title: Effects of Low- Versus High-Fidelity Simulations on the Cognitive Burden and Performance of Entry-Level Paramedicine Students: A Mixed-Methods Comparison Trial Using Eye-Tracking, Continuous Heart Rate, Difficulty Rating Scales, Video Observation and Interviews.
abstract: BACKGROUND
  High-fidelity simulation-based training is often avoided for early-stage students because of the assumption that while practicing newly learned skills, they are ill suited to processing multiple demands, which can lead to "cognitive overload" and poorer learning outcomes. We tested this assumption using a mixed-methods experimental design manipulating psychological immersion.
  
  
  METHODS
  Thirty-nine randomly assigned first-year paramedicine students completed low- or high-environmental fidelity simulations [low-environmental fidelity simulations (LF(en)S) vs. high-environmental fidelity simulation (HF(en)S)] involving a manikin with obstructed airway (SimMan3G). Psychological immersion and cognitive burden were determined via continuous heart rate, eye tracking, self-report questionnaire (National Aeronautics and Space Administration Task Load Index), independent observation, and postsimulation interviews. Performance was assessed by successful location of obstruction and time-to-termination.
  
  
  RESULTS
  Eye tracking confirmed that students attended to multiple, concurrent stimuli in HF(en)S and interviews consistently suggested that they experienced greater psychological immersion and cognitive burden than their LF(en)S counterparts. This was confirmed by significantly higher mean heart rate (P < 0.001) and National Aeronautics and Space Administration Task Load Index mental demand (P < 0.05). Although group allocation did not influence the proportion of students who ultimately revived the patient (58% vs. 30%, P < 0.10), the HF(en)S students did so significantly more quickly (P < 0.01). The LF(en)S students had low immersion resulting in greater assessment anxiety.
  
  
  CONCLUSIONS
  High-environmental fidelity simulation engendered immersion and a sense of urgency in students, whereas LF(en)S created assessment anxiety and slower performance. We conclude that once early-stage students have learned the basics of a clinical skill, throwing them in the "deep end" of high-fidelity simulation creates significant additional cognitive burden but this has considerable educational merit.
authors.affiliation: From the Office of the Deputy Vice Chancellor (Strategic Partnerships) (B.W.M., O.B.J.C., C.J.R.) and School of Medical Sciences (L.A.C.), Edith Cowan University, Joondalup Western Australia; School of Medicine (N.P.R.), Deakin University, Geelong, Victoria, Australia; and School of Paediatrics and Child Health (N.S.), University of Western Australia, Crawley, Western Australia.
authors.forename: Brennen W
authors.initials: BW
authors.lastname: Mills
authors.forename: Owen B-J
authors.initials: OB
authors.lastname: Carter
authors.forename: Cobie J
authors.initials: CJ
authors.lastname: Rudd
authors.forename: Louise A
authors.initials: LA
authors.lastname: Claxton
authors.forename: Nathan P
authors.initials: NP
authors.lastname: Ross
authors.forename: Natalie A
authors.initials: NA
authors.lastname: Strobel
mesh_terms: D000293:Adolescent; D000328:Adult; D000402:Airway Obstruction / Q000628:therapy*; D000488:Allied Health Personnel / Q000193:education* / Q000523:psychology*; D002983:Clinical Competence; D003071:Cognition / Q000502:physiology*; D005133:Eye Movements / Q000502:physiology*; D005260:Female; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008348:Manikins; D017145:Models, Educational; D011795:Surveys and Questionnaires; D014741:Video Recording