General Medicine · Medical Literature
The impact of the learner role in healthcare simulation-based education on learning outcomes: a systematic review.
Abstract
This review examined the impact of learner role-active participant versus observer-on learning outcomes in healthcare simulation-based education using Kirkpatrick's evaluation model. Five databases-PubMed, Scopus, Web of Science, ScienceDirect, and EBSCOhost-were searched for studies published from January 2018 to November 2024. Eligibility criteria, defined using the PICOS framework, targeted studies comparing learning outcomes between active participant and observer roles among health professions students and practitioners. Methodological quality was appraised using the Medical Education Research Study Quality Instrument, and findings were synthesized narratively. This review was registered in PROSPERO under registration number CRD42024611988. Of 648 records, 15 studies involving 1,799 participants met the inclusion criteria; role allocation was specifically reported for 644 active participants and 709 observers. Most studies were conducted in high-income countries (13/15) and nursing programs (11/15). At Kirkpatrick Level 1, most studies reported no statistically significant between-role differences, although an active participant advantage emerged for emotional arousal. At Level 2, knowledge, skills, and most attitudinal outcomes did not differ significantly between roles; active participant advantages were observed for technical skills at delayed follow-up, affective competencies in palliative care, and perceived learning transfer. No study assessed Levels 3 or 4. Most studies found no significant differences between observer and active participant roles at Kirkpatrick Levels 1 and 2. Generalizability across all health professions and settings is limited. Pedagogically appropriate use of the observer role supports learning outcomes and may expand access to simulation-based education.
Clinical relevance
In healthcare simulation-based education, does the active participant role produce superior learning outcomes compared to the observer role across Kirkpatrick's evaluation levels? __SNAPSHOT__ {"studyDesign":"Systematic review with narrative synthesis (no meta-analysis); registered in PROSPERO (CRD42024611988)","setting":"Multi-database search (PubMed, Scopus, Web of Science, ScienceDirect, EBSCOhost); studies predominantly from high-income countries (13 of 15 included studies); primarily nursing program settings (11 of 15 studies); studies published January 2018 – November 2024","sampleSize":"n=1,799 total participants across 15 included studies (from 648 screened records); role allocation specifically reported for 644 active participants and 709 observers","population":"Health professions students and practitioners; predominantly nursing students; majority from high-income country institutions","intervention":"Active participant role in simulation-based education (direct, hands-on engagement in the simulated clinical scenario)","comparator":"Observer role in simulation-based education (watching peers perform the simulation scenario, typically with structured observation frameworks)","primaryOutcome":"Learning outcomes across Kirkpatrick's four-level evaluation framework: Level 1 (Reaction/satisfaction), Level 2 (Knowledge, skills, and attitudinal outcomes), Level 3 (Behavioral transfer to practice), Level 4 (Organizational/patient results)","followUp":"Variable across included studies; some studies included delayed follow-up assessments for skill retention; overall duration not uniformly reported","fundingSource":"Not reported"}
Key findings
Across 15 studies involving 1,799 participants, most studies found no statistically significant differences between the active participant and observer roles at Kirkpatrick Levels 1 and 2. At Level 1 (Reaction), the majority of studies reported no significant between-role differences in satisfaction or engagement, though an active participant advantage was observed for emotional arousal specifically. At Level 2 (Learning), knowledge, technical skills immediately post-simulation, and most attitudinal outcomes did not differ significantly between roles; however, active participant advantages were observed for technical skills at delayed follow-up assessments, affective competencies in palliative care contexts, and perceived learning transfer. No effect sizes, confidence intervals, or p-values were reported in the abstract. No included study assessed Kirkpatrick Level 3 (behavioral transfer to clinical practice) or Level 4 (patient/organizational outcomes). NNT/NNH: not calculable from available data. Adverse events: not applicable to this educational research context.
Practice implications
This review established that, across the majority of included studies, assigning learners to an observer role in simulation-based education did not produce inferior knowledge or skill acquisition compared to the active participant role at the immediate post-simulation timepoint. The review did not establish equivalence by formal statistical methods (no meta-analysis, no pooled effect sizes). Active participant advantages were suggested for emotional arousal, technical skill retention at delayed follow-up, affective palliative care competencies, and perceived learning transfer — but these signals arise from a small subset of heterogeneous studies and should be interpreted cautiously. Critically, no study assessed whether role assignment translated into differential behavioral change in real clinical settings (Level 3) or differential patient outcomes (Level 4), which are the outcomes most relevant to practicing clinicians. Findings are most applicable to nursing students in high-income country simulation programs and cannot be generalized to medicine, pharmacy, allied health, or interprofessional settings without additional evidence. The finding supports pedagogically structured use of observer roles as a legitimate learning strategy, which has direct relevance to resource-constrained simulation programs where not all learners can simultaneously be active participants. Only an abstract was available for review; the full article may contain additional methodological detail, subgroup analyses, and MERSQI quality scores that would affect the strength of these conclusions. __LIMITATIONS__ Narrative synthesis only — no meta-analysis or pooled quantitative estimates; heterogeneity of study designs, simulation modalities, and outcome measures precluded statistical pooling.,Marked overrepresentation of nursing students (11/15 studies) and high-income country settings (13/15 studies), severely limiting generalizability to other health professions and low-/middle-income country contexts.,Complete absence of Kirkpatrick Level 3 (behavioral transfer) and Level 4 (patient outcomes) data across all 15 studies; findings are restricted to immediate or short-term educational endpoints.,Role allocation data were incompletely reported: specific participant counts were available for only 1,353 of 1,799 total participants.,Methodological quality was assessed with MERSQI, but individual study quality scores and their influence on conclusions are not described in the abstract.,Publication bias cannot be excluded: studies finding no between-role differences may be underreported.,Variability in how observer roles were structured (e.g., presence or absence of structured observation guides, debriefing participation) across studies may confound role-based comparisons.,Follow-up duration was not standardized, limiting conclusions about long-term skill retention.,Only an abstract was available for this summary; additional limitations may be present in the full publication. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ Most studies in this systematic review found no statistically significant difference in knowledge or skill outcomes between observer and active participant roles in healthcare simulation-based education, supporting the structured use of observer roles as a pedagogically valid strategy — particularly in settings where simultaneous active participation for all learners is not feasible. Active participant advantages were observed for emotional arousal and delayed technical skill retention in a minority of studies, but no study assessed behavioral or patient-level outcomes. This review is best characterized as hypothesis-generating; practice in simulation program design may be informed, but not definitively changed, by these findings pending higher-quality, interprofessional, and longitudinally rigorous evidence.