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

Document Type

Journal Article


Lippincott Williams and Wilkins


Office of the Deputy Vice Chancellor (Strategic Partnerships)/School of Medical Sciences


Originally published as: Mills, B. W., Carter, O. B., Rudd, C. J., Claxton, L. A., Ross, N. P., & Strobel, N. A. (2015). 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. Simulation in healthcare: journal of the Society for Simulation in Healthcare 11(1), 1-10. Original available here.


Introduction: 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 (LFenS) vs. high-environmental fidelity simulation (HFenS)] 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 HFenS and interviews consistently suggested that they experienced greater psychological immersion and cognitive burden than their LFenS 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 HFenS students did so significantly more quickly (P < 0.01). The LFenS students had low immersion resulting in greater assessment anxiety. Conclusions: High-environmental fidelity simulation engendered immersion and a sense of urgency in students, whereas LFenS 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. Copyright © 2015 Society for Simulation in Healthcare.