Applying simulation learning theory to identify instructional strategies for Generation Z emergency medicine residency education

Abstract

Introduction

Generation Z learners are entering emergency medicine (EM) residency training, bringing unique learning preferences that influence their engagement with residency education. To optimally teach and motivate this incoming generation of learners, EM educators must understand and adapt to the changing instructional landscape.

Methodology

The Simulation Leaders Advancing the Next Generation in Emergency Medicine (SLANG‐EM) Workgroup was created to identify effective educational strategies for Generation Z learners entering EM. Members were faculty in the Society for Academic Emergency Medicine (SAEM) Simulation Academy, well versed in learning theory supporting simulation‐based education (SBE) and actively involved in EM residency education.

Unique treatment/analysis

Through primary and secondary literature searches, the SLANG‐EM Workgroup identified four distinctive learning preferences of Generation Z learners: (1) individualized and self‐paced learning, (2) engaging and visual learning environments, (3) immediate and actionable feedback, and (4) combined personal and academic support. Workgroup members evaluated these learning preferences using a novel conceptual framework informed by the theoretical principles underpinning SBE, recommending instructional strategies for Generation Z EM residency learners across multiple educational environments.

Implications for educators

Instructional strategies were described for the didactic, simulation, and clinical learning environments. In the didactic environment, identified instructional strategies included meaningful asynchronous education, interactive small‐group learning, and improved multimedia design. In the simulation environment, educational innovations particularly suitable for Generation Z learners included learner‐centered debriefing, rapid‐cycle deliberate practice, and virtual simulation. In the clinical environment, described instructional strategies involved setting learner‐centered goals and delivering facilitative feedback in the context of an educational alliance. Overall, these instructional strategies were clustered around themes of student‐centered education and the educator as facilitator, which align well with Generation Z learning preferences. These findings were synthesized and presented as an advanced workshop, “Delivering Effective Education to the Next Generation,” at the 2023 SAEM Annual Meeting.

INTRODUCTION

Generation Z learners, defined by the Pew Research Group as individuals born between 1997 and 2012, ¹ are shifting the educational landscape in undergraduate medical education (UME) ² , ³ , ⁴ , ⁵ , ⁶ and are now entering emergency medicine (EM) training environments in increasing numbers. Bringing novel beliefs and attitudes about work and education, ⁴ , ⁵ , ⁶ , ⁷ , ⁸ Generation Z learners may clash with older educators, who possess different perspectives borne of different experiences. EM residency educators have previously recognized the need to adopt innovative instructional strategies for new generations of learners. ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ However, while there has been discussion on how to accommodate Generation Z learning preferences in college, ¹⁴ , ¹⁵ UME, ³ , ⁴ , ⁵ nursing education, ⁷ , ¹⁶ , ¹⁷ and general health professional education, ⁸ thus far there has been little discussion in graduate medical education (GME) contexts, and none in EM residency. To successfully train the next generation of EM physicians, educators must be equipped with instructional strategies optimal for engaging, motivating, and teaching Generation Z EM residency learners.

Generational theory

Generational theory defines groups who grew up immersed in distinctive cultural and historical events of their time, creating a “once‐in‐a‐lifetime” blend of influences on a cohort's attitudes, beliefs, and behaviors. ⁹ , ¹⁸ , ¹⁹ , ²⁰ Due to these shared impressions and memories, generational groups tend to have identifiable traits that distinguish them from each other (see Table 1).

TABLE 1.

Characteristics of generational groupings since 1945.

Generation (birth years)	Societal	Childhood family	Personal	Work	Education	Technology
Baby Boomers (1945–1964)	Civil rights movement, women's movement, Vietnam War, television, economic prosperity	Traditional nuclear family, stay‐at‐home mother, working father	Optimistic, desire personal gratification, highly competitive	Workaholics, competitive, consensus builders, mentors	Learners dependent on educators, lecture format, process‐oriented	Not particularly tech‐savvy
Generation X (1964–1980)	Limited economic prospects, fall of institutions, political scandals, divorce, AIDS, computers	Nontraditional families, single‐parent homes, “latch‐key kids,” television as babysitter	Independent, skeptical, resilient, more accepting of diversity, self‐reliant, self‐directed	Value work–life balance, comfortable with change, question authority	Independent learners, problem solvers, desire to learn on the job, outcome‐oriented	Interested and facile
Millennials (1980–1997)	Economic globalization, terrorism, 9/11, multiculturalism, technology boom	“Helicopter parents,” play dates, close family relationships	Optimistic, need for praise, collaborative, global outlook	Team‐oriented, used to following rules and having structured time, career change/mobility	Grew up in team‐based educational environment, turn to internet, outcome‐oriented	Very savvy, view technology as a necessity
Generation Z (1997–2012)	Great Recession of 2008, COVID‐19 pandemic, school violence, Black Lives Matter, #MeToo	Involved and present parents, financial hardship, delayed “time to launch”	Diverse, accepting, open‐minded, pragmatic	Entrepreneurial, innovative, team‐oriented	Self‐paced learners, receptive to novel educational environments, outcome‐oriented	“Digital natives” immersed in a global information network from birth

Note: Baby Boomer, Generation Z, and Millennial characteristics adapted from: Mohr et al. ⁹ Copyright 2011 by John Wiley and Sons. Adapted with permission.

Abbreviation: AIDS, acquired immunodeficiency syndrome.

Generational groups are broad and cannot fully describe the complex and unique chemistry that creates individuality. ²⁰ , ²¹ However, age remains one of the strongest predictors of differences in beliefs, attitudes, and behaviors in society. ²² Likewise, age is predictive of differences in beliefs, attitudes, and behaviors in medical education ²³ , ²⁴ , ²⁵ and the clinical workplace. ⁹ , ²⁶ , ²⁷ , ²⁸ Correspondingly, Generation Z appears to have distinct learning preferences compared to prior generations, such as Generation X or Millennials. ⁴ , ⁵ , ⁶ , ⁷ , ⁸ Educator attunement to these preferences may permit more meaningful instruction of Generation Z learners.

Who is Generation Z?

Generation Z grew up in an era of instantaneous digital access, smartphones, and social media, ²⁹ punctuated by the upheavals of the Great Recession of 2008 and the COVID‐19 pandemic shutdowns. ³⁰ These historical events generated widespread economic uncertainty during Generation Z's childhood and adolescence, impacting their familial safety net, future educational plans, and career goals. The cost of college rose at least 134% between 2003 and 2023. ³¹ This generation is characterized as cautious and pragmatic, recognizing that not every path guarantees financial stability and professional success.

From a cultural standpoint, Generation Z is defined by their digital connectivity. In contrast to previous generations of “digital immigrants,” who were introduced to and selectively adopted new technologies later in life, Generation Z is composed of “digital natives,” who were immersed in a rich global network of instantly accessible information from birth. ³² The Pew Research Group found that 97% of U.S. teens say they use the internet “daily,” and 46% say they use it “almost constantly.” ²⁹ Social media use has increased, while face‐to‐face interactivity has decreased, which has been blamed for shrinking attention spans ³³ , ³⁴ and delayed time to personal and professional milestones, such as dating, obtaining a driver's license, employment, and moving out of the childhood home. ¹⁹

Generation Z demonstrates high rates of depression and anxiety compared to prior generations, ¹⁹ with surveys citing the COVID‐19 pandemic ³⁵ , ³⁶ and high‐profile news, such as school shootings and political events, ³⁷ as common sources of stress. According to the Healthy Minds Study, between 2013 and 2021, rates of depression and anxiety doubled among U.S. undergraduate and graduate students, and rates of past‐year mental health utilization increased by 23.5%. ³⁸ While there have been no reliable longitudinal measurements in UME settings, a 2016 meta‐analysis of 129,000 medical students in 47 countries showed that 27.2% of medical students screened positive for depression. ³⁹ Educators must anticipate that Generation Z learners will require additional mental health support in their medical education. ⁴

Simulation‐based education (SBE) and applications for Generation Z

SBE is an integral component of EM education and lends itself well to supporting the learning preferences of Generation Z learners. For example, high‐fidelity simulation takes place in an interactive, multisensory environment with immediate feedback on clinical decision making. Simulation scenarios can be calibrated to the margin of a learner's comfort zone. Additionally, debriefing enables learners to reflect upon their performance with the personalized support of an experienced facilitator. Given the strengths of SBE in Generation Z learning, theoretical principles that support and scaffold SBE may be applicable to other educational arenas in EM.

METHODOLOGY

Creation of the SLANG‐EM workgroup

In 2022, a group of educators from the SAEM Simulation Academy became interested in optimizing education for Generation Z learners, in common recognition of shifting demographics and learner needs in EM clerkship and residency settings. Noting that Generation Z learners seemed particularly responsive to the interactive, individualized, and immediate aspects of high‐fidelity SBE and debriefing, the group sought to more deeply align their SBE practices with Generation Z learning preferences as well as translate these areas of alignment to other aspects of EM residency education.

To investigate this topic, the Simulation Academy formed the Simulation Leaders Advancing a New Generation in EM (SLANG‐EM) Workgroup was formed. The SLANG‐EM Workgroup consisted of 14 adult and pediatric EM simulation educators from institutions across the country. Workgroup members were selected based on expertise in SBE and educational leadership roles teaching medical students, residents, and/or simulation fellows. The academic rank of members ranged from assistant professor to professor, with assistant professors comprising 50% of the workgroup. Most workgroup members were Millennials, and three were Generation X.

Workgroup process and key questions

To set the goal of identifying instructional strategies suitable for Generation Z learners entering EM residency education, the SLANG‐EM Workgroup identified several key questions:

1. What are the most important Generation Z learning preferences that EM residency educators should be aware of?

2. What theories about learning should inform and scaffold instructional choices that support Generation Z learning preferences?

3. When Generation Z learning preferences are viewed through identified learning theories, what instructional strategies appear optimal for EM residency training?

These key questions were explored and clarified by the SLANG‐EM Workgroup through primary literature search and iterative discussion. Our investigative process resulted in a novel conceptual framework presented below, and its outcomes were the basis of the “Delivering Effective Education to the Next Generation” Advanced EM Workshop presented at the 2023 SAEM Annual Meeting in Austin, Texas. This study was reviewed by the Yale Institutional Review Board and determined to be exempt.

ANALYSIS/UNIQUE TREATMENT

Conceptual framework of the SLANG‐EM Workgroup

The SLANG‐EM Workgroup synthesized a conceptual framework that unified and defined the relationships between the key questions above, which is visually represented by Figure 1. In this conceptual framework, we examine Generation Z learning preferences (Figure 1, panel 1) through foundational learning theories in SBE (Figure 1, panel 2), identifying optimal instructional strategies in EM residency educational environments (Figure 1, panel 3) that are informed by those preferences and learning theories.

FIGURE 1.

Conceptual framework for workshop content generation.

Learning preferences of Generation Z learners

Social and cultural influences can impact a generation's perception of learning. In a scoping review on learning styles, preferences, and needs of Generation Z students in health care, Shorey et al. ⁸ identified several distinctive educational preferences within this learner group: (1) individualized and self‐paced learning, (2) engaging and visual learning environments, (3) immediate and constructive feedback, and (4) combined personal and academic support. These identified learning preferences (Figure 1, panel 1) were assessed by the SLANG‐EM Workgroup as representative of the relevant literature and broadly applicable to the EM residency educational context.

Individualized and self‐paced learning

Generation Z learners are the first generation to grow up with Wikipedia, YouTube, social media, and other Internet sources of information. As a result, members of Generation Z may conceptualize the ideal setting and pace for education differently than previous generations. In addition to the physical classroom, Generation Z learners embrace learning in flexible spaces, such as the virtual, remote, or asynchronous environment. ³ Studies have demonstrated that medical students perceive the independent viewing of recorded lectures as a normal alternative to attending in‐person lectures ⁴⁰ and routinely utilize outside sources of medical knowledge, such as question banks and online material, to supplement an assigned framework of required content. ² , ⁴¹ , ⁴² Self‐study with asynchronous resources is perceived by Generation Z learners as an expression of autonomy—a valid time management strategy that enables learners to self‐identify and personalize their educational path. ²³ , ⁴³ , ⁴⁴

Additionally, Generation Z learners appreciate educational content tailored to their individualized needs, with a focus on knowledge and skills directly transferable to hands‐on, real‐world settings. ⁸ , ¹⁷ They have a utilitarian perspective about their education, viewing it as a tool to prepare them for life beyond graduation. ¹⁴ , ⁴⁵ Because they are particularly attentive to what is needed to succeed in the moment, Generation Z learners may view contextless educational content as impractical or irrelevant to their career goals. ⁵

Engaging and visual learning environments

Immersed in interactive digital technology from birth, Generation Z learners have an affinity for visual modalities, particularly video, ⁶ , ⁴⁶ , ⁴⁷ and expect technological engagement in the classroom. ⁵ , ⁴⁸ , ⁴⁹ Continuing a trend from the Millennial generation, ¹⁰ , ¹¹ Generation Z learners tend to favor interactive instructional strategies centered around application of previously learned content, particularly to solve real‐life problems in relevant settings. ⁶ , ¹⁴ , ⁵⁰ In a 2018 survey of 1300 middle and high school students across 49 states, 51% stated that they learned by “doing” (e.g., working through examples), 38% by “seeing” (e.g., reading course materials), and 12% by “listening” (e.g., attending classroom lecture). ⁴⁹

Although Generation Z learners prefer some role in setting the tone and pace of their learning, they also find engagement and social value in group work, ⁷ , ¹⁴ particularly if the group work involves applied and experiential learning. ⁵ , ⁵⁰ To this end, they appreciate educators who are facilitators along their path to learning, rather than “talking heads” lecturing at them. ⁵⁰ Group work may look different in this population of learners compared to prior generations; for example, instead of meeting to discuss a project, they may work independently next to each other on the same Google Doc. ¹⁴

Immediate and actionable feedback

Feedback is a necessary part of medical education. Generation Z learners have a particular affinity for instantaneous and frequent feedback that is applicable to their immediate goals. In a study of college seniors, 58% indicated that they frequently seek feedback on their academic work, and another 38% indicated that they do so occasionally. ⁵⁰ This has been attributed to various causes, including a desire for immediate gratification, ³ , ⁵ , ⁹ challenges in filtering and prioritizing large volumes of accessible information, ³ , ⁵¹ and a pragmatic awareness of the economic stakes of failure. ⁴⁹ , ⁵⁰ Satisfaction with the educational experience improves when Generation Z learners know what is expected of them. ⁴⁵ Timely input from educators allows these learners to adapt and apply, capitalizing on opportunities to grow and evolve.

Combined personal and academic support

Generation Z learners hope that their educators and mentors will contribute to their overall development on both the personal and academic level. In addition to being motivated by educational strategies that have tangible, real‐world applicability, Generation Z learners are drawn to educators who they perceive as passionate, approachable, friendly, and knowledgeable. ⁷ , ⁵² In general, the importance of educators caring about students is well established ⁵³ , ⁵⁴ , ⁵⁵ ; however, for Generation Z learners, it may be a key component to motivating learner engagement and performance. ⁵⁶ , ⁵⁷ Furthermore, given the high rates of mental health challenges in Generation Z learners, encouraging personal and mental health care may be particularly impactful for this learner group. ³ , ⁴

Foundational learning theories in SBE

To identify instructional strategies suitable for Generation Z learning preferences, the SLANG‐EM Workgroup sought to define and describe the guiding instructional theories shaping their approach to learning and teaching (Figure 1, panel 2). There are many theories that attempt to describe the complex process of learning, including behaviorist, cognitivist, humanistic, transformative, and social perspectives. ⁵⁸ Many of these learning theories intersect and overlap with each other, and all have merit in the creation and delivery of impactful education. ⁵⁸ , ⁵⁹ , ⁶⁰

It is important to recognize that most educators are guided by some underlying theoretical framework when they choose their teaching approach, even if that framework is not fully apparent to them ⁶⁰ ; an educator's beliefs influence the education they deliver. Because the SLANG‐EM Workgroup consisted of educators immersed in the development and delivery of SBE, their educational beliefs consequently drew on foundational learning theories supporting this instructional modality. While an in‐depth analysis of all salient theoretical underpinnings of SBE is beyond the scope of this paper, the SLANG‐EM Workgroup leaned on several key constructs summarized in Table 2.

TABLE 2.

Selected foundational learning theories in SBE.

Theory name	Key figure	Core belief	Key components
Principles of adult learning	Knowles	Learner best responds to learning in distinct ways unique to adults.	Adults are self‐directed, active participants in their own learning. Adult learners have a unique foundation of experiences to draw information from. Readiness to learn occurs when learning is relevant to oneself. Learning is goal‐oriented and problem‐centered.
Constructivism	Piaget	Individuals are active learners who construct new knowledge on a foundation of existing knowledge through interactions with their environment.	Cognitive constructivism focuses on how learning occurs within the individual. Social constructivism focuses on how learning occurs when learners interact with other learners and the educator.
Experiential learning	Kolb	Knowledge is gained by a cyclical process that goes through distinct stages as one actively engages with an experience.	Concrete experience involves active participation with an authentic encounter. Reflective observation engages learners in analysis of the experience. Abstract conceptualization creates new understandings based on the experience and observation. Active experimentation involves application of the concept to a new situation.
Sociocultural learning	Vygotsky	Cognitive development is influenced by social interactions, cultural context, and collaborative activities.	Zone of Proximal Development is the difference between what a learner can currently do and what they can achieve with guidance from an experienced educator. Scaffolding involves the process of providing a structure for learners to bridge the gap between their current state to their potential. Language and communication are vital tools for meaningful learning.
Cognitive load theory	Sweller	Working memory has a limited capacity and can only handle so much information effectively at one time.	Sensory memory filters select information to working memory. Working memory encodes information to long‐term memory for storage. Long‐term memory stores information in schemas for easier recall.

Abbreviation: SBE, simulation‐based education.

IMPLICATIONS FOR EDUCATORS

Through this conceptual framework, the SLANG‐EM Workgroup identified instructional strategies in EM residency education (Figure 1, panel 3) adaptive to Generation Z learning preferences. These recommendations were organized into the major educational environments in EM residency: the didactic environment, the simulation environment, and the on‐shift clinical environment. A summary can be viewed in Table 3.

TABLE 3.

Instructional strategies for Generation Z EM residency learners.

Instructional strategy	Learning preference accommodated	Supporting learning theory	Examples of potential applications
Didactic environment
Improvements in individualized interactive instruction	Individualized and Self‐Paced Learning	Principles of Adult Learning Constructivism	Listening to an assigned podcast, followed by online discussion posts. Vetted online interactive module with follow‐up quiz.
(Inter)active learning	Individualized and self‐paced learning Engaging and visual learning environments Immediate and actionable feedback	Principles of Adult Learning Constructivism Sociocultural Learning	Individual concept map creation followed by group discussion. Interactive case‐based discussion in small groups, followed by large‐group synthesis of key takeaways.
Better multimedia design	Engaging and visual learning environments	Cognitive Load Theory	Preview of key terms and concepts before complex presentations. Presentation of words and pictures together, instead of words alone.
Simulation environment
Learner‐centered debriefing	Individualized and self‐paced learning Combined personal and academic support	Principles of Adult Learning Constructivism Sociocultural Learning Experiential Learning Cognitive Load Theory	Learner self‐assessment as a basis for guiding the debrief. Cocreation of debriefing agenda by facilitators and learners.
RCDP	Individualized and self‐paced learning Immediate and actionable feedback	Principles of Adult Learning Constructivism Sociocultural Learning Experiential Learning	Multiple short scenarios that escalate in difficulty. Pause for microdebriefing when incorrect tasks are performed, followed by rewinding or restarting of the scenario.
Virtual simulation	Engaging and visual learning environments	Principles of Adult Learning Constructivism Sociocultural Learning Experiential Learning Cognitive Load Theory	In‐classroom use of a digital platform in a simulated scenario, followed by facilitator‐guided debriefing. Virtual simulation as a mode of immersive distance education.
Clinical environment
Formation of an educational alliance	Individualized and self‐paced learning Combined personal and academic support	Sociocultural Learning	Cocreation of on‐shift educational goals between learner and educator. Active solicitation of learner perspectives regarding their growth and progression.
Learner‐set goals	Individualized and self‐paced learning	Principles of Adult Learning Experiential Learning Theory	Preshift time to discuss, negotiate, and agree upon learning goals. In‐shift time to support learner‐initiated plans for behavior change.
Frequent and facilitative feedback	Individualized and self‐paced learning Immediate and actionable feedback	Constructivism Sociocultural Learning	Incorporation of best feedback practices. Deliberate use of facilitative bedside teaching paradigms.

Abbreviation: RCDP, rapid‐cycle deliberate practice.

Implications for the didactic environment

In this fundamental space for teaching and learning in EM residency, there are substantial opportunities for changes in instructional methodology to better suit the Generation Z learner. These recommendations include: (1) improvements in individualized interactive instruction; (2) an emphasis on interactive small group learning, not just active learning; and (3) thoughtful multimedia use.

Improvements in individualized interactive instruction

To better accommodate the Generation Z learning preference of individualized and self‐paced education, EM residency educators can incorporate increased asynchronous education as part of didactic programming. According to the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for EM, resident educational experiences must include an average of at least 5 h per week of core didactics, up to 20% of which can be spent in asynchronous learning, now renamed to individualized interaction instruction. ⁶¹ Vetted online resources from free open‐access medical education sources, such as online interactive modules, podcasts, blogs, and article compendiums, may complement traditional classroom teaching. ⁶² This instructional strategy enables Generation Z learners to self‐identify and personalize the pace of their education, aligning with principles of adult learning, which defines the adult learner as self‐motivated and self‐directed, with intrinsic desire to learn. ¹⁰

However, pitfalls in incorporating individualized interactive instruction exist. Constructivist learning principles suggest that effectively building new knowledge requires an awareness of learners’ existing knowledge base; as a result, asynchronous learning content must be carefully vetted prior to distribution to residents, particularly to novice residents. Ideally, asynchronous education topics would be selected by identifying gaps in the current curriculum or topics that may be best transitioned to an asynchronous format. ⁶³ Furthermore, ACGME requirements state that passive viewing of written, audio, or visual materials without an evaluation component does not qualify as individualized interaction instruction, ⁶¹ reflecting a belief that engagement with the material is necessary for true understanding. Educators should seek out opportunities to gauge learners’ assimilation of knowledge, such as through asynchronous posteducation testing, ⁶⁴ online discussion, ⁶⁴ , ⁶⁵ or in‐classroom follow‐up. ⁶³

Flipped‐classroom design is a particularly noteworthy educational model that assigns asynchronous content for independent learner review, followed by in‐classroom application. ⁶⁶ , ⁶⁷ This approach is grounded in constructivist learning theory, whereby new knowledge (created during classroom application) is built on previous knowledge (learned from prework). ⁶⁸ To evaluate learners’ readiness for the application phase, educators can employ a range of assessment methods, such as quizzes, ⁶⁹ peer evaluations, ⁷⁰ or confidence evaluations. ⁷¹

Not just active learning—Interactive learning

Recognizing that passive, hours‐long lecture does not adequately address learning needs, ⁷² , ⁷³ medical educators have suggested a broad range of active learning strategies for engaging learners during didactic sessions, including flipped classroom, ⁷⁴ team‐based learning, ⁷⁵ problem‐based learning, ⁷⁶ case‐based learning, ⁷⁷ , ⁷⁸ gamification, ⁷⁹ , ⁸⁰ concept mapping, pro and con debate, panel discussion, audience response systems, chalk talks, and more. ⁷³ , ⁸¹ , ⁸² Active instructional strategies are suitable for Generation Z learners, who enjoy applying knowledge to solve real‐world problems relevant to their personal practice in engaging and interactive contexts. Many of these student‐centered instructional strategies leverage principles of adult learning by prioritizing learners’ immediate needs as well as stressing learners’ responsibility, initiative, and self‐direction.

There are a few additional considerations that educators can keep in mind to maximize the impact of active learning. Active learning is sometimes simplistically understood as instructional strategies that keep students behaviorally busy, rather than cognitively busy; for example, learners playing a matching game with toxins and antidotes may appear occupied but lack higher‐order thinking. A better application of the constructivist theoretical approach requires engagement with thinking tasks that build new knowledge, such as analysis, synthesis, and evaluation. ⁶⁸ Furthermore, alignment with feedback mechanisms is key—in a study of medical students’ experiences with active learning, students viewed active learning as a valuable vehicle for applying and expanding their understanding, but expressed concerns about inadequate presession preparation, unclear objectives, and an evaluation structure that did not award active learning participation. ⁸³ Educators can mitigate this by clearly communicating the expectations, goals, and grading structure for the active learning session ahead of time as well as providing feedback on learner contributions and cognitive processing.

Deliberate incorporation of interactive small groups may also synergize well with Generation Z learning preferences. Since Generation Z spends less time face to face with peers than previous generations and tends to reach professional milestones later in life, ¹⁹ they may enter the residency training environment with blunted communication skills. ³ , ⁵ Collaborative educational activities may build critical teamwork skills needed for professional success. Furthermore, social interaction is a condition in the Zone of Proximal Development (ZPD); facilitated discussion, peer discussion, and other collaborative efforts can enable individuals to reach new understandings of content that they would otherwise be unable to reach on their own. ⁸⁴

Better multimedia design, better learning

Multimedia instructional design should be used to provide learners with an engaging learning experience. Cognitive load theory suggests that three types of cognitive load exist: intrinsic load, which describes the complexity of the task in relationship to the expertise of the learner; extrinsic load, which describes superfluous processing requirements that tax working memory; and germane load, which describes the working memory resources used to manage the intrinsic load. ⁸⁵ , ⁸⁶

In one application of cognitive load theory to multimedia design, Mayer et al. ⁸⁷ suggest a few strategies in selecting and designing instructional multimedia to optimize learner engagement. To reduce intrinsic load, educators can break lessons into learner‐controlled segments and provide a preview of key terms and concepts; to reduce extrinsic load, educators can eliminate extraneous material and highlight essential material; and to reduce germane load, educators can present words and pictures together rather than words alone, as this distributes the work of cognitive processing across both auditory–verbal and visual–pictorial processing channels. These may represent approachable strategies for EM residency educators to appeal to the visually inclined Generation Z learner.

Implications for the simulation environment

Though SBE has intrinsic strengths in meeting Generation Z learning preferences, the SLANG‐EM Workgroup identified additional opportunities to improve and innovate upon this instructional modality, such as: (1) learner‐centered debriefing, (2) Rapid‐Cycle Deliberate Practice (RCDP), and (3) virtual simulation, particularly in asynchronous or classroom contexts.

Learner‐centered debriefing in simulation

Debriefing leverages multiple theories of learning in providing an impactful educational experience for learners. Effective debriefers facilitate learning by engaging and coaching learners within their ZPD, providing learners with an instructional scaffolding to expand beyond their boundaries of foundational knowledge and understanding. ⁸⁸ Scenario design impacts intrinsic load and can be calibrated to the level of the learner. ⁸⁵ , ⁸⁹ Additionally, in aggregate with the remainder of the SBE experience, debriefing guides learners through the stages of Kolb's experiential learning cycle, enabling learners to undergo and reflect on a concrete experience and synthesize new understandings with future applicability. ⁹⁰

In the evolving dialogue about debriefing in SBE, there is a growing recognition of learner‐centered debriefing as a distinct group of debriefing behaviors that move the focus of the discussion away from the facilitator and toward the learners. ⁹¹ , ⁹² , ⁹³ For example, in instructor‐centered debriefing, the facilitator may set debriefing priorities based on his or her own expertise, perceived importance of topics, and instructor‐written scenario objectives; in learner‐centered debriefing, debriefing priorities may be ordered based on learner interests and concerns, thereby adapting the discussion to the learners’ context. This approach recognizes that learners have their own educational needs they can self‐identify and verbalize, with the facilitator assuming a collaborative rather than demonstrative role. Learner‐centered debriefing may be well suited to Generation Z learners, who prefer personalized education that scales with their current skills and knowledge and may value educators who facilitate, support, and empower them on their learning path.

RCDP for customizable progression

Since its introduction in 2014, ⁹⁴ RCDP has attracted significant interest and discussion among simulation educators. ⁹⁵ Unlike traditional simulation, where an instructor conducts a simulation scenario once and then facilitates one in‐depth debriefing, participants in RCDP progress through multiple cycles in which they repetitively perform a specific task, receive targeted feedback on their performance, and perform the task again. Frequent, individualized microdebriefings with an instructor can accommodate learners at every level and facilitate the learner's stepwise advancement in knowledge and skill.

RCDP is uniquely suited to achieve learning goals through Simulation‐Based Mastery Learning (SBML). Independent of a prescribed timeline, SBML is a form of simulation training where all learners receive targeted feedback from the instructor within each learning session in order to master a specific area of knowledge or skill. ⁹⁶ , ⁹⁷ In this way, learners progress at an individualized pace, with focused feedback, thus minimizing the likelihood that learners from a diversity of learning backgrounds and competency levels are left behind. While no theoretical underpinnings for RCDP have been formally described, it likely draws on similar theories of learning in SBE, including collaborative engagement within the ZPD, experiential learning, and constructivism.

Virtual simulation: New technology, new opportunities

Virtual simulation is a broad term encompassing many possible definitions, including virtual reality, virtual standardized patients, augmented reality, and the use of web‐based or electronic‐based platforms to build clinical scenarios, ⁹⁸ sometimes used interchangeably in the literature. We refer to the use of popular free digital platforms, such as Virtual Resus Room ⁹⁹ and Med Sim Studio. ¹⁰⁰

Although virtual simulation has been technologically feasible for some time, it was catapulted into mainstream use in EM residency programs during the COVID‐19 pandemic. ¹⁰¹ , ¹⁰² , ¹⁰³ Unlike traditional high‐fidelity simulation in expensively outfitted centers, virtual simulation employs digital technologies to create high‐stakes case‐based learning in remote or classroom environments. ¹⁰² Though facilitators and learners alike require training and repeated exposure to realize the benefits of a new learning platform, virtual simulation offers an accessible and affordable alternative to high‐fidelity simulation.

The digital natives of Generation Z may easily adapt to this style of interactive, immersive electronic learning. Additionally, because virtual simulation can take place in web‐based or in‐person settings, this presents unique opportunities for asynchronous or distance education, while still realizing the theoretical learning benefits of high‐fidelity simulation.

Implications for the clinical environment

Education in the clinical environment also presents opportunities for change in preparation for the needs of Generation Z learners. Although teaching in the clinical setting has many constraints with time, clinical efficiency, and patient safety provisions, there are several ways in which the learning theories underpinning SBE can be adapted to the next generation of trainees. These concepts include: (1) creation of an educational alliance, (2) learner goal setting, and (3) frequent facilitative feedback.

The educational alliance for feedback and teaching

Traditional teaching methods follow a unidirectional transmission of knowledge from educator to trainee. In contrast, the construct of an educational alliance creates conditions for a collaborative, bidirectional cocreation process by establishing a shared understanding of performance and standards. ¹⁰⁴ This new conceptualization of the educator–learner dynamic builds on research observations that the interpersonal relationship between feedback deliverers and feedback recipients impacts recipients’ perceptions of source credibility. ¹⁰⁵ , ¹⁰⁶ , ¹⁰⁷ , ¹⁰⁸

Although an educational alliance is best established through longitudinal, serial interactions between teacher and trainee, deliberate actions at the beginning of a clinical shift can set the tone for collaborative learning. This can be as simple as a brief check‐in with the trainee to understand their initial emotional or physical state. This strategy supports the Generation Z preference for combined personal and academic support from educators, and also acknowledges their identity as not just an empty vessel, but as an apprentice in a community of practice. Theoretical roots to this approach include sociocultural theory, which proposes that learning occurs through interaction, negotiation, and collaboration; when applied to feedback contexts, educators and learners can establish expectations to discuss learning goals, evaluate gaps between observed and expected performance, and exchange feedback to narrow the gap. ¹⁰⁹

Learner‐set goals: “What do you want to learn today?”

It seems well established that ideal feedback requires educators and learners to set mutually agreed‐upon goals, ¹¹⁰ , ¹¹¹ but the balance between instructor‐set and learner‐set goals is less clear. ¹¹² , ¹¹³ Medical trainees often feel as though educator feedback is absent or not actionable, resulting in uncertainty in how to improve. ¹⁰⁶ , ¹¹⁴ However, if adult learners are viewed as individuals capable of self‐identifying learning needs and seeking information to improve, learner‐set goals may be a strategy to motivate durable behavioral change. ¹¹³ , ¹¹⁵ Additionally, guiding learners to develop specific goals derived from their concrete experience—the basis for Kolb's experiential learning theory—supports their development in reflective learning.

In the EM clinical training environment, learner‐set goals can be identified within an educational alliance by soliciting learner experiences and encouraging them to reflect on their knowledge gaps through self‐assessment. Benefits may include improved rapport between educators and learners and streamlined teaching time that directly addresses learner interests and needs, ¹¹² , ¹¹⁶ , ¹¹⁷ which are adaptive to Generation Z learner preferences.

It can be challenging to enact learner‐set goals in the teaching environment, particularly in the fast‐paced setting of the emergency department (ED). In a single‐institution study piloting a start‐of‐shift learner goal‐setting process in the ED, authors noted that high patient volume was a consistent barrier to goal‐setting, due to lack of time. ¹¹⁶ Additional difficulties for educators may include negotiating learning goals that are too vague, too broad, or too specific and remaining learner‐centered while giving voice to educator concerns. ¹¹² , ¹¹⁶ Educators can manage these concerns by establishing time for learner‐set goals outside of the on‐shift environment, for example through a longitudinal mentorship program; committing to a short goal‐setting session at the start of the shift; and engaging in assessments of goal characteristics. ¹¹⁸ , ¹¹⁹

Frequent facilitative feedback

Generation Z learners have a strong preference toward immediate and actionable feedback but also desire education geared toward individualized learning goals. Time constraints frequently inhibit on‐shift bedside education, but following best practice guidelines can strengthen the educator–learner relationship, translating to greater feedback acceptance and assimilation among learners. Some of these best practices include directly stating that feedback is being given, developing a systematic approach to feedback, giving feedback based on direct observation, and making feedback actionable. ¹²⁰ , ¹²¹ Generation Z learners may particularly appreciate postshift opportunities for follow‐up and personal connection.

Feedback is facilitative in social constructivism; it aims to provide comments and suggestions for learners to revise their practice and gain new understandings, without dictating what those understandings should be. ¹²² Several bedside teaching techniques have been proposed that align with this constructivist perspective of learning in the clinical environment, including the Muddiest Point, Thinking Hats, and Harvesting. ⁸² Other bedside teaching techniques utilize the ZPD, enabling learners to make new connections or solidify new practices that they may have been unable to reach without the assistance of the educator–learner relationship. Examples include 1‐min preceptor, SNAPPs, and Teachable Moment. ¹²³

It is worthwhile to note that the preponderance of feedback literature focuses on educator‐driven strategies for feedback delivery. ¹¹¹ , ¹²¹ In recent years, an evolving discussion in the medical education realm has placed greater emphasis on sociocultural factors, such as the educator–learner interpersonal relationship, learner perceptions of educator credibility, and cocreation of the feedback relationship. ¹⁰⁴ , ¹¹³ , ¹²⁴ This positions educators as facilitators rather than instructors in the feedback process, increasing learner receptivity to feedback through learner‐centered approaches.

CONCLUSIONS

Through our literature review and our unique philosophy as simulation‐based educators, the Simulation Academy formed the Simulation Leaders Advancing a New Generation in EM (SLANG‐EM) Workgroup identified several instructional strategies tailored to Generation Z learning preferences. Across all emergency medicine educational environments, we advocate for an increased emphasis on learner‐centered approaches, with the educator acting as a facilitator cocreating, supporting, and guiding progress toward learners’ verbalized motivations and goals. We also identified existing challenges and future innovations that educators may encounter as they strive to incorporate these instructional strategies in their practice.

There are limitations to this approach. Perspectives on teaching are built on perspectives on learning; consequently, as simulation‐based educators involved in adult and pediatric EM education, the SLANG‐EM Workgroup's approach may not represent the full range of perspectives possible within a larger, more diverse group of stakeholders and educators. Additionally, generational theory presumes that generational groupings have distinct and identifiable characteristics, but many studies describing generational attributes rely on observational or anecdotal data obtained from a subset of the general population. It is critical to acknowledge the limitations of generational theory as it pertains to individual learners situated in local educational contexts.

We acknowledge that any change in educational strategy requires increased effort compared to repeating previous instructional designs. For innovation to take root, educators must have the time, opportunity, and support to learn and practice new instructional strategies. Additionally, educators must buy in to the value of change, which requires introspection regarding the strengths and weaknesses of their own favored approaches. Just as Generation Z has preferences toward learning, educators have preferences toward teaching influenced by their own generational identity.

Our continued effectiveness as lifelong educators requires a durable commitment to meeting the needs of our learners. Learner needs are inevitably evolving, with perspectives and expectations intrinsically intertwined with rapid technological advances and shifting social norms. As Generation Z learners enter our professional realm, EM residency educators must be prepared to recognize and embrace their differences, to build an educational environment that nurtures and welcomes future generations.

AUTHOR CONTRIBUTIONS

Acquisition of the data: Michael Hrdy, Emily M. Tarver, Charles Lei, Hillary C. Moss, Tiffany Moadel, Lars K. Beattie, Michael Lamberta, Stephanie B. Cohen, Michael Cassara, Michelle D. Hughes, Aga De Castro, Nidhi Sahi, Tina H. Chen. Analysis and interpretation of the data: Michael Hrdy, Emily M. Tarver, Charles Lei, Hillary C. Moss, Tiffany Moadel, Lars K. Beattie, Michael Lamberta, Stephanie B. Cohen, Michael Cassara, Michelle D. Hughes, Aga De Castro, Tina H. Chen. Drafting of the manuscript: Michael Hrdy, Emily M. Tarver, Charles Lei, Hillary C. Moss, Tiffany Moadel, Michael Lamberta, Stephanie B. Cohen, Michelle D. Hughes, Aga De Castro, Nidhi Sahi, Tina H. Chen. Critical revision of the manuscript for important intellectual content: Michael Hrdy, Emily M. Tarver, Charles Lei, Hillary C. Moss, Ambrose H. Wong, Tiffany Moadel, Lars K. Beattie, Michael Cassara, Tina H. Chen. Statistical expertise: N/A. Obtained funding: N/A.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Hrdy M, Tarver EM, Lei C, et al. Applying simulation learning theory to identify instructional strategies for Generation Z emergency medicine residency education. AEM Educ Train. 2024;8(Suppl. 1):S56–S69. doi: 10.1002/aet2.10981