Working memory is limited: improving knowledge transfer by optimising simulation through cognitive load theory

Abstract

This analysis explores how to optimise knowledge transfer in healthcare simulation by applying cognitive load theory to curriculum design and delivery for both novice and expert learners. This is particularly relevant for interprofessional learning which is team-based, as each participant comes to the simulation experience with different levels of expertise. Healthcare simulation can offer opportunities to create complex and dynamic experiences that replicate real clinical situations. Understanding Cognitive Load Theory can foster the acquisition of complex knowledge, skills and abilities required to deliver excellence in patient care without overwhelming a learner's ability to handle new materials due to working memory limitations. The 2 aspects of working memory that will be explored in this paper are intrinsic load and extrinsic load. These will be addressed in terms of the learner's level of expertise and how to consider these elements to enhance the learning environment in simulation scenario development and delivery. By applying the concepts of Cognitive Load Theory, this paper offers educators a method to tailor their curricula to navigate working memory and optimise the opportunity for knowledge transfer.

Introduction

Medical education is undergoing a paradigm shift away from traditional didactics toward an increased application of simulation.^1–3 Simulated experiences in healthcare have the unique ability to integrate ethics, teamwork and learners of differing experience levels into one educational experience without risk of patient harm.⁴ Moreover, healthcare simulation differs from the traditional classroom, as it can replicate the physical look and stimuli of a real clinical environment, and is typically interprofessional in nature. Despite these benefits, simulation is also limited by its own inherent complexity. Depending on learner expertise and needs, the intricate experience created by a simulation scenario may overwhelm or underwhelm the learners, impeding learning due to an imbalance of cognitive load.⁵ Educators are faced with the challenge of creating experiences that appropriately stimulate the learner and acknowledge existing expertise.

Healthcare educators have begun to explore the limitations of working memory to meet the needs of such complex learning groups.^6–10 Working memory is short-term memory that transiently holds and processes information for comprehension and problem management. Elements processed by short-term memory are packaged and transferred to long-term memory.^11–13 We rely on working memory when approaching complex problems like patient care. When dealing with new problems, there is limited capacity of our working memory to manage new elements. When using simulation as the platform for education, learners are at risk of overwhelming their working memory and walking away from an educational experience without the intended knowledge transfer.¹¹ Theoretically, this poses a threat to a learner's medical practice and patient safety. Furthermore, underestimating the capabilities of expert learners may be a cause for disengagement and lack of interest in the learning modality.⁶

Within simulation-based education, the debriefing offers a forum to reflect and provide feedback.^{14 15} For successful knowledge transfer, the simulation curriculum, from precourse material, scenario development through the debriefing, should consider working memory limitations. These ideas build off of Sweller's Cognitive Load Theory¹¹ which emphasises the limitations of memory. The application of Cognitive Load Theory will be demonstrated through case scenarios as well as modelled curriculums. The strategies provided will equip educators with practical tools to improve knowledge transfer during simulation-based activities.

Cognitive Load Theory

Cognitive Load Theory is predicated on the idea that individuals have a limited capacity to handle novel information and helps explain why experts and novices solve problems differently.^{11–13 16–18} It has been applied with success in many educational arenas, and Fraser et al⁶ offer an excellent introduction to Cognitive Load Theory within education using simulation.

When solving problems, the difference between an expert and a novice is that an expert has established ‘schema’, or knowledge, stored in long-term memory. Schema serve as a reference when an individual is trying to categorise and distinguish between different problem states. Experts are more capable of addressing problems in an organised fashion, using amassed schema to drive skilled performance with less mental effort. Conversely, novices tend to rely on other problem-solving strategies to manage new experiences and attain their goals. This is exemplified when an expert clinician approaches a patient suffering from chest pain, and uses pattern recognition to uncover concerning signs of a myocardial infarction with only a few questions. Conversely, a first year resident physician may have to ask a multitude of questions, addressing all types of chest pain, and still be left without a clear diagnosis. In order for a novice to shift toward expertise, the focus for the educator is to stimulate the learner to create new schema for problem solving.¹¹

To create schema, learners must rely on their ability to process new information. Working memory has the ability to handle between five and nine elements of information at a time.¹⁹ Factors that can impact an already limited working memory include intrinsic load, extraneous load and germane load. It is the additive effect of these different loads that can overload the working memory and effect ultimately schema formation for the learner (figure 1).²⁰

Figure 1.

Intrinsic load is overwhelming for the working memory to process it effectively. Learners walk away having missed lesson objectives and, as a result, do not achieve the desired schema formation anticipated from the exercise.

Intrinsic load is defined by the elements that are specific to the material to be learned. At times, these elements may be learned as interacting components of a greater system (ie, intravenous catheter insertion during a cardiac arrest), or elements may be extracted from a system and learned in isolation (ie, intravenous catheter placement on a partial task trainer).¹² Some tasks may have more intrinsic load than others. For example, the intrinsic load of placing a peripheral intravenous catheter has fewer burdens on working memory than placing a central venous catheter. An individual's previous experience with a specific task can decrease intrinsic load as they have already mastered and formed related schema.

Extraneous load is the cognitive load conferred on the learner by the structure of the activity. In the example of intravenous catheter placement, having to find the materials to perform the procedure will increase extraneous load and decrease available working memory.²¹ The competition and interaction of these types of loads may define the effectiveness of knowledge transfer achieved through the learning experience.

Germane load addresses the working memory that is focused on learning and creating new schema while handling the intrinsic load. Germane load is responsible for storage of schema into long-term memory.¹² ‘Chunking’ materials that are related simplifies them into meaningful elements and helps facilitate improved recall.^{13 22} If the working memory of the learner is exceeded, learning will be less effective and hindered. Kalyuga argues that there are no empirical results to explain this concept, and that it may be a redundancy of intrinsic load.²³ Therefore, for the purposes of this paper, germane load will be considered a constant that will not be manipulated.

Strategies to address intrinsic load

Perform learner needs assessment

Learning needs assessments can be accomplished by surveys, questionnaires and interviews. Keeping these tools brief and focused around the broad objectives of the lesson will make this task less onerous.²⁴ Regarding expert learners, balancing individual needs versus organisational needs poses a true challenge.²⁵ An institution experiencing a rise in central line infections may mandate a central line maintenance fundamentals course for all providers when, in fact, a focused review of the procedural steps taken by experienced nurses may uncover a simple solution that obviates the needs for a basic course. When considering teamwork, analysis may focus on individual performance skills as well as team approach skills. Understanding attitudes, behaviours and culture will better tailor the simulation scenario objectives.²⁶ Analysis should also consider domain-specific elements such as the multiple patients and distractions in an emergency department while managing critical patients.

Before a scenario or course, a collaborative learning experience where learners work in groups and share their knowledge about a particular topic can illuminate knowledge gaps. Less formally, needs assessment can be done at the beginning of the class using audience response systems or even a show of hands. An educator can also identify learner needs during or after a simulation experience. Immersing learners into a simulation scenario followed by a debriefing allows for a self-guided reflection on action. Facilitator observation during the scenario will also identify potential knowledge gaps that can be targeted during the educational session.²⁵

Design-tailored lesson objectives

Learning objectives are key to all educational activities, and these objectives identified by the educator will define the desired intrinsic load of a simulation activity as performance may degrade at the extremes of overloading and underloading.²⁷ A student will be overloaded if the combined load is too much for the working memory. For example, increasing the number of lesson objectives arguably may raise the intrinsic load. Conversely, a learner may be underloaded if the experience is not challenging enough. If the objectives offer too little new material and underestimate the student's capacity, there is a risk of disengagement. Therefore, it is useful for the learner's level of expertise to be identified using an assessment tool prior to tailoring your lesson objectives.

Simulation can be used as part of the needs assessment to focus lesson objectives. Demaria et al performed a needs assessment of anaesthetists returning to clinical practice after leave. Through observed simulation experiences, learners were rated on non-technical skills as well as tasks specific to anaesthetists in the operating room. The evaluation occurred over 2 days, a significant commitment of time, which may leave this as an option for high stakes needs assessments only. Nonetheless, the needs assessment informed a very tailored set of lesson objectives, focusing the intrinsic load needs of returning clinicians with advanced skills and knowledge to clinical practice.²⁸

Establish a theoretical framework

If the needs assessment has identified knowledge gaps, introducing learners to concepts prior to entering a simulation may enhance schema formation. Through case-based learning²⁹ or collaborative learning approaches,³⁰ knowledge can be transferred and offers conceptual tools to work with when entering into a scenario. If time is an issue, a blended learning model may be more effective. The ‘flipped classroom’, for example, assigns learners self-paced tasks prior to coming to the classroom. Tasks may include readings, group activities or online experiences like videos, lectures or games.³¹ In this way, intrinsic load is lessened, as learners will be drawing from the long-term memory created before the classroom, instead of processing brand new material inside the classroom.

Case example: You have been tasked to design on effective teamwork during cardiac arrest. Your needs assessment has identified little expertise in the area of Advanced Cardiac Life Support (ACLS) among your learners. You decide to use a collaborative learning approach and draft evidence-based topic sheets addressing compressions, ventilation and defibrillation techniques. Through facilitated instruction, the learners teach each other the highlights of the topic sheets. You offer the theoretical framework of code team management and an appropriate resuscitation drawing from ACLS principles.

Familiarise the learner

It is important to introduce learners to the simulation environment.³² Being unfamiliar with the environment and simulators consumes greater cognitive resources, as learners may not know what resources are available in the room. Unless discovering the educational environment is the objective lesson of the curriculum, being unfamiliar may detract from focus on the true lesson objectives. Although important for all learners, it is particularly important for the expert learners, as the unfamiliar environment may pose challenges to their regular pattern of recognition. Although no evidence-based script exists, offering the learners a short ‘preview’ or ‘prebriefing’, by demonstrating how the pulses feel on the mannequin or bag valve mask location can reduce the load imposed by the environment on the available working memory.⁶ It is imperative that rigorous investigation focuses on this, as it is plausible that prebriefing can have a profound impact on the success of the educational intervention.

Pause and reflect during debriefing

Another possible strategy to address intrinsic load is the use of ‘pause-and-reflect’ debriefing, also known as ‘in-simulation’ debriefing. By breaking up the experience, the intrinsic load is made into smaller elements, thus decreasing cognitive fatigue. While some data suggests that participants may prefer end-of-scenario debriefing compared to in-simulation debriefing, further study should look at retention effects of in-simulation debriefing versus ‘postsimulation’ debriefing.³³ It makes intuitive sense, however, that truncating simulation experiences with debriefing breaks up the intrinsic load throughout the scenario.

Hunt et al determined that learner-centred debriefing after 2-hour sessions did not have measurable impact and changed a ‘coaching’ style of debriefing, where educators interrupted the scenario when an error occurred and discussed the situation. The learners would then be offered a ‘10-s rewind’ to try again.³⁴

Eppich et al also offer a structured approach to a pause and reflect-based curriculum, referring to in-simulation debriefs as ‘microdebriefings’. During these microdebriefs, the instructor promotes reflection and highlights elements for improvement. Following the pause, there is opportunity to practise the critiqued elements. This may require the presence of a content expert to address practice standards that are the focus of the scenario. Following the scenario, a facilitated debrief allows for learner-centred reflection. When comparing the duration of traditional scenario/postscenario debriefing model, the pause-and-reflect approach will require more time allocation.

Scaffold concepts simple-to-complex

Taking learners through multiple experiences and graduating the complexity of the experience is another way to address a high intrinsic load activity. Elements learned in isolation will begin to interact in larger systems as learner-relative expertise evolves. In other words, the clinicians would practise basic principles in ‘easier’ scenarios, and gradually the scenarios will grow in difficulty. This allows for incremental development of schema for a whole system.¹²

Hunt et al applied this concept of scaffolding to the curriculum design in Rapid Cycle Deliberate Practice. In their study, resident physicians were exposed to paediatric cardiac arrest scenarios that built off the skills learned in previous scenarios. The first learning objectives were centred around bag valve mask ventilation. Successive cases added elements of a difficult airway, need for cardiopulmonary resuscitation, teamwork coordination and defibrillation. The outcomes, postintervention, noted a significant improvement in resuscitation and defibrillation skills; specifically, a decreased time to compressions and preshock pause times.^{34 35} Considering the number of scenarios performed by each resident, significant efforts would have to be made to secure time for this undertaking.

Pairing this with increasing the number of sessions and simultaneously making the sessions shorter may also prove effective at improving knowledge transfer. Raman et al³⁶ demonstrated that having shorter educational sessions offered in a dispersed curriculum proved to foster knowledge retention. This is not an attempt to fragment the learning experience which may lead to poor transfer. Rather, the educator can intensify the learning into smaller domains around the subject matter being taught.

Schick et al model this curricular application in their Phase-Augmented Research and Training Scenario curriculum design. A large scenario involving crisis resource management is broken down into three phases: preliminary, emergency and management phases. Each phase has a focused single critical action that can be individually assessed. The authors did not perform debriefings after each phase, but the intrinsic load is effectively broken up using this strategy focusing on smaller elements. Although a smaller study, the researchers were able to show an appreciable difference in performance from pretest and post-test evaluations of critical actions in scenarios.³⁷ From a time perspective, the organisation of this curriculum will take significant preplanning. Execution will also take more time as it breaks one larger scenario down into three smaller ones.

Case example: You decide to build your first scenario to be a very straightforward cardiac arrest case. The learners are told that the patient is in ventricular fibrillation, and it is their job to resuscitate the patient. This allows the learners to focus on compressions, without the added concern of figuring out what type of arrest the patient is in. You schedule another time for a scenario where the learners will focus on identifying a pulseless patient and rhythm identification.

Similarly, practising important subtasks as elements of a whole using part-task trainers, known as ‘shaping’, may help focus and store higher complex tasks in long-term memory.^{10 38} For example, a part-task training that rehearses applying the defibrillator to a patient and administering a shock may be a complex task for the novice learner with high intrinsic load. Focused timely feedback with procedural training may help support development of that skill.³⁹ In the surgical setting, practising suturing on a simulated skin or a cadaver is a part-task that can be practised separate from a whole surgical procedure. After such training, the schema formed have decreased the overall intrinsic load when incorporated into a larger system such as the suturing of an incisional wound at the end of an operation.

Applying cognitive load concepts to manage intrinsic load in a curriculum can be challenging. Table 1 offers a toolkit to address intrinsic load.

Table 1.

Intrinsic load strategies to improve knowledge transfer

Strategy	Educational application
Perform learner needs assessment	Determine experience level of participants (ie, novice vs experts, multidisciplinary, etc) Identify knowledge gaps
Design lesson objectives	Formulate appropriate learning objectives Keep learning objectives limited
Establish a theoretical framework	Before entering into a simulation experience learners will benefit from some understanding about the topic being explored Consider introducing course materials before the simulation scenario by flipping the classroom or having actual classroom and hands-on time
Familiarise the learner	Introduce the simulation environment so the learner can focus on the lesson objectives, including (ie, location of supplies…)
Create subtasks	Create learning modules focused on complex skills important to a skill set that may become overwhelming (ie, defibrillator in advanced cardiac life support, chest tube insertion in trauma scenario) prior to entering the simulation scenario
Pause and reflect	Break up the scenario by stopping the simulation once certain lesson objectives have been achieved/or mistakes have been made to allow for reflection on concepts
Scaffold (simple to complex)	Start with simple scenarios and allow the learners to apply their skills successfully Subsequent scenarios will offer more difficulty by adding more learning points to the already processed information

Strategies to address extraneous load

Unlike intrinsic load, because extraneous load is not inherent to the activity, there is opportunity to decrease load on the working memory through careful design of the learning experience.²⁰

Using worked examples and completion principle

Sweller proposed many strategies to reduce extraneous load in its application to medical education.^{11 12 40} One such method to reduce extraneous load is to use worked examples in place of conventional tasks.^{9 11} Cooper and Sweller¹⁶ noted that reviewing worked examples of algebra equations rather than struggling through multiple problem sets improved knowledge transfer. Facilitators can provide worked examples through algorithms, modelled videos of clinical situations or case examples prior to the simulation event either before the class or in the classroom itself. This allows the learner the opportunity to begin the development of schema.⁴¹

Case example: You perform a cardiac arrest simulation-based demonstration as part of your curriculum. The learners watch as you model good behaviour, and use worksheets to take notes focused on the lesson objectives. Following the example scenario, you debrief the learners allowing them to discuss their observations and critiques of the cardiac arrest scenario performed by your team. This allows the learners to see all components of a cardiac arrest prior to their own practice scenario.

Fading the worked examples by gradually leaving out material and allowing the learner to fill in the gaps promotes schema formation. This is accomplished in the simulation environment by inviting learners to run through worked examples alongside the instructor or with a part-task trainer. As noted by Parker et al in their grounded theory study on simulation educational practices, fading allows the transition of learners from other control to self-control. The instructor supports learners in areas beyond their capacity, and as the learner grasps the new elements, the instructor provides less support. The study concluded that the presence of the instructor allows for both a decrease in anxiety during the simulation experience as well as assists in the eventual assimilation toward an expert's frame of reference.⁴² The completion principle benefits novice learners through partially completed tasks without the presence of the facilitator.^{9 11 12} When considering the elements of a scenario, instructors can increase the amount of information available to the learner (ie, laboratory results, radiology results). As a result, the student's attention is directed toward caring for the simulated patient and not information gathering. A curriculum focused on shoulder dystocia manoeuvres, for example, may present the learners with a labouring patient with monitors in place who reports a history of shoulder dystocia. This way, the tasks of monitor placement and discovery of the shoulder dystocia do not distract the learner from the goals, thus decreasing fatigue on the working memory.

Case example: In your PEA arrest curriculum, your learning objectives are focused on performing chest compressions in a timely manner, prompt ventilation and reversal of hyperkalemia. Offering information to the learners that the patient was found pulseless, and the labs demonstrated hyperkalemia, help guide their attention.

Simulation educators practise the completion principle often when they realise they have overestimated the level of expertise of the learner. At times, learners will enter a simulation scenario and stray far from the expected tasks and learning objectives. Facilitators intervene by offering signals and stimuli through changes in vital signs, physical exam and information from actors pushing the scenario in directions that fill in gaps for trainees in early schemata formation.

McRobert et al performed a study looking at the effect of low and high-context scenarios on diagnostic accuracy that ultimately supports the completion principle. Novices and expert emergency physicians were divided into two arms based on expertise. The low-context scenarios had information withheld while the high-context scenarios had all the information scripted and available. Novice learners performed poorly in diagnostic accuracy in situations where limited information was available to them, whereas experts performed well.⁴³ Although an opportunity for reflection was created, the learner's working memory seemed to be overwhelmed by the extraneous load of the experience, and performance was sacrificed.

Avoid split-attention

The Split-Attention Principle addresses how an educator presents information. With conventional teaching, data are sometimes split between sources of related information thus increasing extraneous load. In a classroom, this could happen if there was a step-by-step process written describing how to insert an intravenous catheter, and a separate step-by-step set of pictorial slides depicting the insertion. The delivery of the information in two forms is taxing to working memory. Integrating the materials into one source may promote knowledge transfer.¹²

Chandler and Sweller studied the effects of split-attention comparing two styles of instruction for computer literacy. Conventional instructions in a listed format paired with a computer were offered to group 1, while a modified manual with integrated diagrams was offered to group 2. Testing after the use of the manuals on elements of high-element interactivity demonstrated improved performance in the integrated manual group.¹⁷ By decreasing the extraneous load through addressing the split-attention effect, working memory was freed for transfer of knowledge into long-term memory.

Fenik et al performed a randomised control trial evaluating the use of prepackaged central line kits versus standard kits on procedural performance. Standard kits added the extraneous load of dividing one's attention to gather all the elements necessary for the procedure. There were a significantly reduced number of mistakes in the prepackaged kits group, concluding that the decrease in extraneous load resulted in improved performance.²¹

Educators can design scenarios with patient information consolidated to a single source such as a patient chart or single actor. The novice learner benefits from this attention to curricular detail. Expert learners, on the other hand, may not benefit, as they may be familiar with gathering data from multiple sources such as in the context of the emergency department. This is not to say that switching between tasks is not an important aspect of curriculum, as clinicians are frequently burdened with cognitive interruption. Task-switching should be the focused learning objective of a curriculum for novice learners starting with simple tasks and moving to increased task interactivity.⁴⁴

Consider emotion as extraneous load

Psychology literature suggests that anxiety during high cognitive demand activities impairs processing efficiency.⁴⁵ While using simulation as an educational tool, the effects of a crying family member at the bedside interrupting care could create a high stress experience on the learner. Fraser et al explored the effects of emotion and the relative perception of cognitive load. They concluded that overly heightened emotion, both positive and negative, produces extraneous load. Depending on the learning objectives, this specific extraneous load might be task-irrelevant, and that consumption of working memory may negatively affect performance.⁷

Fraser et al performed another study evaluating the effect of simulator death on learning transfer. The simulation included an unexpected death in a patient with altered mental status in one cohort versus no death in the other cohort. On conclusion of the study, students were evaluated through a simulated patient scenario of a patient with altered mental status ∼3 months after the intervention. Those exposed to the unexpected death underperformed relative to those not exposed in the learning experience. As noted by Fraser et al, this does not suggest that patient death should not be a part of simulation, rather it suggests that it increases extraneous load. As a result, in trainees with few schema, or with novice learners, working memory may be overloaded.⁸ If handling death is one of the learning objectives, then emphasis should be placed on that learning objective during the debriefing.

Experts, on the other hand, may be able to handle such an emotionally charged experience and still achieve learning goals. Further study on how emotion impacts learning in simulation education is another area of potential exploration. Recognising the impact that highly emotional topics may have on a learner within a scenario, as well as the emotional vulnerability created by the learning environment is paramount when designing a simulation curriculum.

Create a psychologically safe context for learning

The learning environment itself represents another possible source of extraneous load. Specifically, the psychological safety of a learning environment may be addressed by managing issues of realism and demonstrating respect for the learners. The authenticity of the activity allows clinicians to act meaningfully and purposefully.⁴⁶ Thus, attention to detail in the simulation scenario is of utmost importance because if it strays from understandings of pathophysiology it may pose undue cognitive strain. Therefore, the environment's relative fidelity may impact the efficacy of an educational experience.

Transferring learning into the work environment, or unit-based training, may lend significant reductions in extraneous load, as individuals will know where their tools are in the environment and better focus on the intrinsic load as a result. Sorensen et al⁴⁷ demonstrated no significant differences in participant knowledge transfer, safety attitudes or stress level between the simulation laboratory and unit-based simulation. Performance indicators of knowledge were via a multiple choice question test. Other performance indicators should be considered for future study as surrogates for knowledge transfer.

A sense of safety falls into the realm of emotion, and may pose unnecessary extraneous load to a learning experience and hinder performance similarly to studies previously discussed^{7 8 45} Learners must be comfortable with their facilitators, and be free to ask questions. Rudolph et al suggest that a simulation briefing should address four major points to create a safe container for the learner. First, it must clarify objectives, roles and responsibilities of the learners and educators. Second, a ‘fiction contract’ must be created, understanding that not everything will seem realistic in the simulated environment but that instructor and learners will make every effort to treat the situation as real. Third, addressing the logistics of the environment and flow of the simulation session allows the learner to understand how to deal with competing commitments and better prepare to enter the learning environment. Last, educators must demonstrate their commitment to respecting their learners and have genuine interest in their perspectives.³² Once a safe container is created, it will allow for educators to challenge their learners to achieve greater transfer of knowledge and capability.⁴⁸

Creating that safe container does not need to be time intensive, and depends on the activity. Longer experiences may require more time to address logistical issues, whereas shorter experiences may only need a few minutes to address psychological safety.

Case example: At the start of class, introduce yourself to the group and explain the experience they are about to embark on. Clarify the expectations and demonstrate a commitment to respecting their concerns, as well as offer a safe environment to learn. Emphasise that this curriculum is not an assessment of the practitioners but an opportunity to practise and gain insight from mistakes.

Underplaying psychological safety is especially dangerous with the expert learner. Although the use of simulation as an educational tool, it may more frequently be construed as an assessment tool evaluating one's capabilities of doing their job. According to Malcolm Knowles, adult learners, especially experts, find it difficult to be judged by another adult.⁴⁹ The evaluative aspect of simulation may suggest disrespect and dependency to the expert learner leaving them vulnerable, questioning their identity as proficient in their field of practice. Every effort needs to be made by the facilitator to create that safe environment to allow the expert to maintain focus on the intrinsic load. One strategy to consider is self-guided reflection for the expert learners to demonstrate respect around their opinions as opposed to sole emphasis on facilitator-guided reflection.

Recognise expertise reversal effect

Schema are what define an expert from a novice.⁴⁰ The more schema that are available to the trainee, the less concern there is for cognitive overload or attention to minimising extraneous load. It is important, however, to recognise that experienced clinicians are sometimes learning new techniques for the first time. Using an ultrasound to place a central venous catheter, for example, instead of relying on landmarks for placement is a novel concept to some experienced clinicians. Theories surrounding cognitive load to support expert learners must be considered when designing the curriculum.

Depending on the topic, experts may not need as much guidance as novices when entering a simulation environment. They apply established schema and approach a variety of situations with rehearsed skill. On account of their preformed schema, they are at risk of expertise reversal effect. Expertise reversal effect is extraneous load that occurs when the curriculum developed for novice learners is applied to experts and may result in no learning or even unfavourable effects.^{12 50}

To clarify understanding of this effect, consider the split-attention effect to decrease extraneous load for the novice learner. Focusing the information such as laboratory values and patient history in a scenario to be delivered through a single source decreases the load on the working memory. Applying the same strategy to expert learners may yield different results. Expert clinicians are skilled at extracting information from many sources such as charts, family members and patients, and may be distracted by the lack of realism associated with a single source of information.^{6 11 50} By allowing experts to rely on their schema through a more realistic experience, learners can more effectively focus on lesson objectives. Decreasing the number of stimuli and allowing for more freethinking and problem solving improves performance.⁵⁰

Case example: The administration is very pleased with the simulation programme you developed, and is now requiring teams with significant ACLS experience to go through your training. You tell your administration that you need time to adjust the curriculum to accommodate for their level of expertise. You redesign the scenarios to allow the providers to collect information, and offer greater freedom to navigate the environment.

Simulation exercises with experts can be focused on deliberate practice and refining schema.^51–53 The freedom structured into the experience allows the expert learner to perform realistic practice. These experiences put their schema to the test and allow for facilitated coaching opportunities. Increased problem solving and decision-making allow the facilitator the opportunity to better expose frames of reference through debriefing.¹⁴ Ericsson suggests that video recording medical procedures or experiences are an effective way for experts to evaluate performance. Through learner-guided reflection as well as facilitator-guided reflection, particular weaknesses in performance can be identified and can become the focus of a tailored curriculum.^{28 54 55} As a result, expertise-reversal effect will effectively be eliminated from the working memory as the design of the simulations are targeted. Time constraints must be considered when considering the feasibility of this approach.

Interprofessional simulation experiences may pose a problem when considering novice and expert learners. Nurses, interns and attending physicians in the same room often have varying levels of expertise in different areas. This situation may result in overload for some and expertise reversal effect for others depending on the objectives of the curriculum. Thoughtful scenario development is key to ensuring learning objectives are relevant to each professional group. Focusing on elements of teamwork, or latent safety threats, are examples of objectives to explore in an interprofessional group.^56–58 It is always interesting to explore these subjects are not often a focus of graduate and undergraduate curricula. As a result, the educator can apply the concepts of cognitive load theory and manipulate the curriculum to optimise knowledge transfer and schemata formation around these concepts.

Pairing the strategies with managing intrinsic load, extraneous load can be tailored to accommodate the learner and optimise the experience for the limited capacity of working memory. Table 2 summarises these strategies and offers an Extraneous Load Management toolkit.

Table 2.

Extraneous load strategies to improve knowledge transfer

Strategy	Educational application
Offer worked examples	Provide learners with examples of modelled behaviours or approaches to problems the learners will confront in the scenario Pairing part-task trainers with a facilitator for demonstration purposes allows for active coaching and refinement prior to commencing simulation scenarios
Avoid split attention	Avoid offering information and materials from multiple sources with novice learners (ie, integrating formulas with diagrams) Consolidate information to a single source Integrate different sensory modalities (ie, pictures and words) into educational materials
Use the completion principle	Facilitators should perform tasks and offer information leaving out only the targeted tasks that the learners are to complete so that their entire focus is on the objectives Offer ‘help’ to the learner when they stray off task, or are confused during the scenario
Consider emotion as load	Stress and emotion can be titrated according to the learner level and ability to handle the emotional complexity of situations created by scenarios
Provide psychological safety	Create a safe container for learners Clarify expectations, script a fiction contract with learners, attend to logistical needs (ie, phone calls, bathroom, breaks, etc) and demonstrate respect for learners and their safety in the environment
Recognise expertise reversal effect	Use a self-assessment tool to identify the expertise level of the learner before participating in a simulation scenario Do not use scenarios designed for novices with experts Recognise experts’ skills sets and allow the experts in the class to use their skills during the simulation

Evaluation tools

As educators, we should regularly evaluate the curriculums we design. Tools should assess both performance improvement as well as the relative complexity of the experience for the learners. Tools to assess the cognitive load of tasks have started to be developed to help better apply the theory. Examples include the subjective rating scale by Paas and van Merriënboer. Together they developed a 9-point scale ranging from ‘very, very low mental effort’ at 1 to ‘very, very high mental effort’ at 9 that has been effectively applied in simulation literature.⁵⁹ More recently, a tool has been created to isolate and measure intrinsic, extraneous and cognate loads within an experience or task.⁶⁰

These tools offer great opportunity for further study by applying them in the realm of simulation education. Creating simulation-based studies that compare traditional curriculums to those created with a focus on cognitive load embedding the curriculum ideas discussed in tables 1 and 2 on intrinsic and extraneous load into scenario instructional design will further elucidate the effectiveness of this strategy. The time constraints and resultant feasibility around some of these techniques may leave educators less excited about their application. However, the importance of effective education that translates to provide better patient care is the goal and awareness of cognitive load that already seems to be demonstrating improved performance.^{8 21 34}

Conclusion

The principle of cognitive load theory has been applied with success to many facets of education, and simulation-based curricula should be no exception. By applying strategies to address extraneous and intrinsic load, we can organise a curriculum and simulated scenarios to achieve the highest level of knowledge transfer to our students. Although this paper does demonstrate that Cognitive Load Theory is actively being applied, the next step is to conduct research evaluating its effectiveness within simulation education. Studies that strive to compare Cognitive Load Theory strategies against strategies that deliberately avoid its application will shed light on its impact on knowledge transfer. With these efforts, we look toward a promising future of improved patient care and outcomes through focused application of refined educational strategies.