Effect of varied levels of complexity in simulation scenarios on educational outcomes for healthcare providers – a systematic review

Introduction Simulation scenarios should be designed in a way that addresses the needs and expectations of learners of varied backgrounds and experience levels. Varied degrees of complexity or difficulty in simulation exercises may be an effective means to optimally align learning objectives with outcomes. Methods This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. A search of PubMed, Embase and Cochrane was conducted over a period of 2 years up until 30 April 2024. Studies comparing simulation training outcomes using a scenario with two or more different levels of complexity were eligible for inclusion. Studies comparing simulation training using the same scenario with learners in different conditions (e.g. sleep-deprived) were excluded. Risk of bias was assessed using Cochrane Risk of Bias 2 for randomized trials and Risk Of Bias In Non-Randomized Studies of Interventions for observational studies. Results In total, 15,348 studies were identified that met criteria for screening, yielding 21 included studies (8 randomized and 13 observational studies). Among study outcomes, 6 randomized and 10 observational studies examined skill; 1 observational study examined knowledge, and 3 randomized and 8 observational studies examined attitudes, stress or confidence. There was significant heterogeneity in study methods, participants, interventions and outcomes of interest; all included studies had at least moderate risk of bias. Evidence for all outcomes was of very low certainty due to inconsistency, imprecision and risk of bias. Fifteen of 21 studies reported at least one outcome for which a significant difference was found between scenario complexity levels. Discussion This systematic review found marked heterogeneity and risk of bias among studies. The findings support the contention that scenario complexity may be a useful component of instructional design in simulation education to enhance outcomes. Future studies should determine how to use differences in scenario complexity to optimize participant engagement and durability of learning objectives.