Applying Cognitive Load Theory to Design Effective Simulation Training


Fraser KL, Ayres P, Sweller J. Cognitive load theory for the design of medical simulations. Simul Healthc.2015;10(5):295—307.

EMS providers are often subjected to ineffective training: death by PowerPoint or verbalizing skills without actual practice. This can be mitigated by simulation training, which can help both novices and experts improve problem-solving abilities. How these simulations are built and delivered greatly determines the learner’s ability to gain, retain and recall new knowledge.

Background: To understand cognitive load theory (CLT), imagine your brain is a computer. Short-term memory (i.e., “working memory”) is your desktop and long-term memory is your hard drive. Short-term memory is limited when dealing with new information–we can remember about seven new things at one time–but this working memory desktop has an incredible and unlimited ability to rapidly access our hard drive of long-term memories. By focusing on a stepwise progression of the seven things we want to remember, we convert short-term learning into schemas– complex algorithms allowing us to think critically and solve problems.

Method and results: This study cites more than 100 scientific papers that might guide us in the design of the most effective simulations, improving their instructional design, delivery and results.

The authors discuss some of the threats that make this kind of learning ineffective: simulations that are unrealistic, too simplistic, too complex, or where the learning environment is unsafe (e.g., when learners are ridiculed or publically humiliated).

Undesired factors that are unnecessary to the learning objectives complicate and distract learners, and become a roadblock to learning. CLT calls these complications “extraneous cognitive load.” The authors explain this as a concept in which one’s limited short-term working memory is redirected to interpret the format of instruction rather than being used to effectively process new information.

Examples of this might include a broken or finicky manikin that requires special manipulation to obtain a blood pressure; auditory information (e.g., an instructor verbalizing signs or symptoms) instead of showing the signs; or having a patient give information as they would in the field.

The authors also discuss the effects of stress on cognitive ability. Stress positively affects learning by narrowing perception and focusing attention to content. It also improves longterm retention, particularly when combined with motor (physical action) learning. But stress negatively affects cognitive workload by shrinking working memory–if the stress is too great, learning capacity begins to reduce and fewer learning objectives are being acquired and stored into long-term memory.

Or course, in the real world, EMS providers need to function, at times with severe stress. The authors suggest that if the stress is intrinsically linked to the information being learned, rather than being peripheral to the task, stress can be used effectively. Poorly designed instructional simulation methods, however, can contribute to extraneous cognitive load and be counterproductive.

CLT suggests a simple-to-complex progression as has been suggested by the sequencing in the new National Registry for EMTs accreditation standards for paramedic programs. It’s also compatible with scaffolding concepts that help learners progress to autonomous practice.

Segmenting is a theory where new content is delivered in small chunks, allowing each to be mastered and stored in long-term memory prior to using the content in simulation. For example, a new skill is introduced in a pre-session video viewed at home, then the student works with a task trainer, then a simple scenario and finally in a realistic simulation. In doing so, the student’s working memory is more effectively used to manage the simulated patient vs. processing new content at the time of the simulation.

Worked example effect, where novice clinicians learn new content by studying worked examples (e.g., watching video of real cases and critiquing them prior to working through a simulation) allows students the opportunity to see the format and logistics of simulation beforehand, more effectively reserving their working memory to learn the patient management process.

Discussion: Research into the most effective ways in which we design and deliver instruction is paramount. CLT concepts have the potential to significantly improve how we use simulation to prepare students for the prehospital environment. However, more analysis into how we measure cognitive load and the most effective types of simulation (e.g., high vs. low fidelity) are necessary steps in this determination.


What we already know: Simulation is universally recognized as an important tool in preparing clinicians for the dynamic world of prehospital medicine.

What this study adds: Poor simulation practices can prove to overwhelm one’s ability to use their limited working memory to acquire, process and permanently store essential new content.


Scaffolding: Learning process that promotes a deeper learning by providing, and gradually removing, supportive elements.

Schemas: Complex memory structures built on previous experiences that allow us to perceive, think and solve problems.

Visit for audio commentary.

Previous articleDifferential Diagnoses are Important for Patient Outcome
Next articleCore CSC Launches New Hemostatic Gauze

No posts to display