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Open research questions in Simulation-Based Education in Healthcare

231 unresolved questions extracted from the limitations and future-work sections of 3,300 Simulation-Based Education in Healthcare papers in our library. Each links back to the study that raised it.

What the literature leaves open

  • Journal of hospital first-line of and implementation determinants of skin-to-skin care in the pediatric cardiac Intensive Care Unit. Journal of Pediatric Nursing, 85, 321- 331. (2025). Nursing Leadership: Lott, K.

    EMPOWERING FIRST RESPONDERS: BOOSTING NURSE AND TEAM READINESS WITH UNIT-BASED CODE PREP TRAINING · 2026 · DOI

  • Background The educational roles of artificial intelligence (AI) and virtual reality (VR) in orthopedic training remain insufficiently defined.

    Beyond acceptance: bounded use of AI and VR in orthopedic education · 2026 · DOI

  • Future research should investigate longitudinal effects, explore diverse educational settings, and incorporate observational or performance-based measures to bet- ter understand the real-world relationship between AI- related engagement and clinical competence.

    Enhancing perceived clinical competence of nursing students in the AI era: the role of AI acceptance and self-directed learning · 2026 · DOI

  • Fourth, the absence of collaborative elements in the XR design was identified as a significant limitation, highlighting a generative tension between individual technological delivery and the inherently social nature of paramedic practice.

    Enhancing Simulation Training through Immersive Reality: MESH360 · 2026 · DOI

  • This aligns with earlier studies suggesting that simu- lation-based learning does not consistently reduce anxiety, particu- larly when essential emotional support elements such as preparatory orientation or comprehensive debriefing are insufficient (39).

    Immersive clinical learning using simulation and its impact on academic performance, satisfaction, self-confidence, and anxiety among pediatric nursing students · 2026 · DOI

  • Simulation has been shown to be effective in orienting trainees to the emergency department (ED) but there is limited literature on simulation for the orientation of newly hired attending physicians.

    The Development and Implementation of a Simulation Orientation Curriculum for Newly Hired Pediatric Emergency Medicine Attending Physicians · 2026 · DOI

  • Contribution: The study provides novel insights into the under-researched role of simulation specialists in MRS, highlighting the skills, challenges, and cultural adaptations required to maintain fidelity in simulations.

    Maintaining fidelity in mixed reality simulation: Insights from simulation specialists at a South African university · 2026 · DOI

  • IMPLICATIONS FOR RESEARCH AND PRACTICE: Few studies exist assessing current practices across institutions for documenting neonatal resuscitations and how standardizing practices can improve care of neonates.

    Current Documentation in the Delivery Room and Strategies for Improvement. · 2026 · DOI

  • Although we aimed to design a well-structured study, several limitations remain. First, the virtual patients lacked nonverbal cues, such as body language, facial expressions, and emotional inflections in speech. These nonverbal elements could have provided He et al. International Journal of Educational Technology in Higher Education (2026) 23:12 Page 23 of 28 participants with a more realistic interaction and helped them establish stronger empa- thy with the patients. Unfortunately, due to technological limitations, we were unable to incorporate these features into the current version of the GenAI-enhanced VR patient encounter practice. Second, the current version of the GenAI-enhanced VR patient encounter practice does not allow students to adjust the virtual patients’ personality traits—only research- ers can do so. This limitation hinders the VR practice from offering more personalized learning experiences. Furthermore, while we consider it unlikely, it is still possible that the participants’ high levels of engagement and positive perceptions were influenced by the novelty effect (Clark, 1983). Since this study involved a single-session intervention, longitudinal stud- ies on the long-term sustainability of these learning experiences, attitudes, and gains are needed as the GenAI technology becomes more commonplace. In future work, we plan to make virtual patients more human-like and explore ways to incorporate nonverbal communication under the guidance of the Realistic-3Cs. We will also create a visual control panel within the VR environment that allows students to customize patients’ personalities. Additionally, we expect to expand participants’ ethnic diversity and include nursing students from different institutions to broaden the gener- alizability of the findings and measure students’ long-term retention of skills and sus- tained improvement in empathy after the VR practice. We believe these enhancements will significantly improve the learning experience and yield more interesting findings, and therefore, we encourage more researchers and educators in nursing education to explore this approach.

    Training nursing skills in a generative artificial intelligence-enhanced virtual reality patient encounter simulation: a qualitative study from a student perspective · 2026 · DOI

  • This case study had several limitations. First, students participating in the initial simulation sessions (December 2020) were enrolled in a specific program focused on opioid use disorder, which may have impacted their competence in the simulation scenario. Second, participating students evidenced specific demographic tendencies (e.g., predominantly cisgender female and White, Non-Hispanic) and thus their experiences with the simulation activity may not be representative of all MSW students. Third, reporting bias was possible given students received field education credit for their participation. Fourth, the sample size of the study was small, and only 67% of participants completed the exit survey. Fifth, the study was carried out during COVID-19 and these disruptions may have impacted the study findings in unforeseen ways. Sixth, interrater reliability was not calculated. Finally, the predominantly qualitative design of the study limits application of the findings. Additional research is needed on all digital simulation formats (e.g., synchronous and asynchronous), as well as exploring online synchronous simulation as (1) a pedagogical approach for current students and (2) a possible format for continuing education. Future research should be more evaluative in design, potentially integrating pre/post measures of competence; longitudinal and comparative studies; and tracking the use of skills in field placements or post-graduation. Notably, while this study focused on online simulation, aspects of the approach may also prove useful in offline or hybrid learning contexts. Simulation should continue to be explored as an effective approach for teaching practice skills to graduate-level students across program formats. As a continuation of the current study, the research team is currently developing, implementing, and evaluating a simulation-based “digital field lab” for students to further increase their skills working with individuals with substance use disorders.

    Online Simulation to Build Competence in Assessment and Documentation With Clients Experiencing Opioid Use Disorder · 2026 · DOI

  • Although this study is the first to use PNA to reveal the “noviceexpert” differences in AI cognition among maternal and child nurses, The findings and limitations of this study provide two key directions for the future research agenda, aiming to deepen…

    AI literacy and attitudes among maternal and child health nurses: a multicenter psychological network analysis of novices and experts in China · 2026 · DOI

  • Several limitations of our study must be considered when interpreting the results. First, this was a pilot study with a relatively small sample size (N=38), limiting statistical power and the generalizability of our findings to broader patient populations. Participants consisted exclusively of health care worker volunteers (faculty, staff, researchers, and students), and specific clinical roles (eg, physicians, nurses, and administrative staff) were not systematically recorded. Health care workers likely possess higher baseline knowledge about postoperative care than typical surgical patients, which may explain the high quiz scores in both groups (>80%) and the lack of a significant difference between formats. This ceiling effect may have obscured the potential benefits of video instruction that could emerge in populations with lower health literacy. Future studies should include patients with diverse educational backgrounds and health literacy levels. Second, we used a convenience sampling approach within a single institution, which may have introduced selection bias and further limited the applicability of our results to diverse clinical settings or populations. Additionally, the study evaluated only short-term comprehension and perceived retention, without assessing long-term retention, behavio- ral adherence, or clinical outcomes such as postoperative recovery or complication rates. including engagement Third, many outcomes, time, retention, and clarity, were based on self-reported data, introducing the possibility of recall, reporting, or social desirability biases. Objective measures beyond immediate quiz performance were not included, limiting conclusions about true knowledge retention or clinical impact. The observed benefits in engagement and perceived effectiveness may have been influenced by the novelty effect of interact- ing with AI-generated avatars, which could diminish over repeated exposures or extended use. The longer engagement times observed in the AI-generated video group may have multiple explanations beyond genuine engagement, including time spent adapting to the video interface, pausing to process unfamiliar avatar presentations, or technical factors such as video buffering or lag reported by some participants. These confounding factors limit the interpretation of engagement time as a pure measure of educational engagement. The study also evaluated only a single generative AI platform (Hey- Gen), and results might differ substantially using alternative AI technologies or avatar presentations. impacting Moreover, participants reviewed educational materials their outside a clinical context, potentially engagement and motivation differently compared with how real postoperative patients would experience. Furthermore, participants’ technical familiarity and comfort with AI technology varied, possibly biasing results toward those more comfortable interacting with digital or AI-generated content. Finally, our study did not formally assess partici- pants’ baseline health literacy levels, limiting insights into whether the observed improvements are equally beneficial across diverse literacy groups. Additionally, health care workers do not approximate the general patient population: most participants had college or graduate-level education, were relatively young, and many had prior postoperative care experience. The knowledge quiz was developed by the study team using publicly available patient education resources rather than a validated instrument, and no formal psychometric testing (eg, Cronbach α) was conducted. The multiple-choice format with easily excludable distractors may have allowed correct answers to be guessed through commonsense elimination, contributing to the ceiling effect observed in both groups (>80% correct). The reading level of the educational materials (eighth to ninth grade) exceeds the American Medical Association recommendation of sixth-grade level for general patient populations, although it is consistent with the National Institutes of Health recommendation of no higher than the eighth-grade level [41] and was appropriate for our health care worker sample.

    AI-Generated Avatar Videos for Postoperative Patient Education Among Health Care Workers: Pilot Randomized Controlled Trial · 2026 · DOI

  • Future research should evaluate AI-generated video instructions in actual patient populations with diverse health literacy levels. Key priorities include (1) larger randomized trials in surgical patients, (2) assessment of long-term retention and clinical outcomes (eg, adherence and complications), (3) comparison across different AI platforms, and (4) costeffectiveness analyses comparing AI-generated videos to traditional production methods. Hybrid text-video approaches and culturally tailored avatar presentations warrant investigation (Figure 5). https://periop.jmir.org/2026/1/e89277 JMIR Perioper Med 2026 | vol. 9 | e89277 | p.

    AI-Generated Avatar Videos for Postoperative Patient Education Among Health Care Workers: Pilot Randomized Controlled Trial · 2026 · DOI

  • The results must be interpreted in light of several limita- tions. Because the majority of participants were affiliated with two organizations, the sample is only partially repre- sentative, meaning that organization-specific influences cannot be ruled out. The cross-sectional design does not allow for conclusions regarding causality or temporal developments in the observed relationships. The target Sommer et al. BMC Medical Education (2026) 26:800 Page 13 of 15 comparability between groups. The findings should also be interpreted in light of the context-sensitive nature of debriefing in real-world settings. In practice, debriefings are rarely conducted in a standardized manner but are dynamically adapted to factors such as learner level, situ- ational complexity, and the emotional tone of the event. These factors may influence both the structure of the debriefing and the way participants engage in reflec- tion and communication. For example, more complex or emotionally charged situations may require greater emphasis on psychological safety. Although these contex- tual factors were not systematically examined in the pres- ent study, their potential influence should be considered when interpreting the observed relationships. Future research may benefit from explicitly incorporating such situational and contextual dimensions to better under- stand how debriefing processes unfold in practice. Open questions and further research needs Future studies should employ longitudinal designs to examine developmental trajectories and potential causal relationships between debriefing quality, psychological safety, and reflective competence. Cross-organizational studies could also clarify the extent to which structural conditions and hierarchical structures influence the results and whether they are transferable to other emer- gency service settings.

    Debriefing in practice: a cross-sectional observational study of self-reflection competence, psychological safety and speak-up in paramedic training · 2026 · DOI

  • skills among midwifery students.10 Simulationbased mastery learning (SBML) represents an intensive approach to competency-based education, in which all participants must achieve a high standard of proficiency before completing the training, as demonstrated through a post-training assessment.11 In Morocco, studies have shown that midwifery students and newly graduated midwives are often inadequately prepared to handle the full scope of midwifery practice, highlighting persistent gaps in the quality of midwifery education.12-13-14 Furthermore, the integration of simulation based learning into midwifery education remains relatively limited, with few studies exploring its application in the training of midwifery students.12 Accordingly, this study aimed to evaluate the effect of SBML with DP on midwives' knowledge, skills and selfconfidence related to the AMTSL. The hypothesis was that combining lectures, SBML with deliberate practice, and subsequent clinical experience would improve these outcomes and promote a more effective to clinical practice.

    Effects of Simulation-Based Mastery Learning versus Deliberate Practice on midwifery students’ knowledge, skills and self confidence in managing the third stage of labour: A quasi-experimental s · 2026 · DOI

  • This study features key strengths, including a clinically relevant simulation-based practical in undergraduate pharmacology and multiple assessments evaluating immediate gains and long-term retention. Baseline pre-test scores were comparable between both the groups and performance in this study related tests did not affect their academic progress.

    Enhancing pharmacology learning through simulation-based training versus traditional teaching: a quasi-experimental study among undergraduate medical students · 2026 · DOI

  • The data extraction tool (Table 3) includes 'technology validation' as a concept but the protocol does not specify what validation criteria, psychometric standards, or fidelity benchmarks should be assessed when evaluating cyberpatient technologies in nursing simulation contexts.

    Use of digital patients in clinical simulation for nursing education: a scoping review protocol · 2026 · DOI

  • The scoping review protocol identifies 'impacts and limitations of the use of technology' as categories for thematic analysis in digital patient simulation for nursing education, but does not specify comparative effectiveness data between digital patient simulation and mannequin-based simulation across different nursing training levels, clinical skill domains, or learner populations.

    Use of digital patients in clinical simulation for nursing education: a scoping review protocol · 2026 · DOI

  • The scope does not systematically examine how proficiency-based simulation training is implemented across multi-professional team contexts in obstetric and surgical emergencies. The integration of proficiency metrics across interdisciplinary simulation training for coordinated clinical care requires explicit investigation.

    Proficiency-based simulation training in healthcare – a scoping review protocol · 2026 · DOI

  • Transfer of learning from proficiency-based simulation training to clinical performance has been demonstrated in specific procedures (epidural analgesia, arthroscopic Bankart repair, robot-assisted prostatectomy), but the mechanisms enabling this transfer and the sustainability of proficiency gains in actual clinical practice remain inadequately characterized across diverse clinical contexts.

    Proficiency-based simulation training in healthcare – a scoping review protocol · 2026 · DOI

  • The review protocol does not address variation in standard-setting procedures for proficiency cutoff scores across different healthcare institutions and training programs. Evidence exists showing variation in passing standards at UK medical schools and Australian medical schools, but comparable data on proficiency thresholds in metric-based simulation training is missing.

    Proficiency-based simulation training in healthcare – a scoping review protocol · 2026 · DOI

  • Current literature on proficiency-based simulation training lacks evidence on the optimal debriefing approaches (PEARLS, GIFT, or 'With Good Judgment' frameworks) for consolidating proficiency achievement in simulation learners. The comparative effectiveness of these distinct debriefing methodologies within proficiency-based training curricula requires systematic evaluation.

    Proficiency-based simulation training in healthcare – a scoping review protocol · 2026 · DOI

  • The scoping review protocol does not specify standardized metrics for proficiency-based simulation training across different healthcare disciplines and procedures. There is a need to systematically identify and compare performance metrics used in proficiency-based progression training to establish consistency in proficiency standards across surgical skills, obstetric emergencies, and anesthesia procedures.

    Proficiency-based simulation training in healthcare – a scoping review protocol · 2026 · DOI

  • Future research must examine the feasibility and implementation of immersive VR debriefing approaches across diverse clinical settings beyond the single pilot centre, including variation in participant demographics, resource availability, and institutional contexts that may affect self-guided versus facilitator-guided debriefing effectiveness.

    Facilitator-guided vs self-guided debriefing in immersive virtual reality paediatric emergency training: a randomised pilot study on learning outcomes and feasibility · 2026 · DOI

  • The pilot study requires adequately powered randomised controlled trials to formally evaluate non-inferiority of self-guided debriefing compared to facilitator-guided debriefing in immersive VR paediatric emergency training, with statistical power calculations for detecting clinically meaningful differences in learning outcomes.

    Facilitator-guided vs self-guided debriefing in immersive virtual reality paediatric emergency training: a randomised pilot study on learning outcomes and feasibility · 2026 · DOI

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231 open questions have been extracted from the limitations and future-work passages of 3,300 Simulation-Based Education in Healthcare papers in our library. Each one below links back to the study that raised it, so you can read the original claim in context.

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