When designing individual learning experiences for each fellow, careful attention is placed on focusing the individual’s working memory to create new schema and impact existing schema. In other words, the fellow’s ability to think, troubleshoot, and problem solve differently upon completing the program is dependent on long-term memory created through the instructional design process delivered by the program [15, 17]. As different topics require different instructional strategies, it is necessary to balance and mitigate intrinsic load and extraneous loads to avoid cognitive overload each day [7, 14, 18,19,20]. The program is delivered over the entire year, meeting 1 day per week, with eighteen structured educational days where the larger group gathers with a specific focus on the knowledge, skills, and attitudes of a simulation educator. Using this format, the agreed curricula, is called the Fundamental Underpinnings of Simulation Education (FUSE).
The simulation center environment and the number of interprofessional fellows set the context for the creation of dynamic learning experiences. A psychologically safe container was created at the start of the fellowship program on the first day. The lack of a psychologically safe context for learning may lead to distraction, or extraneous load, from learning the educational content provided [14, 21,22,23]. The commitment to respecting the learners, attending to logistical details including, scheduling, conduct, vacation and sick days, graduation requirements, clarifying objectives of the fellowship, roles, and confidentiality were all made explicit with the purpose of establishing a safe container . The expectation of the program is that faculty and fellows model the behaviors made explicit on day 1 and that speaking up when psychological safety is breached is applauded. Attention to psychological safety supports honest feedback for coaching and guidance as the fellows are learning [21, 23].
The creation of immersive experiences is the cornerstone of experiential learning in simulation-based education. Merriënboer and Kirschner support learning tasks that mimic those that are reflected in real life. This can be achieved by attending to both fidelity and variability of experiences, which drives the learner toward effective translation into actual clinical practice . Real-life experiences, that can be replicated in simulation, and their associated variability support implicit learning and germane processing, elements that cannot be taught in the confines of explicit instruction (i.e. lecture, group discussion, etc.). Real-life learning, in these instances, help create connections and develop schema [11, 15]. By using participants and faculty of the fellowship as learners, we recreate real-life educational experiences using simulation and foster implicit learning and schema formation. For example, when facilitating a session on difficult debriefing, faculty participate as varied phenotypes of difficult debriefing situations to allow fellows to practice mitigation strategies . When fellows want to explore the effectiveness of the design of a simulation scenario they have created, classmates and faculty participate in the scenario to further explore opportunities for improvement in design.
The Fellowship Leadership purposefully allocated FUSE days in rapid sequence at the beginning of the year to lay down foundational knowledge, so that fellows have enough knowledge and skills to practice when assisting in facilitating simulation-based courses on non-FUSE days. This approach gives new fellows enough information to be competent assistant facilitators in simulation-based courses and to prevent negative transfer during teaching. From a programmatic perspective, a strategic approach was taken to help fellows navigate their learning constructively aligned with the 4-component model. By scaffolding concepts and delivering the content from simple to complex [7, 14], the intrinsic load of the concept is paired down into more manageable pieces and builds off prior knowledge. Similarly, as more expertise develops, the amount of guidance offered is decreased. This way, extraneous load is lessened by deploying instructional design in a way that avoids the expertise reversal effect. This effect recognizes that certain coaching approaches are effective with novices that may not translate as effectively as expertise increases [17, 20].
To highlight this concept, consider debriefing. Debriefing architecture is a foundational topic that is first introduced to the learner  through didactic and collaborative learning. The second exposure to debriefing includes complex question structures including advocacy/inquiry [26, 27] and circular questions [28, 29]. From there, additional elements are added including psychological safety during the debriefing and difficult debriefing situations, where strategies are layered on, such as normalization, attention to body language, and “sign-posting” . Fellows are introduced to debriefing experiences where faculty are debriefed while maintaining certain frames to guide the fellows toward the learning objectives of applying certain strategies to mitigate psychological safety. Complexity is then increased, with the introduction of video debriefing strategies [30,31,32]. Each successive learning activity relies on prior schema created by the previous learning activity [7, 10, 14].
When considering fading guidance, a titration of feedback strategies is applied. Early debriefings may be coached using rapid cycle deliberate practice or pause-and-reflect [33, 34]. Rapid cycle deliberate practice is a simulation-based instructional strategy that focuses on rapid acquisition of necessary skills by repeating the skill with coached direct feedback until it is correct. Pause and reflect is a strategy where the debriefing is paused at regular intervals to allow time to reflect on what has just been said. As developing expertise emerges, feedback tools such as the Debriefing Assessment for Simulation in Healthcare (DASH) can be used. Validated assessment tools such as the DASH  offer more freedom to the Fellow as feedback is post-event and does not interrupt the debriefing experience. Similarly, post-event debriefing conversations are held to offer reflection and coaching. These coaching techniques are exemplary of faded guidance, as gradually the support is withdrawn. Practice in a setting of increased independence paired with variability of experience gives the developing fellow a systematic pathway to expertise. This systematic pathway provides the fellow with strategies to master the unpredictability of varied learning situations.
Establishing and maintaining psychological safety can be used as another example where scaffolding can support learning. The current approaches to psychological safety, how to set a safe container [21, 36] and maintain it , are first introduced through didactic teaching. Fellows begin applying the psychological safety concepts to the simulation scenario prebriefing while practicing with colleagues and receive prompt formative feedback from faculty. Faculty add complexity by intentionally creating situations that mimic safety breaches such as an upset learner during a learning experience or a content expert speaking over other faculty and learners . Fellows are expected to address the breach and restore safety by applying mitigation strategies. Reflection and discussion with the faculty after the experience help reinforce these behaviors. Fellows then move their learning from simulated experiences among their classmates and faculty, to being in real debriefing situations where faculty provide faded guidance and fellows have to apply and integrate their skills with less and less faculty support as the year progresses.
Fellows participating in the program, depending on their prior schemata, exposure, and preference of learning approach, are at different levels of content mastery. As task complexity increases, there is the risk that certain learners may be overwhelmed. By choosing to teach complex learning tasks collaboratively, the processing of information can be carried over multiple working memories to lessen the load and maximize cognitive capacity [37,38,39]. As a result, learners can more uniformly progress toward skill acquisition together over the course of the year.