By:Victoria Brazil (@SocraticEM)
Simulation educators spend a lot of time thinking about cognitive load. We worry about scenario complexity, realism, and whether learners can process the clinical task in front of them. But Remy Roe’s recent article on code-switching in simulation-based nursing education asks us to notice another source of cognitive load – managing how we ‘come across’ to others.
Code-switching describes the ways people adjust speech, behaviour, tone, appearance, emotional expression, and self-presentation to fit the norms of a particular setting. In healthcare education, this might mean trying to sound more “professional”, less emotional, more confident, less casual, more deferential, less direct, or more like the dominant cultural/ gender/ professional group in the room.
For some learners this is occasional and minor. For others, particularly learners from minoritised backgrounds, it can be exhausting. It is the work of clinical reasoning plus self-monitoring. It is noticing the patient’s oxygen saturation while also wondering whether your accent, phrasing, humour, silence, eye contact, or assertiveness is being judged.
Roe’s key contribution is to frame this as cognitive load. Code-switching is not just a social phenomenon. It may function as extraneous cognitive load: mental effort that is not inherent to the clinical task, but is imposed by the learning environment. Simulation already asks a lot of learners. They must assess, decide, act, communicate, manage emotion, and perform in front of peers and faculty. If they are also translating themselves into an acceptable professional version in real time, we should not be surprised if some cognitive bandwidth disappears.
Simulation debriefings may bring this phenomenon into sharp focus. Learners are asked to explain their thinking, reveal uncertainty, narrate emotions, and articulate insights in front of others. For a learner already worried about how they sound, this can be overwhelming.
So, what should educators do?
Not rush in! Hesitation, formality, quietness, emotional restraint, or carefully chosen words may mean many things. The point is not to label the learner. The point is to design and facilitate as though this hidden labour might be present. Remy has a few practical thoughts to offer, from which I’ve picked three that I’m going to use: –
First, normalise the worry. Many people worry about how they come across in simulation. They worry about sounding silly, arrogant, hesitant, emotional, junior, bossy, or not sufficiently “doctor-like” or “nurse-like”. Naming this can be helpful. A pre-briefing might include: “There are many ways to communicate well in clinical practice. In this conversation, we are interested in your thinking, not in polishing the perfect professional sentence.”
Second, give people time to think before they have to speak. Before launching into reactions or analysis, ask learners to write down a few thoughts privately. What were they noticing? What felt difficult? What were they trying to work out? What would they like to understand better? Writing creates a buffer between experience and public articulation. It allows people to organise meaning before also managing impression.
Third, assess communication by what it achieves, not by whether it resembles a dominant style. “Professional communication” is often treated as self-evident, but it can hide a lot of cultural assumptions. Did the patient understand? Was safety improved? Was respect conveyed? Did the team receive the information they needed? These are better questions than whether the learner sounded like our preferred mental model of professionalism.
Where to from here?
Roe’s article is theoretical, and the proposed framework still needs empirical testing. (and I hope we might look forward to a longer program of work from him and his team!)
But it offers simulation educators a useful provocation. Perhaps we are misinterpreting ‘lack of confidence’, or ‘poor communication skills.’ Perhaps our learners are doing two jobs at once: managing the clinical situation and managing themselves for our gaze.
Reading
Roe, R. Code-switching in simulation-based nursing education: A cognitive load theoretical framework. Clinical Simulation in Nursing, Volume 116, 2026.
Photo – AI generated
The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of the University of Ottawa. For more details on our site disclaimers, please see our ‘About’ page