CRITICALLY APPRAISED PAPER (CAP)
Pociask, F. D., DiZazzo-Miller, R., & Samuel, P. S. (2013). Reducing cognitive load while
teaching complex instruction to occupational therapy students. American Journal of
Occupational Therapy, 67, e92–e99. http://dx.doi.org/10.5014/ajot.2013.008078
CLINICAL BOTTOM LINE:
As health care knowledge continues to grow, so does the amount of content occupational
therapy students are responsible for learning. Consequently, occupational therapy educators
continue to explore methods of enhancing student knowledge acquisition through innovative
teaching strategies. One such approach is intended to enhance learning by segmentally
providing basic knowledge first and later introducing the interactive components of the already
introduced concepts (isolated-to-interacting-elements approach). This teaching technique has
been correlated with the reduction of working memory load and cognitive load. However, the
knowledge domains, isolated elements, and guidelines needed for breaking down whole tasks
for different content areas to instruct students without overburdening their working memory are
unknown.
This posttest-only trial provides evidence that using the isolated-to-interacting-elements
approach to divide complex lecture material into short-term lessons reduces cognitive load and
prevents working memory resources from exceeding capacity. Through the use of isolated
stages of instruction, subjects’ cognitive resources were more plentiful for introducing the
interaction of concepts in the final lecture. It is anticipated that learning may actually be
hindered by the presentation of all necessary information in a single lecture.
Occupational therapy educators can use this information to match instruction and instructional
processes with the cognitive capabilities of learners to nurture the learning process. This may
allow both occupational therapy and clinical educators to use a variety of possible instructional
methods and designs to deliver knowledge in academia and clinical practice.
RESEARCH OBJECTIVE(S)
List study objectives.
Determine the level of success instructing beginner occupational therapy students enrolled in a
human locomotion course in a classroom setting has on the attainment of knowledge through
the use of reduced intrinsic cognitive load (p. e93.)
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DESIGN TYPE AND LEVEL OF EVIDENCE:
Level III: Quasi-experimental, posttest-only design
SAMPLE SELECTION
How were subjects recruited and selected to participate? Please describe.
The subjects were recruited to participate in this study through convenience sampling and were
randomly assigned to either the modified or control group. Enrolled first-year, third-semester
master of occupational therapy students in the introductory gait analysis course were asked by
graduate research assistants to volunteer for a study that would test the efficiency of two
educational formats created to instruct human locomotion.
Inclusion Criteria
The students who volunteered for the study were first-year, third-semester master of
occupational therapy students enrolled in the introductory gait analysis course.
Exclusion Criteria
NR
SAMPLE CHARACTERISTICS
N = (Number of participants taking part in the study)
#/ (%) Male
2 (8%)
Ethnicity
NR
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#/ (%) Female
Disease/disability diagnosis
22 (92%)
NR
INTERVENTION(S) AND CONTROL GROUPS
Group 1: Control
Brief description of the
intervention
An expert gait instructor provided education to the students on the
necessary components of gait, including recognition of walking
patterns and impairments and how gait patterns affect engagement in
daily occupations. Gait subject matter experts and the classroom
instructor reviewed the instruction formats and approved them as
accurate and fully equivalent between groups. Students were
lectured face-to-face for 80 consecutive minutes with 1 10-minute
break provided following the first 40 minutes of class. A 25-slide
printout from the PowerPoint presentation was supplied for the
group as well as 16 pages from a gait textbook. A post-instruction
questionnaire was dispersed and completed after the lecture was
given. The Cognitive Load Rating Instrument and the Delayed
Written Posttest were given 1 week after the lecture was complete.
How many participants
in the group?
12
2
Where did the
intervention take place?
NR
Who delivered?
An instructor with 15 years’ experience in gait instruction
How often?
A single, 80-minute lecture
For how long?
One classroom lecture
Group 2: Experimental
Brief description of the
intervention
How many participants
in the group?
Subjects received equivalent lecture material divided into three
lectures delivered by the same expert gait instructor as the control
group. The instructor used the isolated-to-interacting-elements
approach. This procedure was implemented while refraining from
alteration of the content or overall lecture time. Event markers, serial
processing tasks, and fundamental relationships for divided content
were included in the two initial lectures and materials. Gait phases
with regard to event markers and relationships among phases were
incorporated into the final lecture. The lectures were 15 minutes, 25
minutes, and 40 minutes in length. Lectures and materials were
consistent with the control instruction. The instructor was trained to
refrain from including content and discussion of relationships in the
first two lectures unless it was clearly included in the prepared
content. Following each of the three lectures given during the week,
a post-instruction questionnaire was completed by the subjects. One
week after the final lecture, the Delayed Written Posttest and
Cognitive Load Rating Instrument were completed.
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Where did the
intervention take place?
NR
Who delivered?
An instructor with 15 years’ experience in gait instruction (same as
control group)
How often?
A 15-minute lecture was given on day 1, a 25-minute lecture given
day 1, and a 40-minute lecture completed on day 3.
For how long?
Three separate lectures were given on 3 days during 1 week of class.
Intervention Biases: Check yes, no, or NR and explain, if needed.
Contamination:
YES ☐
NO ☐
NR ☒
Comment:
The researchers did not state control of contamination. Students may have
conversed after the lectures were given before completing the posttest. This
may have allowed for contamination of the intervention. Although
participants agreed to keep details of the instruction private until study
completion, it was not possible to completely control for contamination.
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Co-intervention:
YES ☒
NO ☐
NR ☐
Comment: Given the nature of academics, it is possible students from both
groups may have reviewed information from other sources or discussed this
content with other students.
Timing:
YES ☐
NO ☐
NR ☒
Comment:
Site:
YES ☒
NO ☐
NR ☐
Comment:
Intervention took place in authentic classroom conditions.
Use of different therapists to provide intervention:
Comment:
YES ☐
Instruction was provided by the same educator for both groups.
NO ☒
NR ☐
MEASURES AND OUTCOMES
Measure 1:
Name/type of
Cognitive Load Rating Instrument
measure used:
What outcome was Subjective measure of mental workload
measured?
Is the measure
YES ☒
NO ☐
reliable?
Is the measure
YES ☒
NO ☐
valid?
When is the
1 week after final lecture
measure used?
NR ☐
NR ☐
Measurement Biases
Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain.
Comment:
YES ☐
NO ☐
NR ☒
Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain.
Comment:
YES ☐
NO ☐
NR ☒
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Recall or memory bias. Check yes, no, or NR, and if yes, explain.
Comment:
YES ☐
It is possible that there were differences in accuracy or completeness of the
NO ☐
subjects’ memory of their experience between the final lecture and the
NR ☒
posttest.
Others (list and explain):
The Hawthorne effect and testing effects may have been present given the “research” nature of
this project, though random assignment would have likely limited the influence of these threats.
RESULTS
List key findings based on study objectives
Include statistical significance where appropriate (p < 0.05)
Include effect size if reported
Between-group ANOVA calculations revealed that students in the modified instruction group
reported lower total instructional cognitive load [F(1, 22) = 7.592, p = .012, n2 = .26], lower total
examination cognitive load F(1, 22) = 8.587, p = .008, n2 = .28, and higher posttest examination
scores [F(1, 22) = 28.116, p < .001, n2 = .56] than students who received the traditional lecture
format. There was no difference between the groups in the amount of time spent completing the
assessments.
Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR,
and if no, explain.
Comment:
YES ☒
NO ☐
NR ☐
Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain.
Comment:
YES ☒
NO ☐
NR ☐
Were statistics appropriately reported (in written or table format)? Check yes or no, and if no,
explain.
Comment:
YES ☒
Reported in both written and table format.
NO ☐
Was the percent/number of subjects/participants who dropped out of the study reported?
YES ☐
NO ☒
Limitations:
What are the overall study limitations?
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Limitations include decreased generalizability due to the low number of participants in the
study. Also, teaching a single topic of gait in the classroom does not fully reveal the complexity
of realistic learning over a long period of time. There was also a lack in full understanding of the
different relationships among cognitive load, content structure, and performance. More robust
statistical procedures should be used to increase understanding among dependent variables.
CONCLUSIONS
State the authors’ conclusions related to the research objectives.
The researchers concluded that students’ cognitive load was decreased with the use of the
isolated-to-interacting-elements approach. The breakdown of lecture material into short-term
lessons reduced cognitive load and prevented working memory resources from exceeding the
appropriate level needed to learn. The isolated stages of instruction in the first two shorter
lectures increased students’ cognitive resources available for the final lecture. Learning may
actually be hindered by the presentation of all necessary information in a single lecture.
Therefore, it is important to match instruction and instructional process with the cognitive
capabilities of learners to nurture the learning process. These results may assist clinical
educators with instructional methods and provide effective ways for teaching complex concepts
in academics.
This work is based on the evidence-based literature review completed by Shalyn K.Hample, OTS, and Anne M. Haskins, PhD,
OTR/L, Faculty Advisor, University of North Dakota.
CAP Worksheet adapted from “Critical Review Form--Quantitative Studies.” Copyright  1998, by M. Law, D. Stewart, N.
Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission.
For personal or educational use only. All other uses require permission from AOTA.
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