May 4, 2023By Teresa Gore

Application of Cognitive Load Theory in Healthcare Simulation

Cognitive load theory (CLT) is applicable to healthcare simulation to provide a framework for simulation design. CLT is an instructional theory that focuses on the relationship between the working memory and long-term memory. CLT can guide educators to design learning opportunities to promote information transfer from short-term memory to working memory to long-term memory. Too much information at one time can actually hinder learning as barriers in the transfer of information from the working memory to long term memory. This article will explore how cognitive load theory can support healthcare simulation development.

Working Memory

The working memory is the part of the brain to intake and process new information. If the transfer of information from working memory to long term memory does not occur, the information is forgotten. The working memory has limited capacity for a maximum duration of about 20 seconds, meaning one cannot not memorize information greater than 20 seconds in duration. The human mind has the ability to only hold about seven chunks of information, such as the recall of a list of digits. In addition, one has a maximum concurrent limit to process two to four chunks of information at a time. To learn, one can process activities to facilitate learning. Some process activities are organizing, contrasting, comparing, and other manners of working on information. Learners can control the cognitive load through conscious decision-making on how and what to learn in order to control the input of a memory. Educators can assist with the control of input through different strategies in the presentation of information.

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Long Term Memory

The long term memory is where information is stored from the working memory that is learned. This part of the brain has vast storage capacity. Information can be recalled from a long time ago. The ability to connect the working and long term memories is how learning is facilitated. The redundancy and split attention effects are barriers to the transfer of information from working to long term memory.

Redundancy effect occurs when information is not taught directly and contains unnecessary information. The unnecessary information clogs the transfer from working to long term memory because one cannot guarantee what information is retained and what is discarded. This can result in the wrong information retained.

Split attention effect occurs when learners attempt to process two or more sources of information at the same time. The split focus between the sources results in the learners’ working memory unable to decipher what is the most important information. This can lead the learner to retain less information overall.

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Cognitive Loads

Cognitive load theory has three types of loads that impact what is learned:

Intrinsic load refers to the complexity of the information to be learned. Some topics are harder to comprehend and learn than others. Intrinsic load can only be altered through a change in the nature of what is learned or by the act of learning itself. Educators can improve the intrinsic load through presentation of information in small chunks and the opportunity to apply the information through experiential learning.

Extraneous load is the distractor to learning. Extraneous load can occur in the presentation of the information, environmental factors, and non-essential information that distracts the learner from the valuable information. Educators can decrease the amount of extraneous information through delivery methods, the amount of information to learn, and strategies employed in the process of learning. An example to impact the extraneous load for novice learners is to decrease the distractors in a simulation such as alarms, interruptions, and limitation of the amount of unnecessary information.

Germane load is learning constructed using best practices and is purposefully designed. Germane load allows the working memory to transfer information into the long-term memory. The transfer to long-term memory is enhanced by pattern development and schemas. Educators can increase learning through design and development in healthcare simulation through the incorporation of INACSL Healthcare Simulation Standards of Best Practice.

Healthcare SImulation Standards of Best Practice

The Healthcare Simulation Standards of Best Practice by INACSL can guide the development of quality simulation that is supported by cognitive load theory. The Simulation Design Standard states the simulation should be constructed with measurable objectives that build upon the learner’s foundational knowledge and use a learner-centered facilitative approach that is driven by the objectives, learners’ knowledge and level of experience, and the expected outcomes.

Scaffold Learning in Healthcare Simulation

One way to improve learning in healthcare is to scaffold information to impact the intrinsic load. This is especially true with novice learners. Novice learners need step by step instructions to perform a skill. As the foundational information is transferred from working to long term memory, additional tasks and skills can be added. An example of this is to have an intravenous (IV) skills lab for the learner to practice how to initiate IV access for fluid initiation. Once this skill is learned, the next phase could be to develop a simulation scenario for the learner to assess the manikin, determine the need for an IV access, insert an IV access, and initiation of IV fluid therapy.

Healthcare simulation has emerged as an effective strategy for clinical educators to optimize learning opportunities. Cognitive load theory is highly relevant to teaching in the simulation environment. Cognitive load theory is an effective framework to guide clinical educators in the design and implementation of experiential learning opportunities for all healthcare professional learners.

Tips to Avoid Cognitive Overload in Healthcare Simulation

  • Create simulations with manageable nuggets of information.
  • Incorporate repeated exposure to simulations into your curriculum.
  • Create a series of simulations which gradually build knowledge from simple to complex.
  • Expose your learner to training concepts before they complete simulated training.

Read More About Cognitive Load Theory and Simulation


  • Fraser, K. L., Ayres, P., & Sweller, J. (2015). Cognitive load theory for the design of medical simulations. Simulation in Healthcare, 10(5), 295-307.
  • Sweller, J. (2010). Element interactivity and intrinsic, extraneous, and germane cognitive load. Educational psychology review, 22, 123-138.
  • Szulewski, A., Howes, D., van Merriënboer, J. J., & Sweller, J. (2020). From theory to practice: the application of cognitive load theory to the practice of medicine. Academic Medicine, 96(1), 24-30.

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