Table 3 The key educational frameworks which influence simulation-based procedural training and their relationship to our simulation design

• A framework for acquisition of skills across multiple domains incorporating behaviourism and cognitivism.

• Consists of (i) baseline learner assessment (ii) defining learning objectives in units of varying difficulty (iii) defining mastery standards (iv) educational activity (v) formative assessment and feedback against pre-set standard (vi) repetitive practice until standard met (vii) movement to next educational unit.

• Highly protocolised—all learners aim to reach uniform competence in set units before moving on to the next unit.

• Incorporates deliberate practice with pre-defined passing standard.

• Impacted by time-limitation and may not be appropriate for all interventions (e.g. those without easily measurable outcomes).

• Pericardiocentesis requires a universally high level of competence for all trainees.

• It is highly protocolised and lends itself well to a mastery-based approach.

• A baseline level for learners is assumed based upon requirements to enter training programme.

• Learning units consist of internal anatomy; surface anatomy; equipment familiarisation and setup; procedure completion; post-procedure management.

• Focuses on deconstructing a complex task or skill and rebuilding it from smaller components.

• Expectation of achieving competence in each of these subordinate tasks (educational units).

• The knowledge may be theoretical knowledge such as anatomy and landmarks and psycho-motor knowledge.

• Fragmenting the information allows the teaching to be delivered in chunks with repetitive cycles, debriefing and feedback.

• Pericardiocentesis can be a complex task for learners and benefits from breaking the procedure down into small tasks.

• These subordinate tasks build the checklist.

• Information can be given in stages and re-tested. For example, pre-course learning material given to establish theoretical knowledge which is then tested at the beginning of the session.

• Originated from research on training in music performance.

• Deliberate practice occurs in cycles: defined unit goal–practice–feedback.

• Involves motivated learners, informative feedback, performance monitoring and error correction.

• Can be seen as the ‘educational activity’ in mastery learning programmes.

• Feedback is critical to correct errors in performance until the passing standard is met.

• Potentially time consuming due to the variability in time taken to reach the passing standard.

• Pericardiocentesis requires all learners to reach a minimum competency standard.

• Deliberate practice would facilitate this and provides support to learners who take longer to master the skills.

• Debriefing and feedback is facilitated by the checklist and may be undertaken by dyad learners or course faculty depending on the educational unit.

• Helps us to understand how people learn as there is a limit on how much new information people can consume at one time.

• Cognitive load factors include:

o intrinsic load—difficulty level of the task;

o germane load—inherent difficulties aiding learning;

o extrinsic load—external factors impeding learning.

• High intrinsic and germane load and low extrinsic load promote consolidation of long-term memories from working memory.

• These factors influence design by shaping the required fidelity of the simulation.

• See Reedy [57] and Fraser et al. [61] for a deeper understanding of the theory and the application to simulation design.

• For pericardiocentesis we want a focus on upskilling novices to perform a manual task by providing a cognitive framework.

• We need to limit the extraneous load. For example, excluding actors playing allied healthcare professionals.

• The complexity of the situation (simulation scenario design) can be increased to increase extraneous load to engage more advanced learners.

• Design should be based on achieving the intended learning objectives whilst providing enough stimulus for learning.