In relation to teaching, Shulman¹ ratifies at least 7 knowledge items necessary for a teacher: pedagogical, curricular, disciplinary, didactic knowledge of the content, of how students learn, of the educational system, and of the purposes of education itself. This means that the teacher, in addition to the knowledge of his profession, must know pedagogy, general, and specific didactics, and therefore, it would not be justifiable for a professional to teach without having previous training for it. Teaching based on simulation follows the same logic, and yet, teacher training in this area is heterogeneous.^2,3

Learning is a concept that has changed according to the prevailing paradigm: in behaviorism it was assumed as the permanent change in behaviors; cognitivism considered it an enduring change in the mental scheme, which leads to a change in behavior; and constructivism assumed that the student should be the architect of his or her learning and that these are constructed through social interaction. Knowledge is not susceptible of being transmitted from one mind to another in a passive manner, but must be constructed in a social manner. These theories have been adapted and adopted by the health sciences.⁴

Accordingly, improving teaching and learning processes requires incorporating at least 3 components: the MMs of subjects with an evolutionary perspective of learning, metacognition as an objective of intentional and conscious teaching and learning,^5,6 and the use of strategies based on experiential learning. We shall refer to these elements in the following paragraphs.

Our brain makes representations of the world, as scale models, to understand it, explain it and predict it. In the theory of representations, 3 levels are described: images, propositions, and mental models.⁷ MMs are internal representations of external realities, and they are complex, dynamic, and modifiable cognitive constructs. In their structure, at least 4 dimensions are recognized: ontological, epistemological, motivational, and cognitive-linguistic.^5,6 The ontological dimension refers to the vital and developmental process of the individual; the epistemological dimension refers to scientific knowledge, the knowledge built, which can be declared and demonstrated; the cognitive-linguistic dimension represents the use of language, the way of expressing, learning, thinking, arguing, and interacting with others; and the motivational dimension refers to the intention to do; to the underlying force that can lead to carrying out a task (Fig. 1).

Figure 1 Source: Authors, from Tamayo ⁵ and Vosniadou.⁶

In didactics, MMs have been used to explain them, make them aware, work on them, and restructure them.⁸⁾ Recently, a concept that has been under scrutiny for decades has gained strength: interdisciplinary education⁹ as a felt need. This perspective allows the formation of high performance multidisciplinary teams, which may come to share their MM¹⁰; being aware of these MM and reconfiguring them through their inspection can enhance team learning, efficiency, and safety for patients.

Learning implies a change from an initial model to a new MM; it requires intention, action, reflection, and maintenance. At this point, the theory of defrosting, which has been used in simulation, despite being rational and task-oriented, does not consider feelings and experiences. A more accepted theoretical model is the spiral theory¹¹⁾ which consists of 5 levels: pre contemplation, contemplation, preparation, action, and maintenance. Change requires time, and this time is variable, dependent on the individual and his motivation.

Instead, the theory of conceptual change⁶ states that knowledge is generated in specific domains, it starts with naïve theories and becomes more complex as thought evolves until it is plausible from the perspective of scientific knowledge. This change is usually slow and gradual, except if the individual is able to intentionally direct his or her learning, that is, can use metacognitive strategies.

Thinking about thought includes 3 domains: metacognitive knowledge, metacognitive strategies, and metacognitive experience.¹² We will deal with strategies (knowing how), which include: planning, which refers to thinking about the steps to resolve a situation, and monitoring and control, referring to reflection, within the process, on how the strategy is working, to proceed to regulate it and, if necessary, to reformulate it.¹³ The metacognitive activity is fundamental in the processes of change and restructuring of the MM. Incorporating it in an intentional way allows the student to know the objective of the tasks proposed by the teacher, to be aware of his own difficulties, and to evaluate the efficiency of his actions, thus improving his learning.

Simulation is defined as the use of special devices in specific places, by people trained in special techniques, in order to imitate real contexts and thus, allow learning.¹⁴

Education based on clinical simulation attempts to represent reality without placing the patient at risk; it is continuously being developed, working on the constructs of learning theories, didactics, cognitive psychology, industrial engineering, technologies, human resources,¹⁵⁾ and patient safety.¹⁶ An integral way of doing it, in our view, is structured clinical simulation as an emerging concept (Fig. 2), a construct that includes clear learning objectives, representations that are congruent with reality, structured reflection (debriefing), and evaluation.

Figure 2 Source: Authors.

We recommend that learning objectives include disciplinary skills, non-technical skills (asking for help, leadership, role-taking, closed-loop communication, resource mobilization, situational awareness, etc.).¹⁷ and metacognitive strategies. These objectives should be shared with the students before starting the simulation exercise, when the teacher provides guidance on what will be done during the session, in order to establish an atmosphere of trust and psychological assurance.¹⁸

There must be verisimilitude in the scenario that is simulated with respect to the facts of real life where the subjects unfold physically, conceptually, and psychologically.¹⁹ In debriefing, the student should be allowed to express the emotions generated during the simulation, and it is recommended to reconstruct the situation from the perspective of those who experienced it, and identify the MM's, so that the teacher can diagnose and propose a possible treatment for what was found. Here, critical insight on what students think is fundamental. It is important to understand that the change in the MM will not be immediate, and that the student should be motivated in the areas of theory of change and meta-cognitive strategies.

It is desirable for a team to achieve high levels of development, and therefore, to be trained in the use of summative assessment (declarative knowledge), task accomplishment, application of scales validated for Non-Technicall skills (NTS) (procedural knowledge) and application of formative evaluation, which is possible through a good debriefing.²⁰