The impact of the learner role in healthcare simulation-based education on learning outcomes: a systematic review.
PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSION 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.