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• Phase Two: Skills acquisition. This phase is designed to de­ CLT was initially presented by Sweller et al in 1988. In CLT,
velop and refine behavioral, technical, and cognitive skills. there are three types of cognitive processing “loads” placed
• Phase Three: Application and practice. This phase includes on the learner’s mind: intrinsic, germane, and extraneous. It
practicing skills under conditions that approximate the op­ is the sum of these three loads that describes the total amount
erational environment and that gradually attain the level of of mental effort required by working memory, also referred to
stress expected. as the overall cognitive load of a task. The intrinsic load is the
inherent mental workload (difficulty) imposed by the material
In the first phase, preparatory information is provided to or task. If elements or pieces of information need to be un­
trainees. They are taught about the physiological response to derstood and employed simultaneously, then an activity is said
stress normally and how these natural physiological mecha­ to have high element interactivity, which increases the intrinsic
nisms can interfere with the specific cognitive processes and load. Additionally, some concepts, in and of themselves, are in­
technical skills during resuscitation. It ensures that everyone herently more difficult to understand than others. The intrinsic
understands this deterioration is normal. Furthermore, it gen­ cognitive load is generally the most difficult to alter, but good
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erates accurate predictions of how they will respond, which coaching and teaching may have a mitigating effect. Direct
is critical to future success. By providing them with precise guidance and feedback to novices working through skills for
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expectations, people perform better under stress. Behavioral the first time avoids frustration, helps prevent errors, and en­
scientists have noted that giving individuals preparatory infor­ forces correct practice. 56­59 This reduces intrinsic load as well as
mation before engaging in stressful situations tends to render improving performance and the transfer of skills. Specifically,
stressful tasks less novel, increases the predictability that one for a complex information­processing skill during a computer
will experience stress, increases one’s sense of self­control, and simulation game, direct guidance and feedback helped experi­
decreases the tendency to misinterpret the stress response as mental subjects complete tasks faster and answer questions cor­
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catastrophic. Another important part of this phase is clari­ rectly more frequently than was the case without such guidance
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fying that providers are not helpless in the face of this hard­ and feedback. For complex aviation tasks, such as landing a
wired response. Crucial to success is the belief that people fighter jet on an aircraft carrier, direct guidance and feedback
have the capacity to exert control over their behavior. This during aviation simulation resulted in fewer procedural errors
understanding of self­efficacy has been linked to improved and fewer deviations from the glideslope on approach to the
performance in different domains. 50,51 This understanding also carrier. In contrast, some traditional training philosophies
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allows one to predict potential areas of weakness and to moti­ that do not provide guidance and feedback, such as “training
vate individuals to obtain the necessary skills to improve their to failure,” “let them figure it out by making mistakes,” or
response under stress. 52,53 “they have to fail to get it right,” are likely unhelpful when it
comes to training novices (see extraneous load, below).
Perhaps the most time­intensive and most important part of
the training paradigm is phase two. The goal of this phase is It is important to mention that learners should have the time to
to develop the host of technical and nontechnical skills needed work through more complex situations and solve novel prob­
to perform effectively without the addition of stressful stimuli. lems without guidance. However, this seems to be beneficial
The goal is to learn and develop constructive coping mech­ only with experienced learners who have consolidated foun­
anisms and to build successful performance habits. The fun­ dational principles and have strong skills. These individuals
damental technical skills of emergency medical care must be benefit less from activities that guide them and that reduce the
established in conjunction with various cognitive and behav­ intrinsic load of the material because these persons have likely
ioral techniques. mastered them already. More experienced individuals can
thrive with the introduction of challenges, nuance, and active
In phase 3, application and practice are designed to rehearse forms of learning. Complicated scenarios that force this group
the skills sufficiently developed in phase 2 under increasingly of learners to actively engage, make and commit to decisions,
stressful conditions. This allows trainees to experience, in re­ and execute skills facilitate deep processing and improved re­
al­time simulation, the various performance challenges they tention of information. 62­65
will face in a specific setting (e.g., combat, active shooter).
It also reduces uncertainty and anxiety as well as increases The germane load represents the working­memory resources
confidence when individuals realize that they can overcome used to manage the intrinsic load. It can be thought of as the
stressors. Finally, stimuli experienced during stress training are “brain power” used to make sense of information presented,
less distracting when experienced in real life. Requisite to these incorporate it with information already known to the learner,
desired effects is a graduated approach to stress exposure. It and store it for future recall. In the parlance of cognitive science,
is by incrementally increasing the level of stress that the desir­ this is referred to as the construction and automation of sche­
able outcomes (i.e., familiarity, resilience, and confidence) are mas. Because of working memory’s finite capacity, the brain
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developed. 44­45,51 uses schemas—structures that organize and relate many pieces
of information into one unit—to increase efficiency of process­
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Effective Teaching and Development of ing and enable automation. This is the theoretical explanation
Medical Skills for the Prehospital Trauma Setting why complex, challenging, or stressful scenarios benefit experts
If the goal of TCCC, TECC, and STB training is to teach but do not help novices. Experts experience notably less intrin­
live­saving medical skills so that the trainee can reproduce sic cognitive load from tasks they have mastered; therefore, they
these skills in the future on the battlefield or at the scene of an can put substantially more mental resources toward the germane
emergency (i.e., near and far transfer of skills), it is important load for processing complicated situation­based exercises. 67
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to understand how the brain accomplishes these tasks. Under­
standing the process of information recognition, consolidation, The third cognitive load, extraneous load, is irrelevant to
storage, and recall can be framed within the concept of CLT. the material’s substance. It detracts from learning and has

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