The role of emotions, stress, learning stage, and cognitive load on learning in emergency events: a mixed methods study.

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Learn more: PMC Disclaimer | PMC Copyright Notice Sci Rep . 2026 Apr 10;16:16864. doi: 10.1038/s41598-026-47852-5 The role of emotions, stress, learning stage, and cognitive load on learning in emergency events: a mixed methods study Abdullah Alismail 1, 2, 3, 4, ✉ , David Lopez 1 , Andrew Vosko 5, 6 , Kristin Ireland 1 , Laren D Tan 1, 2 Author information Article notes Copyright and License information 1 Department of Cardiopulmonary Sciences, Loma Linda University Health, Loma Linda, CA USA 2 Department of Medicine, School of Medicine, Loma Linda University Health, Loma Linda, CA USA 3 Department of Cardiopulmonary Sciences, Rush University, Chicago, IL USA 4 Research and Innovation Institute, Ministry of Defense Health Services, Riyadh, Saudi Arabia 5 Department of Biomedical Sciences, Bernard J Tyson, School of Medicine, Pasadena, CA USA 6 Claremont Graduate University, Claremont, CA USA ✉ Corresponding author. Received 2025 Jul 28; Accepted 2026 Apr 3; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13230901  PMID: 41963581 Abstract Simulation-based education is used to train healthcare providers; however, studies examining how emotional load stress level and cognitive load influence learning during real emergency events remain limited. This gap limits our understanding of how learning occurs which is essential for preparing novice learners for real code blue events as well as inform curriculum development and design. Therefore, the purpose of this study was to evaluate how EL, SL, CL, and learning stages influence novice learners’ experiences during real emergency events, code blue, in the Intensive Care Units (ICU). A mixed-methods approach was used utilizing surveys and individual semi structured interviews. Inclusion criteria were learners had to be either a respiratory therapy students or medical residents attended a real critical event in the intensive care unit event. Their mentors evaluated them as well in the event. 50 participants—27 learners and 23 mentors participated in the study. For learners, the average age was 26.48 ± 3.8, with 55.6% being female. A total of 13 (48%) were respiratory therapy students and 14 (51.9%) were residents. The mean CL for learners was 6.67 ± 1.30 Vs 6.39 ± 1.53 for mentor evaluation, respectively. EL from both learner and mentor evaluation was toward positive emotions. Thematic analyses of the qualitative interviews among learners were: (1) Environment presentation has an effect on learning, (2) Team leader presentation in the critical event is a critical factor to team members learning and success, (3) The team function in the event in a singular mindset, (4) Unexpected events are memorable events, and (5) Learning is continuous via reflective practices post event. Learners showed more positive emotions and were in the phase where learning mostly occurs in CL during the emergency events. The themes that evolved in qualitative analysis shed light for future studies on the importance of team debrief on learners learning and emotional state. Supplementary Information The online version contains supplementary material available at 10.1038/s41598-026-47852-5. Keywords: Cardiac arrest, Code blue, Emergency events, Cognitive load, Emotional level Subject terms: Health care, Medical research, Psychology, Psychology Introduction Healthcare providers in the area of critical care such as Intensive Care Units (ICU) and emergency departments (ED) are always trained, prepared and educated to manage life-threatening patient events such as cardiac arrest, shock, or trauma in a timely and coordinated manner 1 – 8 . In these high-acuity settings, emergency events typically follow protocols and clinical guidelines such as Advanced Cardiac Life Support (ACLS) by the American Heart Association (AHA) 9 . Therefore, the stress level in a room during an emergency event is high compared to other areas in the hospital 10 – 12 . Moreover, when there is a cardiac arrest (code blue) event in the ICU or ED patient room, stress and chaos can occur and affect the entire care team 13 . As a result, this stress and chaos have been shown to be linked to burnout and depression for these healthcare providers over time 14 – 16 . To reduce the negative effects of high stress emergency events in the ICU and ED settings, several initiatives have been established by clinician educators to train staff and trainees using a simulation-based education [SBE] approach 17 . In an SBE, learners practice in a controlled simulated critical care environment that is structured using evidence-based pedagogical approaches 18 , 19 . The literature on SBE training has demonstrated its efficacy in training healthcare providers and students in various areas of SBE. For example, several factors have been reported to influence learning in these types of emergency events: (1) stress level, (2) emotions level, (3) cognitive load, and (4) cognitive apprenticeship level 11 , 20 – 26 .However, simulation training differs fundamentally from real-life ICU and ED emergency events. When novice learners experience an actual code blue event in these high-acuity settings, the true authentic emotional intensity and unpredictability of the event create a learning context that cannot be fully replicated in simulation. Both novice learners and experienced professionals can experience a high stress level, emotional level, and cognitive load during read emergency events, which may lead to post traumatic stress syndrome 20 – 22 , 27 – 29 . Learning in these emergency event environments can be defined from different levels. First, from a social constructivist theory framework on learning, where multiple simultaneous forces in the ICU or ED patient room environment influencing learning outcome for the participant 30 , 31 . Second, cognitive load theory emphasizes that cognitive load and reflection practices (e.g. self or group reflection) shape learners 32 , 33 . Third, knowledge in these emergency event environment develops using previous learner knowledge (i.e. textbook or classroom) and thus cognitive growth and learning is a process that can occur at any moment, i.e., an “aha moment” 30 , 34 – 36 . Therefore, to address this gap in the literature and provide an empirical evidence to inform medical education practice , the purpose of this study was to evaluate how emotional level, cognitive load, learning stage that is defined in the following section, and stress occur in a real emergency event among novice learners and its effect on learning. Emergency events are defined as cardiac arrest ,code blue, in the ICU. In addition, learning in this study is defined and assessed from a cognitive knowledge development perspective, not a psychomotor skill perspective. Methods Study location A large academic hospital in Southern California comprising six hospitals with a total of 1046 beds and around 18,000 employees. In this study, data were collected at one adult hospital which has 320 beds. Design Study design was an exploratory sequential mixed methods design utilizing questionnaires and an individual interview approach. Inclusion criteria were that participants had to be either a respiratory therapy students or medical residents (internal medicine or emergency medicine) rotating in an adult ICU and attended a code blue event. Their mentors evaluated them as well in the event. Exclusion criteria were events occurred in Non-ICU settings, non-code blue events, and healthcare providers from professions other than the inclusion criteria. The two professions, respiratory therapy students and residents, were selected due to variance reasons. First, both of them represent a novice learner in the early stages of their clinical training who are expected to participate in real code blue events but have limited prior real-world experiences. Second, both professions have distinct and critical role during cardiac arrest events: respiratory therapist manage airways, bag-mask ventilation, and intubation assistance, while medical residents contribute to clinical decision-making, medication orders, procedures, etc. Third, unlike registered nurse’s patient workload of 1:1 ratio in the ICU setting, both respiratory therapist and medical residents manage multiple patients which introduces additional cognitive load and task-switching demands that may influence their learning outcomes 37 – 39 . The survey part of this study serves as an exploratory component while the interviews serve as the primary aim that unpacks the quantitative component when it comes to understanding learning. Learners were recruited via an email sent to a selected respiratory therapy program, internal medicine residency, and emergency medicine residency programs at a large academic institution in southern California. Informed consent was signed after learners agreed to participate in the study. Learners received a monetary gift card as an incentive at the end of their study completion. Figure 1 Fig.1. Open in a new tab Study diagram. Phase I: survey Learners completed two surveys: 1) a baseline survey that covered demographics and code blue and emergency room events experience in simulation, as well as real events 2) post- event survey that was completed after encountering a real emergency event in an adult Intensive Care Unit. Learners answered questions related to their stress level (SL), emotional level (EL), cognitive load (CL), and cognitive apprenticeship stage (learning stage) within the event. In addition, their mentors in the same event were invited to participate and asked to complete an anonymous survey evaluating the learner performance in the event, evaluating the same outcomes and questions: emotional level, cognitive load, and cognitive apprenticeship level. Within the paper, the term mentor will be used to identify preceptor/mentor/clinician educator who mentored the learner for the day and/or event. For respiratory therapy students, their respiratory therapy mentor in the event evaluated them. For residents [internal medicine or emergency medicine], their attending physician who was present at the event evaluated them as their mentor. The following section defines the main outcome measures within the survey. Supplement 1. Main outcome measures The following outcome measures were completed by both the learner as self-evaluation and their mentor, with the mentor evaluation reflecting the event they participated in. The learner solely responded to these questions based on their experience during the event they just participated in. Their mentor rated how they perceived the learner during the event itself. Emotional level Emotional level was measured using a validated eight-item bipolar tool by Barrett and Russell 40 . Each item on the scale ranged from -2 to +2 with a 0.5 interval. The scale contains a total of 8 bipolar items [Tense: Calm, Nervous: Relaxed, Stressed: Serene, Upset: Contended, Sad: Happy, Depressed: Elated, Lethargic: Excited, and Bored: Alert]. The learner responded to these questions, reflecting on what they felt during the event they had just encountered. Their mentor rated how they perceived the learner during the event itself. Cognitive load Cognitive load was measured using a validated one-question tool by Paas et al that asks the learner to rate how much they have invested mentally in the code blue event they just participated in. This single question has a 9-unit scale that ranged from very, very, low mental effort to very, very, high mental effort 41 This scale measures overall cognitive load and does not differentiate subcomponents of CL such as intrinsic and germane load. Cognitive apprenticeship level In addition to the above two outcome evaluation measures, from a learning stage perspective, each learner was asked to evaluate themselves in terms of which category of the cognitive apprenticeship model they thought they were in at the event (e.g., modelling, scaffolding, etc.) 42 . Learning stages are as follow in order: Modeling stage; Coaching; Scaffolding; Articulation; Reflection; and Exploration. Stress levels Stress level was measured using one question on a four-point Likert scale: very low to very high. Phase II: Interview After completing the post-code survey, learners were invited to participate in a semi-structured individual interview. Interview guide is attached in the Supplement files. Questions were developed utilizing the conceptual framework of cognitive apprenticeship model and prior literature on the main outcomes’ measures. The questions were developed by the authors who were experts in their fields (medical education, qualitative methodology, study design, pulmonary medicine, respiratory therapy, and education). The interview was tested and piloted on a sample learners that were not included in this study. The interviews were conducted by two study investigators (AA and DL).The interview was recorded using a digital recorder and then transcribed using the following steps: 1) auto transcription via a third-party website. 2) An independent human transcriber then reviewed the auto-translation and audio for accuracy. Data were then coded and analyzed for categories and themes, and categorized for emerging themes by two investigators [AA and DL]. When there is a discrepancy, it was handled by a third investigator in the study. Atlas. Ti application was used for analysis. The usage of Atlas.Ti was simply for manual coding and then evaluate emerging themes. Auto-analysis and Auto coding was not used. Ethical approval This study was approved by the institutional review board of Loma Linda University Health, Loma Linda California [IRB number: #5190349]. Each participant reviewed and signed an informed consent. The learners signed a written informed consent and then were given a code for their name. In the interviews, each learner that participated in an interview, were given a random gender-neutral code name in the analysis part. These names were then used as codes in our thematic analysis and coding. Mentors gave their consent and participated anonymously by simply evaluating the learner they evaluated in an anonymous survey. Reflexivity and positionality statement The authors of this study consist of two faculty members with more than 50 years of combined experience in respiratory therapy profession and education. While both investigators share the same professional background as the respiratory therapy participant group and hold supervisory positions relative to the respiratory therapy learners, neither author was involved in the event itself. To acknowledge and mitigate potential bias from professional identity and positionality, we implemented several strategies. First, we pilot-tested the semi-structured interview guide to ensure open-ended questioning that allowed learners to freely reflect on their own learning experiences during the event. Second, both interviewers independently conducted interviews using a standardized approach to promote consistency and reduce individual interviewer influence. Specifically, to further minimize hierarchical bias, the investigator with no direct oversight of respiratory learners (DL) conducted interviews with the respiratory therapy participants, while the investigator with direct supervisory responsibility (AA) interviewed the resident participants. Third, a third party transcribed all interviews to minimize investigator interpretation during transcription. Fourth, reflexive journals were maintained throughout data collection and analysis to document evolving understandings and assumptions. Qualitative analysis was conducted independently by both investigators, with explicit focus on participants’ learning experiences as learners rather than through the lens of their professional role or hierarchical status. Following independent analysis, the coding and identified themes were reviewed by two external experts in medical education and higher education who were not involved in the interviews and had no prior relationship with the study participants. These external reviewers critically examined the analysis to identify potential biases and ensure consistency and rigor in theme development. This was then followed by the investigators meeting with the external reviewers to discuss findings, address any inconsistencies and establish consensus on final themes. This step ensured that our professional background as respiratory therapists with the respiratory therapy group did not unconsciously influence data interpretation. Finally, all participants were assured of confidentiality and informed that participation would not affect their employment, grades, or professional standing. Data analysis Data was analyzed using SPSS for Windows version 28 (IBM Corp., Armonk, NY, USA). Data was summarized using means and SD values for continuous variables and frequency (%) for categorical variables. Paired T- Test was used to assess changes in main outcome measures pre and post event. Spearman correction was used between Learner Self-Evaluation Emotions level Vs their Cognitive Load. The level of significance was set at p ≤ 0.05. For the interview part of the study, thematic analysis was carried by where the data was coded and analyzed by two investigators [AA and DL] and categorized for emerging themes. Analysis was then compared and if there was any discrepancy, a third investigator was invited. Data collection and analysis proceeded iteratively until thematic saturation was achieved where additional data no longer yielded new codes or contributed to new themes. Atlas. Ti version 9.1.0 application was used for analysis. Results A total of 50 respondents agreed to participate in the study (Learners n = 27, Mentors n = 23). For learners, the mean age was 26.48 ± 3.8, with 55.6% being female. A total of 13 (48%) were respiratory therapy students and 14 (51.9%) were medical residents. Majority of them have had mock ER simulation experience, 92.6%. When asked regarding having a real ER event experience, 70.4% indicated they had experience with a median of 5 events. For code blue, more than 88% of the learners indicated had mock simulation experience and attended an actual code-blue event with 10.45 ± 7.67 real code blue experience. Table 1 Table 1. Learner demographics. Variable N = 27 (100%) Gender Male Female 13 (44.8) 16 (55.2) Profession Internal medicine Emergency medicine Respiratory therapy 12 (44.4) 2 (7.4) 13 (48.1) Level in the Profession First year Second year PGY1 PGY2 PGY3 8 (29.6) 8 (29.6) 3 (11.1) 3 (11.1) 3 (11.1) Having prior experience in healthcare Yes No 9 (33.3) 18(66.7) American Heart Association Credentials BLS ACLS PALS NRP 27 (100) 24 (88.9) 9 (33) 4 (14.8) Had mock ER scenario before Yes No 25 (92.6) 2 (7.4) Had Mock Code Blue scenario before Yes No 24 (88.9) 3 (11.1) Had real ER event Yes No 19 (70.4) 8 (29.6) Had a real Code Blue event Yes No 24 (88.9) 3 (11.1) Open in a new tab Post-critical event The mean cognitive load was reported as Self Evaluation, 6.67 ± 1.30 Vs Mentor evaluation, 6.39 ± 1.53, respectively. Learning experience within the critical event was rated as 40.7% average and 59% above average by learners. Stress level within the event was mostly in both self-evaluation and mentor evaluation, p > 0.05. No statistically significant difference was found between learner self-evaluation and mentor evaluation, p > 0.05. Table 2 . Table 2. Frequency (Percentage) of learning stages based on the cognitive apprenticeship model. Learning stage Learner self-evaluation N = 27, n (%) Mentor evaluation of learner N = 23, n (%) Modeling stage 5 (18.5) 3 (13.1) Coaching stage 8 (29.6) 7 (30.4) Scaffolding stage 3 (11.1) 5 (21.7) Articulation stage 4 (14.8) 6 (26.1) Reflection stage 5 (18.5) 1 (4.3) Exploration stage 2 (7.4) 1 (4.3) Stress level Very Low – 1 (3.7) Low 16 (59.3) 15 (65.2) High 7 (25.9) 7(30.4) Very high 4 (14.8) – Cognitive load [mental effort] Very very low Very low low 1(4.3) Rather low Neither low nor high 8 (29.6) 7(30.4) Rather high 3(11.1) 4(17.4) High 7(25.9) 5(21.7) Very high 8(29.6) 4(17.4) Very very high 1(3.7) 2 (8.7) Open in a new tab Learner emotional level from both self-evaluation and mentor evaluation tended toward positive emotions with only one statistical significance in Upset: Contended emotion, p = 0.025. Table 3 and Fig. 2 . In Fig. 2 , it shows a visual representation of the finding represented by a clustered boxplot between the learner self-evaluation and mentor evaluation. Table 3. Mean ± standard deviation for emotional level in both learner self-evaluation and mentor evaluation of them. Learner self-evaluation Mentor evaluation of learner P -Value* Tense: calm 0.370 ± 1.42 0.870 ± 0.989 0.078 0.144 Nervous: relaxed 0.304 ± 1.17 0.652 ± 0.88 0.198 0.236 Stressed: serene 0.304 ± 1.33 0.609 ± 0.85 0.304 0.270 Upset: contended 0.370 ± 1.27 1.174 ± 0.73 0.025 0.031 Sad: happy 0.022 ± 1.21 0.609 ± 0.84 0.066 0.078 Depressed: elated 0.348 ± 1.00 0.500 ± 0.839 0.578 0.616 Lethargic: excited 0.761 ± 0.915 0.761 ± 0.91 0.936 0.818 Bored: alert 1.413 ± 0.973 1.283 ± 1.04 0.673 0.452 Open in a new tab *First p -value reported from paired t-test. *Second p -value reported from Wilcoxon Signed Ranks Test. Fig. 2. Open in a new tab Cluster boxplot that shows differences between both learner self-evaluation and mentor evaluation for the emotional level state of the learner. Correlation analysis Table 4 shows Spearman correlation analysis of learner self-evaluation of emotions Vs cognitive load. Statistical significance with negative correlation was found only in Tense: Calm Vs CL, p = 0.047. There was no statistical significance found when looking at learner SE Vs Mentor CL as well as Mentor evaluation of learner emotion Vs learner SE of CL. Table 4. Spearman correlation analysis of learner self-evaluation emotions Vs. cognitive load. Emotion Cognitive load Tense : calm R = -0.385 P = 0.047* Nervous : relaxed R = -0.273 P = 0.168 Stressed : serene R = -0.291 P = 0.142 Upset : contended R = -0.075 P = 0.709 Sad : happy R = -0.032 P = 0.872 Depressed : elated R = 0.062 P = 0.758 Lethargic : excited R = 0.162 P = 0.421 Bored : alert R = 0.229 P = 0.251 Open in a new tab When adding stress, correlation analysis of learner SE of CL Vs stress, there was no statistically significant found, r = 0.238, p = 0.233. Statistical significance with negative correlation was found between learner stress SE Vs Tense: Calm (r = − 0.518, p = 0.006), Nervous: Relax (r =− 0.482, p = 0.011), and Stressed: Serene (r =− 0.392, p = 0.043). Results of reliability analysis on the following survey scales from learners’ self-evaluation (emotional level, cognitive load, stress, and learning stage) showed a Cronbach’s alpha = 0.70. Thematic analysis of interview A total of 18 learners participated in the interview section of the study, independently. A Total of 208 codes were found which led to 24 categories. Of the 24 categories, a total of five themes emerged with examples Table 5 . The interviews duration was an average of 36 ± 7.24 with a median of 37.18 (min = 26.27, max 49.55) minutes long. Below is the list of themes and a description of each. An example of each theme that provides an insight for each theme is provided in Table 5 . Table 5. Emerged themes along with an example quotation for each. Theme number and name: Example quotes * 1- Environment presentation has a critical role on learner ..There’s lots of people .. there’s lots of noises going around. Obviously, you are doing chest compressions. It adds a certain gravitas to what you are doing. And I think especially being that like, you know, this is my future job as an emergency physician. There is a little bit more added pressure to perform well …there were nurses that we’re trying to help me fix the glidescope [a tool that assist in intubating patients with a tube in their oral airways using a camera], as well. So, then it just it also contributed to having the room so packed and everyone’s trying… and the doctors trying to intubate the patient, and so it just created chaos. There was a lot of people in there, like there is four of us trying to figure out how to turn on the glide. So, I think that added onto the attending’s stress as well, since the patient has been … it was a delayed intubation. Yeah. So other than that, no. Like everything was fine. Yeah. [Avery] …I would tell them that it’s a lot faster pace than just going and doing rounds. That you’ll see… a lot of people working together at one time. And. It, it’ll all work out smoothly if everybody works together, but it is going to be fast pace.” …I think the other hard part was just that it continued for so long. It was more just kind of like the family that was really pushing for that. And they were there watching it and they were pushing for us to keep going. Which, I think under different circumstances, especially because there was no reversible cause from our standpoint, we wouldn’t took on that long. [ Quinn] 2- Team Leader presentation in the critical event is a critical factor to team members learning and success Francis: Usually what I’ll do is I’ll let them know that I’m Dr. (name). I’m the resident. What’s going on. And then I’ll just start assigning if roles haven’t already been assigned. I’ll start assigning roles and then I’ll start indicating which step needs to be done next in terms of the code. Like starting CPR, bagging, and such. But I’ve found that most of our nursing staff in the ICU are very competent in codes. And so, they’re already usually in the appropriate places already. And I’m just kind of guiding everyone. [ Francis] …I think the ones where I run them is more memorable, mostly because like I learn more, rather than just sitting off to the side and letting my attending run the code. So. That’s about it. [ Emerson] 3- Team members function as a singular mindset …So, I just kept going and going. And even though I was mentally tired, I was already getting at that point where like, OK, I just wanted to switch. But I don’t know what happened. I just kept going until I heard, like, OK. We found a pulse. And then that’s when I stopped [ Riley] …I knew that we were more focused on what we can do for the patient versus how well is my peer doing. So I guess. [Angel] …I feel like when that’s happening, I actually get a little bit more focused. I don’t know if it’s just the adrenaline and in kind of my body’s response, but I feel a lot more focused and I’m able to really try to run, like I mentioned, run through the different scenarios, and try to reverse what it is that initially triggered the initial code. [ Francis] ..I guess if you want to work in a setting like that, you have to be, you have to think critically, not only critically, but like your attitude shows it, because if you’re you know, if you’re all over the place, if your mind isn’t concentrated on that one priority, then that messes up the whole routin e for the responders, the nurses, the physician, you know. [ riley] 4- Unexpected events are linked to learning by being a memorable event …It was stressful. I think also I was at, nearing the end of a shift, and I was really tired, and I don’t recall exactly, but I think I had probably been… Not sleeping, but kind of resting because it was at night and I was in the call room when I got the page that, you know, come to bed side before the patient started to code. And then it was not one of my primary team patients, it was on the other team, but I was, I had to cover because I was the only one overnight. So that made it more stressful because I didn’t know the patient that well. [ Blake] …She’s very young, coming in with a genetic condition, polycystic kidney disease. And then she, when she came in, she looked pretty OK. I mean, she was talking to me. She was sitting up in bed. The only thing that was a little bit off was her lactate was elevated, which we thought maybe there was something going on. Maybe she had, like, you know, decreased profusion of her bowels or something. So, we like, OK, we’re going to follow, you know, we’re doing all the appropriate tests, ordering the stuff. Came in that next morning and heard that she… I heard somebody say something about a patient coding multiple time. So, I’m like okay, that’s interesting. I didn’t think it was her because she’s so young, you know, come to find out it actually was her. And then in the middle of rounds, she coded again. [ Sawyer] …Me, my preceptor, we were just doing our regular rounds and then all of a sudden Code Blue and we both just ran and there was one person already doing compressions, but he was already getting tired. [Riley] 5- Learning is continuous via reflective practices post event Avery: Yes. My first code. The patient did not make it. And I me, personally, I did feel a little emotional just because I was, I’ve never been exposed to that. I’ve never been familiar with that type of setting. So, but my preceptor at the time debriefed with me and told me that, like, you know, we did everything that you could, and you did fine with compressions and stuff like that. And so that’s just how it is. [Avery] …We debriefed afterwards, and everyone was very, very happy with how it went. And so, yeah, I was. I was being evaluated at that point. And Dr. [attending] gave good advice back. Like his main thing was saying, like, oh, you know, let’s make sure we have the backboard in there next time as early as possible. But it was nice to have three other physicians in the room with me, because the other thing, too, is when you’ve been coding for a little while and epinephrine is not working and the blood is not working, then you start going into your Hs and Ts and so running through those with three other physician brains in there to try to figure out, OK, what have we not done yet [Parker] Open in a new tab *The listed names in the brackets are made up names by the researchers. The researcher chose gender neutral names to avoid any gender stereotypes and to promote inclusivity and anonymity across participants’ representations. Theme 1: Environment presentation has a critical role on learner This emerged as a theme as most of the learners described how the environment presentation played a role on their learning in the event. In this theme, learners described the effect of how environment presentation played an essential role to the learner by its impact on stress, cognitive load, and smoothness of the event. Learners described their experience during an emergency event. For example: the presence of people, healthcare providers, within a patient’s room added additional stress and gravitas, and high expectations for them. In addition, due to the increased number of people within the room, potential unexpected experiences such as equipment failure, added additional stress and pressure on the learner and consequently on their performance. During these situations, the learners’ goal was to be as calm as possible. Having to appear calm in these situations was reported as causing additional angst and stress. In addition, stress and anxiety from other team members could make the situation worse for the learner. Moreover, another reported factor was the presence of a family member in the room, adding additional stress to the situation and environment. See examples in Table 5 . Theme 2: Team Leader presentation in a critical event is a vital factor in team members learning and success. The reason team leadership emerged as a theme was due to many learners identified the importance of the team leader in organizing communication and teamwork to have a successful learning outcome. The concept of leadership during the analysis evolved by those who held leadership role, as well as the follower role within the event. With good and firm leadership, communication and teamwork were identified by the learners as successful elements of a good successful emergency event outcome. Furthermore, those who were team leads in the event itself based on ACLS protocol, when asked what made them assume this team lead role, three reasons reported: 1) ranking of resident/learner status [i.e. 1 st year vs 2 nd year], 2) initial assumption and responsibility to become team leader (identifying self as leader), 3) previous experience and perception by team members of their good leadership skills. In addition, delegation was reported to be the main attribute of effective and successful leadership. On the contrary, having multiple leaders within the code event resulted in more chaos in the patient room/event among team members. See examples in Table 5 . Theme 3: Team members function as a singular mindset. Singular mindset evolved as a theme as many learners shared how they felt, cognitively, during the event. Learners, in various roles, shared the concept of a ‘singular’ and ‘focused’ mindset. In this mindset, they are primarily focused on the designated role and task that they were given by either the team leader or have assumed the role by themselves. Within any code, there are many different types of equipment that give team members objective physiological data about the patient, such as heart rate, respiratory rate, and oxygen levels, as well as team members providing the emergency event effectiveness. Some stated that they rarely looked at these monitors as they are focused on what they are doing at the moment, such as chest compression. Simultaneously, during these singular and focused mindset moment, they are trusting other team members to inform them whether their efforts and outcomes doing well or not based on the physiologic data provided through the advanced equipment at the bedside and observations. See examples in Table 5 . Theme 4: Unexpected events are linked to learning by being a memorable event. Learners have shared the element of “surprise!” and what makes an event memorable to them in which it has evolved as a theme by itself. The element of surprise and not expecting the patient to go into cardiac arrest or the event to occur was a common theme. This theme entailed multiple factors and rationales stated and not just the sudden occurrence of the code itself, for example the tiredness of the learner due to being on-call for many hours, the code occurring at the end of their many hours shift, or the patient who coded [i.e., went into cardiac arrest] was not their patient and unfamiliar to them. Furthermore, a sub-theme component here was the quick shift in patient condition and diagnoses that the learner did not expect. See examples in Table 5 . Theme 5: Learning is continuous via reflective practices post event. Reflection kept evolving throughout the learners interviews after each event they participated in where it evolved as a theme driven by reflective practices framework. Learning emerged from the reflective practice framework post emergency event; it was also linked to a concept that was identified by the learners as “mental check” by talking with someone else about what happened. Some learners felt that reflective discussion following the event not only aided in learning, but more importantly, assisted in reaching satisfaction with their performance and eventually positive patients’ outcomes. Most have reported how post-event debrief helped improve their learning, emotions, reduce stress, and improve confidence. See examples in Table 5 . Discussion The purpose of this study was to evaluate and understand how aspects of learning occur and evolve in critical and emergency events among learners. The idea was to evaluate the following key aspects: emotions, stress, cognitive load, and learning level contribute to learning. An important strength of this study is its real-life ICU and ED context, which complements prior simulation-based research. Most prior studies answered similar research questions, but in a simulation environment or with a purely quantitative or qualitative approach. In this study, we utilized a mixed methods approach for various reasons. First, the design was an exploratory sequential approach. The survey part of this study served as an exploratory component while the interviews serve as the primary aim that unpacked the quantitative component when it comes to understanding learning. The reason for this design was to minimize the Dunning-Kruger effect, which is a cognitive bias in which the learner self-evaluation over or under estimate in their responses 43 , 44 . By doing so, the interviews provided an in-depth contextual account and meaning of the learners’ true experiences which helped the interpretation and triangulation of the quantitative self-evaluation of the surveys used in the study. Results of this study show that learners believe that their mental effort was leaning towards higher load compared 63.3% mental effort or cognitive load during emergency events [EE] towards a higher load compared to their mentors’ evaluation of them, which was, 68.8% respectively. Analysis between learner vs mentor evaluation on the same outcome showed no statistically significant difference ( P > 0.05). Interestingly, the qualitative analysis revealed that learners described their mental state as almost in auto-mode in the moment, based on the given role. This singular mindset could be attributed to the fact they are following an algorithmic approach using ACLS guidelines. Some factors of higher mental effort qualitatively occurred during debriefing or after the event in which patient outcomes were discussed among team members. Although learners’ mindset appeared to lean towards the high mental effort, debriefing following the event seemed to be a critical factor in understanding the event. It could be argued that mental effort could decreases when debriefing occurs due to the critical factor debriefing adds to learning. Fey et al. 45 conducted a phenomenological study to explore nursing students’ perception of team debriefing and how it affects their learning show how safe environments effects learning. Safe environment and feedback from multiple perspectives helped the students’ learning in their findings. This could explain the rationale of how learning is a continuous process that emerges during the debriefing, which uses reflective practices that carry over to the next event based on the learners’ previous experiences. At the same time, the element of surprise and unexpected occurrence of event or its outcome, as described in one of the study themes, could explain the reason behind having a higher cognitive and mental effort during the event. Learners are in a singular mindset that they might not be ‘thinking while doing’ rather focusing on the task that was given to them by the team leader. A recent study by Steinbach et al. 46 highlighted the critical role of effective leadership during clinical emergencies, emphasizing behaviors such as maintaining composure, establishing a clear plan of action, and delegating responsibilities. These leadership qualities aid in guiding the team and provide learners with the structure necessary to focus on their tasks, mitigating some cognitive burdens they experience in high-pressure scenarios like what the learners in this study went through. The quantitative results of the learners’ cognitive load were similar to the findings of Pawar et al. 21 . In their study, they assessed the cognitive load pre and post-simulation event. They reported a 6.61 ± 2.3 cognitive load for physicians and 6.62 ± 1.7 for nurses with a p = 0.73 vs 6.67 ± 1.30 in this study. The primary distinction between Pawar et al. 21 and this study is the environment, as their research was conducted in a simulation setting rather than real-world scenarios. Similarly, Imperio et al. 22 reported a comparable cognitive load score of 6.14 ± 1.6. These finding also correlated with some aspects of the chaos in the environment that were observed in the learners’ interviews when themes I and III emerged. Although the environment was described as chaotic by the learners, teamwork and communication played a significant role in possibly having a moderate to high cognitive load (rather high mental effort). It could be argued that without cohesiveness of teamwork and no communication between team members, the level of cognitive load could be higher due to the environmental effects on the learner. It has been reported that maximal learning occurs when cognitive load lands between 3 to 6 on the scale. This study and others were at the borderline of this recommendation. The mean average score of cognitive load/mental effort in this study and Pawar et al. 21 were both near the suggested maximal learning experience the learner can have, i.e., scores of 3 to 6 21 – 24 , 47 . In a recent qualitative methodology study, Sewell et al. 48 evaluated attending physicians’ perspective among learners using CLT theory as a perspective on learning outcomes 48 . Interestingly, attending physicians reported seeing their learners having a high cognitive overload, which is very close to what this study reported in the CLT Likert scale, where both learners’ and mentors’ evaluations showed a mean average of rather high mental effort with no statistical differences between the two. Although Sewell and colleagues 48 did not interview learners as their study objective was not in an emergency and critical environment, their findings are useful and adds perspective of the expectation of the mentor, teacher, towards the learner in any clinical workplace environment. The results of this cognitive load and qualitative analysis (singular mindset and the unexpected component of emergency event) adds to the current literature the real-world emergency event analysis of cognitive load among novice learners compared to seasoned staff or simulation environment observed in other studies. As indicated in the results section, learners were inclined towards positive emotions rather than negative emotions when responding to the survey. These findings are similar to those of Pawar et al. 21 , post simulation data, where they were more towards positive except for Tens: Calm and Stressed: Serene. However, Imperio et al. 22 reported that learners rated their most recent emergency events mostly towards negative emotions with few on the positive side. This contrast between the quantitative and qualitative findings suggests an ambivalence in learners’ emotional experiences during code blue events. While quantitative Likert ratings leaned toward positive emotions, the qualitative reflections revealed a more nuanced emotional state, where stress and chaos were prominent. This highlights the limitations of objective emotional scales in fully capturing the dynamic and often conflicting emotions experienced during real-life emergencies. This study contributes to a growing body of research on ambivalence by demonstrating that learners in code blue events experience a duality of positive and negative emotions. As Rothman et al. 49 suggest, ambivalence can foster adaptation, flexibility, and engagement in challenging environments 49 . Similarly, the dynamic interplay of emotions during critical care training underscores the need to embrace this duality as a potential strength, especially when supported by debriefing strategies that enhance reflective learning. While learners in this study rated themselves towards the positive side of the emotional scale spectrum, the qualitative analysis of their interviews showed some interesting findings about the actual emotional state of the learner vs the quantitative analysis. This can be explained by how the chaotic and dynamic factor in the environment seems to be more realistic to describe the actual story compared to using an objective emotional scale survey. We believe that what was described in Theme I, environment presentation, played a major role in driving the emotionally taxing concept on the learner. More specifically, the people’s factor that added more pressure when there is a family member at the bedside, as this can be a double edge sword 50 . The literature have showed the effect and use of the cognitive apprenticeship model in health professions education aid in enhancing critical thinking and reasoning among learners 51 . Using the cognitive apprenticeship model, the results showed that mentors rated the learners to be at a lower learning stage compared to what the learner believed to be. Various aspects can interpret the reasons behind this finding such as the learner higher expectation of themselves or the code outcomes. Therefore, it can be argued that the outcome of the event could influence the findings. Although the model was developed by Collins et al. 52 and discussed clinically by Stalmeijer et al. 25 , it is critical to note that to the author’s acknowledge this scale has not been validated in other studies in such environment and design 25 , 26 , 42 , 52 . The argument in the literature is that the learner will, or is expected to climb the ladder in this model over time with the same teacher/educator 25 , 26 , 42 . However, it is not feasible due to scheduling restraints in anticipating emergency event environment such as code blue (cardiac arrest). The learner in these events have multiple mentors at any given time and they will most likely be assigned with a different mentor daily. This in fact brings a challenge to clinical educators when it comes to assessing or evaluating their students in clinical situation where they have to obtain multiple evaluations from multiple mentors on the learners’ clinical performance. Limitation This study has several limitations. First, it was collected at a single academic center where it prevents it from being generalizable. Further, the low sample size of the learners as well as the professions selected in this study is also another limitation. Future studies should consider expanding the professions to include nursing students, as they are critical members of the emergency team. In addition, the number of actual codes/emergency events was not tracked as part of data collection in this study. This means that several study participants might have attended the same event and evaluated by one mentor. Most importantly, having different events might provide different findings to this study. The study also was conducted during COVID-19 period where the findings might be influenced. Therefore, future studies are encouraged to confirm and validated our findings. Furthermore, learners were not followed longitudinally with the same mentor; therefore, progression through cognitive apprenticeship stages is inferred cross-sectionally rather than observed over time. Future studies should consider approaching similar research question by evaluating cognitive load using additional scales such as Leppink scale where it adds a multidimensional view for evaluating the mental effort of the learner 53 , 54 . Moreover, evaluate learning and its aspects in this study in a non-intensive care unit (ICU) and non-Emergency Department environment such as general floors/wards. It can be argued that ICU/ED environment is very structured, organized, and its team are trained to be in a stressful environment. While non-ICU such as general floors emergency events are more stressful and chaotic which might have a different effect on learners’ ability to learn. Self-efficacy is another construct that was not tested in this study as it was not the focus of our research questions. Our goal was to not to focus on learner confidence in performing the task in the future or the performance of the task from a psychomotor perspective. However, we believe this should be addressed in future studies as an added main outcome measure to evaluate the learners’ confidence in performing future emergency events by themselves. Finally, there is a potential concern that the learners’ self-assessment approach could be influenced by the Dunning-Kruger effect, where less experienced learners may over/underestimate their own evaluation in the cognitive load, emotional load, stress, or learning stage 43 , 44 . Our mixed-method design approach by adding the qualitative individual interviews likely mitigates this impact. They provided an in-depth, contextual accounts of learners’ experience which helped to interpret and triangulate the quantitative part of the study offering a valuable opportunities for developmental feedback and enhanced the metacognitive awareness 55 , 56 . Conclusion In conclusion, the main purpose of this study was to evaluate how emotional level, cognitive load, stress, and learning stage occur in a real emergency event among novice learners and its effect on learning. The results of this study showed that learners had positive emotions during emergency events and were at the accepted levels of learning when it comes to cognitive load during event. The thematic analysis of the qualitative part of this study shed light for future studies on the importance of team debrief on learners learning and emotional state, paving the way for future studies. In addition, future studies should examine evaluating non-ICU emergency events as well as self-efficacy. Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1 (21.4KB, pdf) Supplementary Material 1 (214.2KB, pdf) Acknowledgements We would like to thank Professor David Drew, PhD and Professor Lucracia Santibanez,PhD for all their support and insight in this project. Author contributions AA: Literature Review; Study Design; data collection; analysis; and writing of the draft and final manuscript. DL: literature review; data collection; analysis; and writing of the manuscript. AV: literature review; study design; study analysis and interpretation KI: analysis; writing of the manuscript LT: literature review, data collection; and writing of the manuscript. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Competing interests The authors declare no competing interests. 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[ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1 (21.4KB, pdf) Supplementary Material 1 (214.2KB, pdf) Data Availability Statement The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. 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