice in HBP and Upper GI Surgery, setting up the first HBP/Upper GI Unit in NZ in 1994. His surgical interests include laparoscopic surgery, pancreatic disease and gastro-oesophageal disease. Professor Windsor is widely credited with coining the phrase Integrated Cognitive Simulation, and is founder of SIMTICS, that provides simulation technology that assists in healthcare learning.