Helping experts and expert teams perform under duress: an agenda for cognitive aid research

In recent years, there has been a keen interest in how checklists and other cognitive aids can help clinicians during clinical crises. Studies from anaesthesia [1–3], and emergency medicine [4, 5] have shown that displaying cognitive aids during emergencies reduces omissions, time to perform tasks and improves team skills, communication and performance in most instances [6–9]. In research where no difference was found, the cognitive aids are almost always found to have been introduced without education or have flaws in their physical design [1]. Cognitive aids are ‘implementation tools’ used at the same time that the work is being performed. Consequently, cognitive aids used in emergency situations must be very different from those used in routine settings in both form and function because of the requirement of the content to be physically and cognitively accessible during times of stress [1, 10]. Emergency aids should include only those points that are important or commonly omitted rather than provide a comprehensive ‘how-to’ guide for adherence to local policies and procedures. In short, the function of emergency cognitive aids should be to support trained expert teams to remember and excel, rather than to help novices cope with situations beyond their expertise. A study in this issue by Everett et al. [11] attempted to prove that cognitive aids can be used to improve the retention and performance of technical aspects of emergency management several months after initial exposure. While on the face of it there appears to be no effect of the aid, the poorer results when the teams did not have access to a cognitive aid in later scenarios could be interpreted quite differently. Education about how to use the checklists invariably includes content about technical performance such that the initial training raised the technical performance in the initial testing. The higher level of performance was only maintained when the cognitive aid was present, suggesting either a lack of ability to cope without the cognitive aid, or that the prompts helped the participants remember their training. This finding is almost identical to Ward’s study [12] that showed undergraduate students’ technical performance in basic life support was retained at two months after training only when a cognitive aid was available. Similar problems with finding an effect immediately after education with cognitive aids have been found in other studies where retention was not measured [7]. In contrast, the lack of a measurable effect on team performance was hampered by poor inter-rater reliability and the use of a team measurement tool that was not validated for this context. Nevertheless, the study shows there are still lessons to be learned about the purpose and function of emergency cognitive aids and how we investigate them.