**2. Human learning models and simulation-based education**

Simulation is often considered simply as an exercise where learners perform actions in an environment simulated to resemble reality, and facilitators are present to ensure its smooth running and to lead a discussion afterwards. As a relatively new method of teaching in medical education, there are often misunderstandings about simulation training and inadequate knowledge of its execution. High-quality simulation is backed by evidence-based educational theories and includes purposefully designed scenarios and well-trained facilitators.

Kolb's theory on experiential learning forms the foundation of simulation-based education. In his theory, learners enter the learning cycle through experiencing an event—either a real patient experience or simulated activities ('concrete experience'). Afterwards, through selfreflection or reflection assisted by facilitator ('reflection'), a new insight of the event is created ('abstract conceptualization'). Finally, this new insight is applied in a similar simulated or real-life event ('active experimentation') [1].

Neil Flemming's VARK model describes four modalities in an individual's preferred method of learning—Visual, Auditory, Reading and Kinesthetic [2]. Different individuals learn more effectively when they receive specific types of stimulation. Simulation, through active engagement with hands-on action, produces better training effect in kinesthetic learners.

Simulation experiences can trigger learner emotions and it is known that a highly activated core affect can positively influence the uptake and retention of knowledge and skills. The Change Theory proposed by Lewin/Schein highlights the relationship between affect and learning. It theorized a three-stage model of change, namely unfreezing, transition and refreezing. 'Unfreezing' refers to the motivation to change by adding new force or removing existing concepts that are influencing behaviour. It unavoidably leads to emotional stress, largely a sense of dissatisfaction with oneself as a result of disconfirmation of the present condition. Moreover, it creates a survival anxiety as the pre-existing belief is rejected and a learning anxiety in which the previously learnt knowledge has to be unlearnt. 'Unfreezing' is followed by 'transition', a process of moving onto a new state, which requires reconstruction of one's thoughts, feelings and behaviours. 'Refreezing' is the final stage in which the newly acquired knowledge, concepts and behaviours are adopted and assimilated [3].

The principles underlying simulation scenario design, together with the debriefing process, are largely developed based on one of these educational theories. Simulation training aims to facilitate acquisition of knowledge and skills and to change one's perceptions and behaviour. The following sections further elaborate on scenario design and debriefing in ECMO simulation.
