Trending Topics

Applying learning theory to EMS simulation practice

Simulation training in EMS allows for internalizing skills, mimicking behaviors and reflecting on strategies until they become foundational knowledge


Simulation also implements many adult learning theories, including cognitive learning theory.

Photo/Aaron Dix

Advances in emergency medicine require constantly updated training methods as our technologies become more advanced; however, these methods need to be relevant to the real world experiences our students will be facing. Teaching in a simulated environment allows for information transfer and improved recall when these skills are performed in the field.

Simulation is not new to the educational realm. The military and the aviation sector have been using it for decades, because real-world training in both of these realms would be dangerous and expensive.

While simulation has been defined many times, it generally relates back to the idea that simulation is “a person, device, or set of conditions which attempts to present [education and] evaluation problems authentically,” with an emphasis on authentically [1]. What makes simulation so valuable to EMS learning experience is that it provides a safe venue for students to actively practice procedures, acquire skills and reflect on the experience in an otherwise volatile environment. It is simply not possible to have every student practice every procedure they learn on a live patient.

Cognitive theory: set the stage for internalizing EMS strategies

Simulation also implements many adult learning theories, including cognitive learning theory. Cognitive learning theory posits, “the key to learning and behavior involves the individual’s … perception, thought, memory, and ways of processing and structuring information” [1].

Students have a unique perception when they come into the classroom. It is often based on previous experiences with education; “Oh this is going to be another boring lecture” or “I heard this instructor is really good with cardio!” What an individual thinks about the information being presented affects whether or not it is stored in memory.

Does the individual find the exercise stimulating and important, shuffling it on to long-term memory? Or do they see it as irrelevant, briefly stored in short-term memory before being forgotten?

This information processing also plays on the idea that information is built into schemas. When a student learns something and internalizes information, they hold onto it like a specific file in a filing cabinet, ready to draw it out when needed. As relating information is gathered and internalized through learning, this schema grows. Simulated environments allow students to grown these schemas.

Social learning theory: students learn EMS skills by mimicking

Simulation also allows the student an opportunity to learn from others. Social learning theory states learning is an active process in which people learn through the observation of others, either other students in the group or the instructor demonstrating how to perform a skill.

When students see a particular type of behavior, they appear to mimic it in the future. If the behavior they recreate is met with positive reinforcement, they continue to demonstrate this behavior. They are not really mimicking at all; they have learned a behavior.

Everyone has run calls with a provider they truly admire and look up to. Naturally, a specific way or doing something, such as how that provider introduces him or herself on an emergency scene or a technique for starting IVs in children, is remembered. The next time you’re faced with that situation, you remember what effective technique your mentor used and try it for yourself.

The same can be said for negative encounters. When you see a provider treat a certain frequent flier disrespectfully, you subconsciously learn that behavior is OK and may find yourself repeating it next time you have that patient. As educators, we can use simulation to model the behaviors that we want students to emulate.

Constructivist learning: EMS instructors can pause for reflection

Perhaps most important to simulation is the theory of constructivist learning, which states, “learning is an active versus passive endeavor that includes dialogue, collaborative learning, and cooperative learning” [1]. Simulation allows for all of these facets to take place. Learning is constructed on prior knowledge – getting back to those growing schemas – and when students have the opportunity to talk and discuss the new information, they are adding to what they already know, clarifying ideas and learning from others. Unlike a real patient, the instructor has the opportunity to pause the simulation and allow students to discuss what they are doing and why without adverse effects.

Transfer theory: use basic assessment skills as foundation

Many other learning theories can also be applied to the realm of simulation. Transfer theory is defined as “[reusing] knowledge from past related tasks to ease the process of learning to perform a new task” [2]. Think of scaffolding. By using transfer theory, new tasks are, in a sense, easier to learn because they are scaffolded into previously learned knowledge and skills.

For example, when students learn how to perform a basic skill, such as an assessment, whenever they are taught further assessments or the nuances of a specific assessment, they have a foundation of prior knowledge to associate and integrate new knowledge with: they have been taught to perform a medical assessment, so when they are taught to perform a trauma assessment, they have a basis for comparison. Simulation uses transfer theory to help create a more realistic learning environment for students, better matching what they will see and how they will operate in the real world.

There is also a chance for students to practice critical reflection, aiding in the education process. In a simulation, the instructor has the opportunity to pause the simulation and allow students to analyze and deconstruct why they gave a medication or performed a certain procedure and the effects of the same on the overall patient outcome. This analysis not only tests the students’ knowledge, but also prepares them to educate their patients on the chosen treatment modality without blindly following a protocol.

Threshold theory: break down barriers to learning

Simulation is also related to threshold theory. According to Foote, “threshold theory identifies certain concepts as foundational within a discipline … [and] that, once learnt, are transformative to a student’s understanding of the subject” [2]. Threshold theory can also be used to identify and breakdown potential barriers to student learning, by indoctrinating EMS students to a method of practice.

We, as educators, are pulling out the most important skills students need to learn and teaching them in a realistic environment so that they will be able to show up on the scene of a respiratory distress patient and think to themselves, “I know what to do,” because they have done something similar in the controlled setting of the classroom.

Implementing simulation in the EMS classroom

Simulation can be implemented in the classroom in a variety of ways. The simulated environment must be authentic and provide an opportunity for experiential learning – learning by doing [1]. There must also be an opportunity for reflective practice: allowing the students to stop and discuss what they are doing and for the instructor to pose questions.

Debriefing after the simulation has been cited as “the most important part of the learning experience because it provides time for reflection to occur” [1]. It is the opportunity for students to take the information they have learned and tie it to a schema and to make sure that the information makes it from short-term memory to long-term memory. When they make this transfer of information, they will be able to draw on these experiences in the real world and provide the best patient care possible.

Many tools exist to provide simulated patient encounters. These can be costly investments, but just thinking outside the four walls of the classroom can be effective too:

  • Try having students perform their trauma assessment on a patient while sitting in a vehicle instead of on the floor of the classroom. Rehearse with the patient beforehand what complaints he will have and what behavior to display.
  • Bring in outside patients who can help students get experience with real demographics, such as a grandparent when covering special patient populations, or a child when covering pediatrics. Have each bring their current medication list and shot records so that students can see what a true encounter with each of these patients looks like.
  • Partner with another class. Fire, rescue and EMS do not have to be separate. If your training facility allows, have students practice working operations with other groups while they perform their drills. They can work together to extricate a patient and provide medical care (please use a manikin in potentially harmful environments) or practice rehab on the crews.

1. Rutherford-Hemming T. (2012). Simulation methodology in nursing education and adult learning theory, Adult Learning, 23(3);129-137. doi: 10.1177/1045159512452848

2. Yang L, Hanneke S, Carbonell J. (2012). A theory of transfer learning with applications to active learning, Machine Learning, 90(2);161-189. Available at:

3. Foote W. (2013) Threshold theory and social work education, Social Work Education, 32(4); 424-438. doi: 10.1080/02615479.2012.680436

Melissa Meyers, NRP, combines her experience as a firefighter, paramedic and educator to bring dynamic, thought-provoking, and experiential learning to all of her classes. Melissa is ALS program manager at the Maryland Institute for Emergency Medical Services Systems. She holds a Master of Education degree from Liberty University with a concentration in teaching and learning English, and certification as a National Registry Paramedic.