Abstract Purpose Simulation curricula continue to struggle with adequately preparing trainees for the operating room. One reason for this phenomenon may be the lack of application and enactment of learning and instructional theories into simulation curricular design and practice. Few educators have taken a reflective approach to understand how surgical simulation succeeds and fails to incorporate best practices for learning based on theory. As such, this study aims to examine simulation sessions to identify gaps in practice by nesting two key frameworks from general education into surgical simulation: learning integration and the cognitive apprenticeship model. Methods We conducted an observational qualitative study in which we recorded simulation sessions with fifteen trainees and surgeons and deductively applied components of the above frameworks to transcripts. Subsequently, we analyzed gaps in the transcripts with regard to the application of these frameworks as theoretical concepts informing the analysis and interpretation. Results We organized results around the four fundamental tenets of learning integration, with principles of the cognitive apprenticeship model explored to provide further units of analysis. In doing so, we identified that simulation instructors adequately modeled, coached, and scaffolded to enable early phases of learning integration. However, instructors less aptly enabled reflection and self-guided exploration, which are critical components of learning integration. Conclusions We found areas in which instruction diverged from ideal standards as informed by our theoretical frameworks, thus highlighting the importance of regular simulation review to ensure that well-designed and intentioned simulation curricula continue to reflect the best educational principles when enacted in practice.
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