Procedural Learning in Mixed Reality: Assessing Cognitive Load and Performance

Immersive technologies offer promising advancements in medical education, particularly in procedural skill acquisition. However, their implementation often lacks a foundation in learning theories. This study investigates the application of the split-attention principle, a multimedia learning guideline, in the design of knot-tying procedural content using a mixed reality (MR) technology, specifically Microsoft HoloLens 2. A total of 26 participants took part in a between-group design experiment comparing integrated and split-source formats for learning arthroscopic knots, with the performance and the cognitive load assessed. The initial hypotheses were not confirmed, as results did not show significant differences in performance during recall, nor in extraneous and germane cognitive load. However, the findings on intrinsic cognitive load highlight the complexity of participant engagement and the cognitive demands of procedural learning. To better capture the split-attention effect, future research should address the high element interactivity in MR representations. The study provides some foundation for designing procedural simulation training that considers both learners' needs and cognitive processes in highly immersive environments. It contributes to the ongoing exploration of instructional design in MR-based medical education, emphasizing both the potential and challenges of multimedia learning principles in advanced technological contexts.