Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Comparing the Learning Effectiveness of Healthcare Simulation in the Observer Versus Active Role

Systematic Review and Meta-Analysis

Delisle, Megan MD; Ward, Mellissa A. R. MD; Pradarelli, Jason C. MD, MS; Panda, Nikhil MD; Howard, Jeffery D. MD; Hannenberg, Alexander A. MD

doi: 10.1097/SIH.0000000000000377
Review Article

Summary Statement The benefits of observation in simulation-based education in healthcare are increasingly recognized. However, how it compares with active participation remains unclear. We aimed to compare effectiveness of observation versus active participation through a systematic review and meta-analysis. Effectiveness was defined using Kirkpatrick's 4-level model, namely, participants' reactions, learning outcomes, behavior changes, and patient outcomes. The peer-reviewed search strategy included 8 major databases and gray literature. Only randomized controlled trials were included. A total of 13 trials were included (426 active participants and 374 observers). There was no significant difference in reactions (Kirkpatrick level 1) to training between groups, but active participants learned (Kirkpatrick level 2) significantly better than observers (standardized mean difference = −0.2, 95% confidence interval = −0.37 to −0.02, P = 0.03). Only one study reported behavior change (Kirkpatrick level 3) and found no significant difference. No studies reported effects on patient outcomes (Kirkpatrick level 4). Further research is needed to understand how to effectively integrate and leverage the benefits of observation in simulation-based education in healthcare.

From the University of Manitoba (M.D., M.A.R.W.), Winnipeg, Manitoba, Canada; Ariadne Labs (M.D., J.C.P., N.P., A.A.H.), Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, Boston, MA; McMaster University (M.A.R.W.), Hamilton, Ontario, Canada; Hiram C. Polk Department of Surgery (J.D.F.), University of Louisville, Louisville, KY; and American Society of Anesthesiologists (A.A.H.); and Tufts University School of Medicine (A.A.H.), Boston, MA.

Reprints: Megan Delisle, MD, Department of Surgery, University of Manitoba, Room 344–825 Sherbrook St, Health Sciences Centre, Winnipeg, Manitoba, Canada R3A 1R9 (e-mail:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Online date: May 24, 2019

© 2019 Society for Simulation in Healthcare