The authors have no acknowledgements.

All methods described here were found to be exempt from review by the Indiana University Institutional Review Board.
1. Preparation
<ol>
	<li>E-mail the GRIEV_ING pocket card (Figure 1) to all faculty one week prior to the scheduled simulation session.</li>
	<li>E-mail the death notification simulation scenarios (<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61646/JoVE RCDP Standardized Patient Case Materials.docx" target="_blank">Supplement 1</a>), that include patient role and background history, to the standardized patients one week prior to the scheduled simulation session.</li>
	<li>Prepare the simulation examination rooms prior to beginning the death notification simulation exercise.
	<ol>
		<li>Place a chair for the standardized patient and a stool for the learner in each examination room.</li>
		<li>Print patient scenario information (<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61646/JoVE RCDP Patient Scenario Information door note.docx" target="_blank">Supplement 2</a>), which includes name, age, gender, background, present condition and survivor present, and post outside each exam room for learners. Have faculty read death notification scenarios prior to the start of the session.</li>
	</ol>
	</li>
</ol>
2. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise Pre-brief
<ol>
	<li>Gather all faculty and learners in one room. Review the simulation session goals and objectives.</li>
	<li>Review logistic details about RCDP and the simulation environment.</li>
	<li>Form a fiction contract with the learners and pledge to respect the learners.&#160; 
	NOTE: A fiction contract is an agreement between the educators and learners. This creates the expectation that educators attempt to create as realistic of simulation environment as possible while the learners pretend that things are real and actively participate in the educational experience14.</li>
	<li>Divide the learners into groups of no more than 4-5 learners.</li>
	<li>Assign each learner group an examination room with a faculty member and standardized patient.</li>
	<li>Give each learner a GRIEV_ING pocket card to reference during the simulation (Figure 1).</li>
</ol>
3. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise
<ol>
	<li>Select one learner from each group to perform the initial death notification scenario.</li>
	<li>Position the standardized patient in the exam room. Have the learners to review the simulation scenario case details posted outside the exam room.</li>
	<li>Start the initial death notification scenario. Run the scenario from start to finish without interruption. Identify specific areas that necessitate feedback.</li>
	<li>Perform a micro-debriefing at the conclusion of first scenario. Give succinct feedback to learners on initial performance in less than 5 minutes.</li>
	<li>Reset the scenario and place the learners outside the room. Perform the same simulation scenario from the beginning. Begin with the same learner as the leader for the second round of the scenario.</li>
	<li>Apply the RCDP technique during the scenario. Pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. Have the standardized patient to restart the scenario. 
	NOTE: In order to allow multiple students to participate in a single scenario, faculty can switch out the participating learner by &#8220;tagging in&#8221; observing students to continue the scenario. For example, if John started the scenario, faculty can stop, give feedback and rewind the scenario. Faculty then &#8220;tags in&#8221; Sam to resume the scenario as the new active participant from where John left off. Faculty should make sure all learners have an opportunity to be in the &#8220;hot seat&#8221; throughout the allotted training time.</li>
	<li>Perform a micro-debriefing at the conclusion of the scenario training period. Provide constructive feedback to the learners.</li>
	<li>Repeat the scenario again from the start and continue with the RCDP approach. 
	NOTE: The goal is to need less interruptions each time the scenario is performed. The RCDP simulation exercise requires 45-50 minutes.</li>
</ol>
4. Rapid Cycle Deliberate Practice GRIEV_ING Wrap Up
<ol>
	<li>Gather all faculty and learners in one room for a group wrap-up at the conclusion of the simulation training. Focus on key take-home points from the training and allow for learner feedback during the 15 minute wrap-up.</li>
</ol>

<ol>
	<li>National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables. Centers for Disease Control and Prevention Available from: <a target="_blank" href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf">https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf</a> (2016)</li><li>Waiters, D. T., Tupin, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Family+grief+in+the+emergency+department.">Family grief in the emergency department.</a> Emergency Medicine Clinics of North America. 9 (1), 189-206 (1991).</li><li>Breslau, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trauma+and+posttraumatic+stress+disorder+in+the+community:+the+1996+Detroit+area+survey+of+trauma.">Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma.</a> Archives of General Psychiatry. 55 (7), 626-632 (1998).</li><li>Stewart, A. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complicated+bereavement+and+posttraumatic+stress+disorder+following+fatal+car+crashes:+recommendations+for+death+notification+practice.">Complicated bereavement and posttraumatic stress disorder following fatal car crashes: recommendations for death notification practice.</a> Death Studies. 23 (4), 289-321 (1999).</li><li>Shoenberger, J. M., Yeghiazarian, S., Rios, C., Henderson, S. O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Death+Notification+in+the+Emergency+Department:+survivors+and+physicians.">Death Notification in the Emergency Department: survivors and physicians.</a> Western Journal of Emergency Medicine. 14 (2), 181-185 (2013).</li><li>Park, I., Gupta, A., Mandani, K., Haubner, L., Peckler, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Breaking+bad+news+education+for+emergency+medicine+residents:+A+novel+training+module+using+simulation+with+the+SPIKES+protocol.">Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol.</a> Journal of Emergencies, Trauma, and Shock. 3 (4), 385-388 (2010).</li><li>Hobgood, C., Harward, D., Newton, K., Davis, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+educational+intervention+"GRIEV_ING"+improves+the+death+notification+skills+of+residents.">The educational intervention "GRIEV_ING" improves the death notification skills of residents.</a> Academic Emergency Medicine. 12 (4), 296-301 (2005).</li><li>Chancey, R. J., Sampayo, E. M., Lemke, D. S., Doughty, C. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Learners'+Experience+During+Rapid+Cycle+Deliberate+Practice+Simulations:+A+Qualitative+Analysis.">Learners' Experience During Rapid Cycle Deliberate Practice Simulations: A Qualitative Analysis.</a> Simulation in Healthcare. 14 (1), 18-28 (2019).</li><li>Hunt, E. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pediatric+resident+resuscitation+skills+improve+after+"rapid+cycle+deliberate+practice"+training.">Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training.</a> Resuscitation. 85 (7), 945-951 (2014).</li><li>Taras, J., Everett, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+Cycle+Deliberate+Practice+in+Medical+Education-+a+Systematic+Review.">Rapid Cycle Deliberate Practice in Medical Education- a Systematic Review.</a> Cureus. 9 (4), 1180 (2017).</li><li>Ahmed, R. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rapid+Cycle+Deliberate+Practice:+Death+Notification.">Rapid Cycle Deliberate Practice: Death Notification.</a> The Clinical Teacher. , (2020).</li><li>Stephenson, E., Poore, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tips+for+Conducting+the+Pre-Brief+for+a+Simulation.">Tips for Conducting the Pre-Brief for a Simulation.</a> The Journal of Continuing Education in Nursing. 47 (8), 353-355 (2016).</li><li>Rudolph, J. W., Raemer, D. B., Simon, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Establishing+a+safe+container+for+learning+in+simulation:+the+role+of+the+presimulation+briefing.">Establishing a safe container for learning in simulation: the role of the presimulation briefing.</a> Simulation in Healthcare. 9 (6), 339-349 (2014).</li><li>Hughes, P. G., Hughes, K. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Briefing+Prior+to+Simulation+Activity.">Briefing Prior to Simulation Activity.</a> StatPearls. , (2020).</li></ol>

The authors have nothing to disclose.

The RCDP death notification curriculum consists of several critical steps. First, the prebrief is critical to introduce the concept of RCDP and create psychological safety for learners. Learners who feel psychologically safe have less anxiety and feel more comfortable making mistakes, allowing for optimization of the learning experience13,14,15. In addition, the curriculum requires that educators provide learners with an overview of the GRIEV_ING framework and death notification materials prior to the simulation session. This allows the students to be more engaged in the simulation and use the session to refine death notification skills. Each learner is given a GRIEV_ING pocket card during simulation session. Learners in an observational role are able to follow along and remain actively engaged. Possible modifications of this simulation protocol include altering group size or providing the GRIEV_ING pocket card to the learners prior to the event.
During the simulation, a key step is running the first death notification scenario from start to finish without interruption. This needs assessment displays the learner&#8217;s baseline skill and enables the faculty member to identify areas of weakness and provides a roadmap when subsequently implementing the RCDP technique. RCDP provides the student an opportunity to incorporate the feedback provided and demonstrate optimal performance. It allows learners to practice through repetition with expert feedback and direct coaching. Faculty can correct performance gaps while maximizing the time spent practicing. This has been shown to increase learning without cognitive overload9.
Lastly, it is critical to repeat the same scenario again from the start and continue with the RCDP approach. The goal is to have fewer interruptions each time the scenario is performed. This allows learners to continuously improve throughout the simulation session and leads to mastery9,10,11. This differs from traditional simulation training in that faculty can immediately visualize improvement in performance.
There are few limitations to executing the RCDP death notification curriculum. This exercise does not require any particular equipment or setup. It does require one standardized patient per every 4-5 learners. Standardized patients should be trained and have experience playing the role of a grieving patient. This training includes acting methods on how to accurately portray psychosocial characteristics and emotions. It can be provided by the simulation staff or standardized patient liaison. In addition, faculty must be knowledgeable in RCDP in order to use this technique successfully in the training. Lack of faculty with formal simulation training and experience using RCDP creates practice variation. This introduces subjectivity into the training experience.
Currently, there is limited literature on improving delivery of bad news using RCDP. This innovative technique allows learners to rewind and practice each part of the scenario until mastery is achieved. Future directions for this study include assessment of skill retention using the RCDP technique, directly comparing this technique to traditional simulation approaches, and investigating how this curriculum translates to effectiveness of death notification in the clinical environment.

Death notification is an important and challenging aspect of Emergency Medicine. An emergency medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. On average 270,000 patients die in United States emergency departments each year1. This number is anticipated to increase as the population ages2. Unskilled death notification can lead to the development of pathologic grief and posttraumatic stress disorder3,4,5. It is paramount for emergency medicine physicians to be trained in and practice death notification.
Graduate and undergraduate medical educators employ a variety of death notification techniques when teaching residents and medical students to deliver bad news6,7,8. One example is the GRIEV_ING curriculum. It provides medical personnel a conceptual framework for death notification. The curriculum has demonstrated improvement in learners&#8217; confidence and competence when delivering bad news8.
Rapid Cycle Deliberate Practice (RCDP) is a simulation-based medical education technique that uses within-scenario debriefing9. This technique is based on the concepts of mastery learning and deliberate practice9,10,11. It allows educators to pause a scenario, provide directed feedback, and then let learners rewind and continue the simulation scenario the &#8220;right way.&#8221; The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news12.
In preparation for this curriculum, learners are given a 45-minute lecture on the principles of death notification and the GRIEV_ING conceptual framework. Prior to starting the simulation session, faculty perform a prebrief of the objectives, RCDP and simulation environment logistic details, establish a fiction contract with the learners and pledge to respect the learners13,14,15. The learners are split into groups of 4-5 and assigned an examination room with a faculty member and standardized patient. Each learner is given a GRIEV_ING pocket card to reference during the simulation. To start, one learner is selected from each group to perform the first death notification scenario. This first death notification serves as a needs assessment for the faculty. It is allowed to run from start to finish without interruption. Next, the same learner performs a new death notification simulation using the same scenario, this time RCDP is used by the faculty to provide feedback throughout the death notification scenario. Faculty pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. The scenario is then restarted by the standardized patient.

<table><tbody><tr><td>Chair</td><td></td><td></td><td></td></tr><tr><td>Facial Tissues</td><td></td><td></td><td>Standardized patients will need for simulated crying</td></tr><tr><td>GRIEV_ING pocket card</td><td></td><td></td><td></td></tr><tr><td>Stool</td><td></td><td></td><td></td></tr></tbody></table>

setup and execution of the rapid cycle deliberate practice death notification curriculum

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners&#8217; confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the &#8220;right way.&#8221; The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.

As noted in Ahmed et al., the study involved 22 emergency medicine residents12. Learners&#8217; median self-efficacy and knowledge scores increased from 3 to 4 and 65 to 90, respectively, when comparing pre- and post-simulation results. In addition, pre- and post-intervention death notification performance scores improved (Table 1).
Qualitative themes from the post-curriculum surveys by Ahmed et al. were that this exercise was a great experience and provided instant feedback12. Residents felt the RCDP Death Notification Curriculum solidified their death notification skills and allowed them the opportunity to refine their technique. Only one resident preferred the tradition simulation method with no interruptions.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/61646/61646fig01.jpg" /> 
Figure 1: GRIEV_ING pocket card.&#160;Pocket card with overview of GRIEV_ING curriculum. This figure has been modified from research by Ahmed et al.12. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61646/61646fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Pre</td>
			<td>Post</td>
			<td>P-Value*</td>
		</tr>
		<tr>
			<td>Self-efficacy Survey</td>
			<td>3.0 (3.0-4.0)</td>
			<td>4.0 (4.0-5.0)</td>
			<td>&#60;0.0001</td>
		</tr>
		<tr>
			<td>MCQ Scores</td>
			<td>65.0 (40.0-80.0)</td>
			<td>90.0 (80.0-90.0)</td>
			<td>&#60;0.0001</td>
		</tr>
		<tr>
			<td></td>
			<td>Case A</td>
			<td>Case B</td>
			<td>P-Value*</td>
		</tr>
		<tr>
			<td>Death Notification Scores</td>
			<td>78.7 (72.3-85.1)</td>
			<td>84.0 (80.9-93.6)</td>
			<td>0.0303</td>
		</tr>
		<tr>
			<td colspan="4">*estimated using Wilcoxon</td>
		</tr>
	</tbody>
</table>
Table 1: RCDP Death Notification Curriculum results. Scores from participants (N=22). Median pre- and post- scores were calculated. Wilcoxon rank sum test was used to test for score differences between pre- and post-intervention groups. All statistical analysis was performed using SAS Version 9.4. This table has been modified from research by Ahmed et al.12.

Watch this Scientific Journal Video about Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum at JoVE.com

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

The goal is to demonstrate how to apply the rapid cycle deliberate practice debriefing technique to the GRIEV_ING death notification curriculum.

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and ...

setup-execution-rapid-cycle-deliberate-practice-death-notification

Nanyang Technological University

Research

Education

JoVE Core

JoVE Journal

Nursing

Medicine

Unit 1

The Nursing Process III

SCIENTISTS IN ACTION

4.1K Views.  Florida Atlantic University Schmidt College of Medicine. The goal is to demonstrate how to apply the rapid cycle deliberate practice debriefing technique to the GRIEV_ING death notification curriculum.

Video: Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

Modulating Cognition Using Transcranial Direct Current Stimulation of the Cerebellum

Numerous studies have emerged recently that demonstrate the possibility of modulating, and in some cases enhancing, cognitive processes by exciting brain regions involved in working memory and attention using transcranial electrical brain stimulation. Some researchers now believe the cerebellum supports cognition, possibly via a remote neuromodulatory effect on the prefrontal cortex. This paper describes a procedure for investigating a role for the cerebellum in cognition using transcranial direct current stimulation (tDCS), and a selection of information-processing tasks of varying task difficulty, which have previously been shown to involve working memory, attention and cerebellar functioning. One task is called the Paced Auditory Serial Addition Task (PASAT) and the other a novel variant of this task called the Paced Auditory Serial Subtraction Task (PASST). A verb generation task and its two controls (noun and verb reading) were also investigated. All five tasks were performed by three separate groups of participants, before and after the modulation of cortico-cerebellar connectivity using anodal, cathodal or sham tDCS over the right cerebellar cortex. The procedure demonstrates how performance (accuracy, verbal response latency and variability) could be selectively improved after cathodal stimulation, but only during tasks that the participants rated as difficult, and not easy. Performance was unchanged by anodal or sham stimulation. These findings demonstrate a role for the cerebellum in cognition, whereby activity in the left prefrontal cortex is likely dis-inhibited by cathodal tDCS over the right cerebellar cortex. Transcranial brain stimulation is growing in popularity in various labs and clinics. However, the after-effects of tDCS are inconsistent between individuals and not always polarity-specific, and may even be task- or load-specific, all of which requires further study. Future efforts might also be guided towards neuro-enhancement in cerebellar patients presenting with cognitive impairment once a better understanding of brain stimulation mechanisms has emerged.

Transcranial direct current stimulation (tDCS) over the cerebellum exerts a remote effect on the prefrontal cortex, which can modulate cognition and performance. This was demonstrated using two information-processing tasks of varying complexity, whereby only cathodal tDCS improved performance when the task was difficult, but not easy.

Numerous studies have emerged recently that demonstrate the possibility of modulating, and in some cases enhancing, cognitive processes by exciting brain ...

Behavior

The Deese-Roediger-McDermott (DRM) Task: A Simple Cognitive Paradigm to Investigate False Memories in the Laboratory

The Deese,&#160;Roediger and McDermott&#160;(DRM) task is a false memory paradigm in which subjects are presented with lists of semantically related words (e.g., nurse, hospital, etc.) at encoding. After a delay, subjects are asked to recall or recognize these words. In the recognition memory version of the task, subjects are asked whether they remember previously presented words, as well as related (but never presented) critical lure words (&#39;doctor&#39;). Typically, the critical word is recognized with high probability and confidence. This false memory effect has been robustly demonstrated across short (e.g., immediate, 20 min) and long (e.g., 1, 7, 60 d) delays between encoding and memory testing. A strength of using this task to study false memory is its simplicity and short duration. If encoding and retrieval components of the task occur in the same session, the entire task can take as little as 2 - 30 min. However, although the DRM task is widely considered a &#39;false memory&#39; paradigm, some researchers consider DRM illusions to be based on the activation of semantic memory networks in the brain, and argue that such semantic gist-based false memory errors may actually be useful in some scenarios (e.g., remembering the forest for the trees; remembering that a word list was about &#34;doctors&#34;, even though the actual word &#34;doctor&#34; was never presented for study). Remembering the gist of experience (instead of or along with individual details) is arguably an adaptive process and this task has provided a great deal of knowledge about the constructive, adaptive nature of memory. Therefore, researchers should use caution when discussing the overall reach and implications of their experiments when using this task to study &#39;false memory&#39;, as DRM memory errors may not adequately reflect false memories in the real world, such as false memory in eyewitness testimony, or false memories of sexual abuse.

The Deese-Roediger-McDermott DRM Task: A Simple Cognitive Paradigm to Investigate False Memories in the Laboratory

Here we present the Deese,&#160;Roediger and McDermott&#160;(DRM) task, a tool to study false memories in the laboratory. Subjects study lists of semantically related words (e.g.,&#160;nurse, sick, etc.), and later falsely remember an unstudied word (doctor) that represents the gist, or theme, of the word list.

The Deese,&#160;Roediger and McDermott&#160;(DRM) task is a false memory paradigm in which subjects are presented with lists of semantically related words ...

Reducing State Anxiety Using Working Memory Maintenance

The purpose of this protocol is to explain how to examine the relationship between working memory processes and anxiety by combining the Sternberg Working Memory (WM) and the threat of shock paradigms. In the Sternberg WM paradigm, subjects are required to maintain a series of letters in the WM for a brief interval and respond by identifying whether the position of a given letter in the series matches a numerical prompt. In the threat of shock paradigm, subjects are exposed to alternating blocks where they are either at risk of receiving unpredictable presentations of a mild electric shock or are safe from the shock. Anxiety is probed throughout the safe and threat blocks using the acoustic startle reflex, which is potentiated under threat (Anxiety-Potentiated Startle (APS)). By conducting the Sternberg WM paradigm during the threat of shock and probing the startle response during either the WM maintenance interval or the intertrial interval, it is possible to determine the effect of WM maintenance on APS.

This protocol demonstrates how to measure anxiety-potentiated startle during the Sternberg Working Memory paradigm.

The purpose of this protocol is to explain how to examine the relationship between working memory processes and anxiety by combining the Sternberg Working ...

Extinction Training During the Reconsolidation Window Prevents Recovery of Fear

Fear is maladaptive when it persists long after circumstances have become safe. It is therefore crucial to develop an approach that persistently prevents the return of fear. Pavlovian fear-conditioning paradigms are commonly employed to create a controlled, novel fear association in the laboratory. After pairing an innocuous stimulus (conditioned stimulus, CS) with an aversive outcome (unconditioned stimulus, US) we can elicit a fear response (conditioned response, or CR) by presenting just the stimulus alone1,2 . Once fear is acquired, it can be diminished using extinction training, whereby the conditioned stimulus is repeatedly presented without the aversive outcome until fear is no longer expressed3. This inhibitory learning creates a new, safe representation for the CS, which competes for expression with the original fear memory4. Although extinction is effective at inhibiting fear, it is not permanent. Fear can spontaneously recover with the passage of time. Exposure to stress or returning to the context of initial learning can also cause fear to resurface3,4.
Our protocol addresses the transient nature of extinction by targeting the reconsolidation window to modify emotional memory in a more permanent manner. Ample evidence suggests that reactivating a consolidated memory returns it to a labile state, during which the memory is again susceptible to interference5-9. This window of opportunity appears to open shortly after reactivation and close approximately 6hrs later5,11,16, although this may vary depending on the strength and age of the memory15. By allowing new information to incorporate into the original memory trace, this memory may be updated as it reconsolidates10,11. Studies involving non-human animals have successfully blocked the expression of fear memory by introducing pharmacological manipulations within the reconsolidation window, however, most agents used are either toxic to humans or show equivocal effects when used in human studies12-14. Our protocol addresses these challenges by offering an effective, yet non-invasive, behavioral manipulation that is safe for humans.
By prompting fear memory retrieval prior to extinction, we essentially trigger the reconsolidation process, allowing new safety information (i.e., extinction) to be incorporated while the fear memory is still susceptible to interference. A recent study employing this behavioral manipulation in rats has successfully blocked fear memory using these temporal parameters11. Additional studies in humans have demonstrated that introducing new information after the retrieval of previously consolidated motor16, episodic17, or declarative18 memories leads to interference with the original memory trace14. We outline below a novel protocol used to block fear recovery in humans.

Conditioned fear can be diminished through an inhibitory process called extinction, but can resurface under conditions such as the passage of time or exposure to stress. Our protocol presents a novel way of preventing fear recovery by introducing extinction during the reconsolidation window (the re-storage phase of a reactivated memory).

Fear is maladaptive when it persists long after circumstances have become safe. It is therefore crucial to develop an approach that persistently prevents ...

Neuroscience

Using a Classroom-Based Deese Roediger McDermott Paradigm to Assess the Effects of Imagery on False Memories

Associated word list procedures can elicit false memories in predictable ways by inducing associative processing, thus making it harder to monitor the accuracy of memories. The purpose of the method presented here was to induce false memories using lists of either semantically or phonologically related words and to assess the effects of imagery instructions on the recall and recognition of those false memories. To do this, we used a modified version of the Deese Roediger McDermott (DRM) paradigm. We adapted word lists from previous DRM studies to suit imagery procedures and created an automated presentation to present the word lists in classroom settings. We then recruited undergraduate classes and instructed some of the classes to create mental images of the list words as they were being presented, while instructing the other classes to simply remember the words. The automated presentation presented word lists to participants, one word at a time, alternating between phonologically and semantically related lists. Participants used paper-pencil recall packets to immediately recall list items, complete a distractor activity, and take a subsequent final recognition test. Often, participants immediately recalled and later recognized words that were related to the list items but were not actually presented; these are known as critical lures and indicate a false memory. The protocol detailed here describes a four-step procedure - list presentation, immediate recall, distractor phase, and final recognition - that can assess the effects of list type and imagery instruction within the DRM paradigm on memory. The automated nature of the list presentation provides the ability to systematically vary variables of interest, and the paper and pencil method of data collection affords an easily accessible method for collecting data in classroom settings. The protocol also offers options to modify the procedure to a more traditional DRM paradigm without imagery and/or list type manipulations. The use of this protocol can provide results relevant to both classroom learning and cognitive science principles.

The method presented here induced false memories using lists of related words and also assessed the effects of imagery instructions on the recall and recognition of those false memories. This protocol details a modified version of the Deese Roediger McDermott (DRM) paradigm.

Associated word list procedures can elicit false memories in predictable ways by inducing associative processing, thus making it harder to monitor the ...

Using Practice Testing, Public Speaking, and Source Monitoring to Examine the Influences of Learning Strategies and Stress on Episodic Memory

Prior research demonstrated that learning information via retrieval practice, which entails studying and taking practice tests, resulted in less memory impairment under stress than learning information via repeated studying. The present experiment combined three experimental procedures to further examine the memory mechanisms underlying the efficacy of retrieval practice in the context of stress. A list-discrimination task was implemented, in which participants learned two distinct wordlists. This was combined with a retrieval-practice manipulation, as half of the participants engaged in practice testing and half engaged in conventional studying during learning. A week later, participants underwent stress induction, using the Trier Social Stress Test. Before and after stress induction, participants completed tests of item and source memory (i.e., list discrimination). The combination of these three procedures yielded informative results: retrieval practice, in the context of stress, improved item memory but not source memory relative to conventional studying. Limitations and future directions for the use of this methodology are discussed.

The present experiment combined three experimental procedures &#8212; a retrieval-practice learning manipulation, a list-discrimination task, and a stress-induction technique &#8212; to examine the influences of different learning strategies and acute stress on multiple measures of episodic memory.

Prior research demonstrated that learning information via retrieval practice, which entails studying and taking practice tests, resulted in less memory ...

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can be&#160;achieved by either&#160;thrombolysis with recombinant tissue-plasminogen activator (rt-PA), the standard therapy for stroke patients who present within the first hours of symptom onset without contraindications, or by an endovascular approach, if a proximal brain vessel occlusion is detected. As the efficacy of both therapies declines over time, every minute saved along the way will improve the patient&#39;s outcome.
This critical situation requires thorough work and precise communication with the patient, the family and colleagues from different professions to acquire all relevant information and reach the right decision while carefully monitoring the patient. This is a high fidelity situation. In nonmedical high-fidelity environments such as aviation, Crew Resource Management (CRM) is used to enhance safety and team efficiency.
This guide shows how a Stroke Team algorithm, which is transferable to other hospital settings, was established and how regular simulation-based trainings were performed. It requires determination and endurance to maintain these time-consuming simulation trainings on a regular basis over the course of time. However, the resulting improvement of team spirit and excellent door-to-needle times will benefit both the patients and the work environment in any hospital.
A dedicated Stroke Team of 7 persons who are notified 24/7 by a collective call via speed dial and run a binding algorithm that takes approximately 20 min, was established. To train everybody involved in this algorithm, a simulation-based team training for all new Stroke Team members was conceived and conducted at monthly intervals. This led to a relevant and sustained reduction of the mean door-to-needle time to 25 min, and enhanced the feeling of stroke readiness especially in junior doctors and nurses.

Every min counts in acute stroke care. This guide shows how to establish a Stroke Team algorithm and enhance its performance with regular simulation training. The principles of Crew Resource Management (CRM) facilitate a straight workflow, reduce door-to-needle times and increase staff satisfaction.

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can ...

Mechanical Ventilation Boot Camp Curriculum

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased morbidity and mortality. A three-day simulation-based boot camp serves to provide one-on-one instruction with a critical care provider. These intensivists may dispense personalized immediate feedback as learners engage in hands-on practice with a real mechanical ventilator. Multiple different pathologies can be reviewed that may not be encountered in the clinical setting. Learners can visualize immediate consequences of their actions and may troubleshoot and ask questions, all while in a safe learning environment. We describe the use of human-patient simulators connected to breathing simulators and mechanical ventilators. Potential curriculum executors should be aware of the cost of the equipment and the time needed to dedicate to boot camp execution; however, this intensive interactive training has been shown to increase provider competency, knowledge, and confidence in ventilator management. This curriculum outline provides guidance on how to execute a simulation-based boot camp to train providers on the management of mechanically ventilated patients.

This curriculum outlines how to execute a simulation-based boot camp to teach providers how to manage mechanically ventilated patients.

Medical management of mechanically ventilated patients is challenging to novice providers. Incorrect management of this population may lead to increased ...

Setup and Execution Of the Blindfolded Code Training Exercise

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.

The blindfolded code training exercise, which blindfolds the team leader in a code resuscitation simulation, is an advanced teaching technique to improve closed-loop communication, organizational skills, and critical thinking.&#160;

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to ...

A Visuospatial Planning Task Coupled with Eye-Tracker and Electroencephalogram Systems

The planning process, characterized by the capability to formulate an organized plan to reach a goal, is essential for human goal-directed behavior. Since planning is compromised in several neuropsychiatric disorders, the implementation of proper clinical and experimental tests to examine planning is critical. Due to the nature of the deployment of planning, in which several cognitive domains participate, the assessment of planning and the design of behavioral paradigms coupled with neuroimaging methods are current challenges in cognitive neuroscience. A planning task was evaluated in combination with an electroencephalogram (EEG) system and eye movement recordings in 27 healthy adult participants. Planning can be separated into two stages: a mental planning stage in which a sequence of steps is internally represented and an execution stage in which motor action is used to achieve a previously planned goal. Our protocol included a planning task and a control task. The planning task involved solving 36 maze trials, each representing a zoo map. The task had four periods: i) planning, where the subjects were instructed to plan a path to visit the locations of four animals according to a set of rules; ii) maintenance, where the subjects had to retain the planned path in their working memory; iii) execution, where the subjects used eye movements to trace the previously planned path as indicated by the eye-tracker system; and iv) response, where the subjects reported the order of the visited animals. The control task had a similar structure, but the cognitive planning component was removed by modifying the task goal. The spatial and temporal patterns of the EEG revealed that planning induces a gradual and lasting rise in frontal-midline theta activity (FM&#952;) over time. The source of this activity was identified within the prefrontal cortex by source analyses. Our results suggested that the experimental paradigm combining EEG and eye-tracker systems was optimal for evaluating cognitive planning.

The study of cognitive planning combining EEG and eye-tracking systems provides a multimodal approach to investigate the neural mechanisms that mediate cognitive control and goal-directed behavior in humans. Here, we describe a protocol for investigating the role of brain oscillations and eye movements in planning performance.

The planning process, characterized by the capability to formulate an organized plan to reach a goal, is essential for human goal-directed behavior. Since ...