A Systematic Review of Emotional, Cognitive, and Logistical Factors Influencing Simulated Patient Performance in Simulation-Based Education

Introduction

Simulation-Based Education (SBE) is integral to clinical training, enhancing skills through immersive scenarios.¹ At the core of SBE’s success are simulated patients (SPs), also known as standardised patients, who play diverse roles in the education and assessment of trainees.² SPs significantly enrich learning by fostering safe, patient-centered environments that enhance communication and technical skills.^3–8 A key feature of SP programs is the provision of feedback from a patient’s perspective, which has been highly valued for bridging theoretical knowledge and practical application.^9–13 Such feedback not only facilitates immediate corrective action but also promotes self-reflection and continuous improvement.^14,15

Participation as an SP also benefits the individuals themselves, increasing their health knowledge, empathy, and understanding of clinical contexts.⁵ Nonetheless, SPs face challenges: they often come from varied backgrounds and must simultaneously portray roles, observe learners, provide feedback, and sometimes assess performance.^16,17 Cultural context critically shapes feedback dynamics¹⁸ in SP programs. Dimensions such as power distance, individualism–collectivism, and communication style influence how SPs deliver feedback and how students perceive it. For instance, in hierarchical cultures SP feedback may be undervalued compared to faculty, whereas in egalitarian settings it is received more collaboratively.^18–20 Similarly, learners in collectivist contexts may prefer group-oriented comments, while those in individualist cultures expect personalized critique. These cultural differences highlight the need for training SPs to adapt their feedback style to diverse educational settings, ensuring that feedback remains authentic, actionable, and equitable.^19–22 High-stakes assessments such as OSCEs impose further demands, requiring SPs to perform complex scenarios under observation, which can be emotionally and physically draining.^5,23 This imposes cognitive load,²⁴ as SPs must quickly internalise character details and medical information,²⁵ potentially compounded by factors like age.^26,27 Although cognitive load effects on students are well documented,^28–32 SP-specific challenges warrant further study.

Given SPs’ growing role, understanding how multitasking and environmental demands affect their performance is imperative. Most existing research focuses on learner outcomes, with limited insight into SP experiences.^33,34 A previous narrative review by Plaksin et al¹⁶ identified benefits and risks for SPs but did not focus on contextual factors. Importantly, theoretical frameworks such as cognitive load theory are seldom applied to SP performance, leaving synthesis of factors somewhat unstructured. To address these gaps, we ground our analysis in Sweller’s cognitive load theory and propose a conceptual framework integrating emotional, cognitive, and logistical domains to organize factors influencing SP performance. Sweller’s CLT highlights human limits on working memory when managing complex tasks. In the SP context, playing a patient and observing learners is a dual task that overloads memory, causing cognitive strain and performance errors.³⁵ This systematic review aims to synthesize recent literature on SP performance factors, their implications for learners, and directions for future research.

Materials and Methods

Search Strategy: This review followed PRISMA guidelines.³⁶ Six databases (Ovid Medline, PubMed, Web of Science, CINAHL, Scopus, Embase) were searched (April 2024; updated January 2025) for peer-reviewed articles on human SPs in undergraduate medical education (see Appendix A). Search results from each electronic database were imported into Covidence© 2021 (systematic review software, Veritas Health Innovation, Melbourne, Australia (available at www.covidence.org) which facilitated de-duplication, screening, and data extraction. In addition, the reference lists of the included articles were hand-searched to identify additional relevant studies. Search concepts included SP performance, SP roles, and simulation-based education.

Eligibility Criteria: Studies were selected for inclusion based on the following criteria: 1) peer-reviewed journal articles published in English, within the last 10 years; 2) studies focused on the role of human SPs in simulation-based education for undergraduate medical students; 3) articles that evaluated factors affecting SP performance, including training, coaching, and skills development. Articles were excluded if they did not meet these characteristics or were literature reviews, editorials, commentaries, or conference abstracts. This timeframe was chosen because previous reviews covering literature up to 2014 have already explored earlier developments in simulation practices involving SPs.¹⁶ The decision to focus on more recent articles is based on significant advancements in simulation methodologies and their integration into medical education over the past decade.

Data Extraction and Synthesis: Two reviewers (EFF, BSMA) independently screened titles/abstracts and full texts. An 87% agreement (Cohen’s κ=0.80) was achieved in eligibility decisions. Discrepancies were resolved by consensus and discussion with additional reviewers (UHM, EA). Data extraction used a Covidence template, collecting study details (authors, year, aims, design, participants) and results related to SP performance factors and student learning. We performed an inductive thematic analysis: relevant findings from each study’s results and discussion were coded line-by-line without using a pre-existing framework, allowing themes to emerge organically. Codes were iteratively refined and grouped into themes and overarching domains (emotional, cognitive, logistical).

Risk of Bias Assessment: Two reviewers (EFF, BSMA) independently assessed study quality using the QATSDD tool,³⁷ which scores each of 16 criteria from 0 to 3. Total scores were converted to percentages (<50% low quality, 50–80% medium, >80% high). Disagreements were resolved by discussion; no disagreements affected overall category of assignments.

Results

The search yielded 518 records (506 database results, 12 from hand-searching). After removing 11 duplicates and screening titles/abstracts (92 full texts reviewed), 19 studies^24,38–55 met inclusion criteria (see PRISMA Figure 1).

Figure 1 Prisma flow chart.

Characteristics of the Included Articles

Table 1 presents the summary characteristics of the 19 included studies. Studies spanned nine countries: USA (6), Australia (3), UK (3), Netherlands (2), and one each from France, Germany, Switzerland, Sweden, UAE. There were 607 total participants. Fifteen studies were qualitative, two mixed methods, and two quantitative. Fifteen studies included only SPs: four included SPs plus faculty or students. Only one study quantitatively measured SP cognitive load; the others used surveys or interviews.

Table 1 Characteristics of the Reviewed Articles

Enablers and Barriers to SP Performance

Analysis revealed three domains affecting SP performance (Table 2).

Table 2 Enablers and Barriers Affecting SPs’ Performance and Student Learning

Emotional Influences

SPs often draw on personal experience, enhancing authenticity and emotional realism in scenarios.^46,49 Many SPs felt fulfilled by contributing to student learning, which was motivating.^39,41 Feedback methods such as “sandwich-style” and out-of-role discussions helped SPs process their feelings.^47,55 However, intense or repeated scenarios led to SP fatigue and exhaustion, compromising performance.^40,42 Sustaining continuity over long-term simulations was difficult, affecting character consistency.⁴¹ Some SPs reported limited personal development from their roles, leading to disengagement.²⁴ Additionally, SPs sometimes struggled with balancing strict standardization and authenticity, critically self-assessing their performances.⁵⁴

Cognitive Influences

Acting as an SP developed individuals’ communication skills and clinical understanding, which benefited them personally.⁴² Thorough mental preparation for their role made SPs more attentive during simulations.³⁸ Adequate feedback and recognition from instructors and peers increased SP satisfaction.³⁹ However, cognitive demand could be overwhelming. According to cognitive load theory, tasks like improvisation and maintaining simulation integrity impose high intrinsic and extraneous load.⁵⁴ For example, SPs required to improvise and observe students simultaneously missed over 75% of learners’ nonverbal cues.⁵⁶ When SPs had to portray a patient while evaluating the learner, their observational accuracy declined.²⁴ SPs also reported stress from fear of making errors or role overload.⁴⁷ Ethical dilemmas in simulating sensitive conditions added to their mental load.⁴³

Logistical Influences

A supportive environment and effective training were crucial for SP motivation. Well-designed preparation programs improved SP confidence and performance.⁴³ During the pandemic, online role-play increased SP comfort and safety.⁴⁸ Conversely, logistical challenges hindered SP performance. Scheduling conflicts, inadequate compensation, and interruptions to continuity in extended simulations undermined SPs’ ability to stay in role.^39,43 Weak mentoring and unclear instructor expectations also reduced consistency. In virtual simulations, technical problems and communication issues further impair realism.⁴⁸ Unspoken group dynamics and mismatched faculty expectations similarly had negative effects.⁴⁷

Impact of SP Performance on Student Learning

Two main themes emerged regarding SPs’ impact on learners: educational enhancements and learning challenges.

Enhancement of Educational Outcomes

SPs significantly improve simulation realism, which enhances learner outcomes. Particularly, older SPs deepen student empathy for older patients.^40,47 Authentic interactions with SPs foster student emotional and professional growth.⁴¹ Longitudinal encounters with the same SP let students build clinical continuity and relationships.⁴¹ SPs trained in clear, engaging communication increase students’ preparedness for varied patient encounters.⁵⁰ SPs also serve as both patient and assessor, providing immediate, actionable feedback that strengthens student knowledge and clinical practice.^42,53,55 This real-time reflection enhances learning during simulations and equips students to adapt in clinical environments.

Challenges in Learning Outcomes

Variability in SP portrayal sometimes causes learner confusion. If SPs were overwhelmed by emotional or cognitive demands, they could not fully engage students, diminishing their learning experience.⁴¹ Ethical tensions and the emotional toll of difficult roles could complicate scenarios, affecting both SPs and learners, and potentially undermining educational safety and effectiveness.⁴³

Risk of Bias Assessment

QATSDD scores ranged from 62% to 95%. Twelve studies (63%) were medium quality (50–80%) and seven (37%) were high quality (>80%). No study was rated below 50%. Common weaknesses were lack of explicit theoretical grounding and limited user involvement in study design (Appendix B).

Across the 19 studies, QATSDD scoring indicated a generally moderate quality evidence base (Appendix B). The predominance of qualitative studies and lack of experimental designs limit the strength of conclusions. We note again that one included study was co-authored by a review author (EFF), though its quality score was determined independently to avoid bias.

Discussion

This systematic review builds on the work of Plaksin et al¹⁶ by incorporating new literature and explicitly applying theory to interpret findings. We used cognitive load theory as a guiding framework, which helps explain how multitasking and mental demands affect SP performance. Our conceptual model (emotional, cognitive, logistical domains) provides a unifying lens for diverse findings, strengthening explanatory coherence.

Our synthesis highlights SPs’ pivotal role in medical education: by bringing realistic patient portrayals, they enhance learner empathy, communication, and clinical skills.^43,56–60 Older SPs, in particular, enrich sessions by sharing life experience, which has been shown to increase students’ empathy toward aging patients.⁴⁷ The value of SP feedback is evident; structured feedback methods help SPs process their experiences and deepen learning.^47,61,62 These outcomes align with adult learning theory and experiential learning principles, emphasizing the importance of authenticity.^57,63

However, SP performance can be compromised by various factors. Fatigue and emotional strain^23,33,43,48 can reduce the fidelity of SP portrayals, thereby limiting educational value. Inconsistencies in portrayal (due to overload or insufficient training) may confuse students. The cognitive challenges of improvisation and dual roles (acting and observing) are consistent with cognitive load theory: when working memory is taxed, performance suffers.^54,56 For example, SPs missing critical cues while multitasking⁵⁶ underscores how high intrinsic and extraneous load hamper effectiveness. This finding suggests that SP roles should be designed to manage cognitive load (eg, by limiting multitasking demands).

Our findings also reveal gaps in the literature. Most evidence comes from qualitative reports; few studies quantified SP workload or learning outcomes. This limits our ability to compare across contexts or to synthesize effect magnitudes. Only one study measured SP cognitive load quantitatively,⁵⁶ despite its thematic prominence. Future research should use methods to integrate SP perceptions with objective measures, including physiological mixed workload indices and learner performance scores. This would clarify how SP cognitive and emotional states directly affect learner outcomes.

Notably, cultural factors emerged as important but underexplored. SP programs reported benefits from diversity,⁴⁰ yet no study empirically assessed cultural context. Drawing on Hofstede’s theories,⁶⁴ one might hypothesize, for instance, that SP feedback may be received differently in high versus low power-distance cultures. Similarly, uncertainty-avoidance could influence SP improvisation preference.⁶⁵ These are promising avenues to ensure SP programs are culturally sensitive.

Contradictory findings are acknowledged: SPs both benefiting from and being burdened by their roles, and we analyse them in context. For example, whether SP experiences are positive or negative may depend on support structures. Some studies reported that well-supported SPs experienced personal growth,^42,66 while others noted neglect of SP welfare.^24,47 This contrast suggests actionable improvements, emphasising that robust SP support and feedback might tip the balance toward positive outcomes.

Implications for Practice

The findings highlight several actionable strategies for strengthening SP programs. Program designers should implement structured training and routine debriefing to reduce cognitive load and emotional strain while also training faculty to collaborate effectively with SPs by setting clear expectations and supporting their roles. Curriculum developers can enhance authenticity by embedding SP feedback into learning objectives and acknowledging SPs’ cognitive limits—adopting a “good enough” fidelity approach that balances realism with local resources to avoid overburdening SPs. To ensure sustainability, programs should assess the cost-effectiveness of different training models (in-person, online, hybrid) and pursue scalable approaches such as peer mentoring, modular training packages, and e-learning platforms. Finally, integration strategies, including role-specific preparation and systematic support mechanisms, can be embedded within existing curricula with minimal additional resource demands, ensuring SP programs remain both effective and feasible.

Future Research

This review highlights several critical gaps in the literature that must be addressed to enhance the effectiveness of SP roles and improve associated educational outcomes. We propose five priority areas for future research, organized by urgency and potential impact:

First, current evidence is largely qualitative, with only one study directly measuring workload. Newlin-Canzone et al⁵⁶ found that SPs missed over 75% of non-verbal cues when required to improvise while observing, underscoring the intensity of their cognitive load. Further quantitative research is essential to validate these findings and guide targeted support strategies to reduce stress and improve simulation fidelity. Second, longitudinal studies on SP well-being: Most research addresses immediate or short-term effects of SP participation. Longitudinal work is needed to explore the cumulative emotional and psychological impact of repeated exposure to high-stakes or emotionally demanding scenarios on SPs’ resilience, mental health, and retention. Third, evaluation of SP training and support frameworks: While effective preparation and feedback are widely acknowledged as important, rigorous evaluations of training strategies remain scarce. Studies such as Schlegel et al³⁹ highlight their potential value, but further evidence is needed on best practices, cost-effectiveness, and scalability to ensure SPs are consistently supported across programs. Fourth, cultural and ethical dimensions of SP roles: Cultural context critically shapes SP performance and feedback delivery. Hofstede’s cultural dimensions⁶⁴ provide a lens for understanding differences in power distance, collectivism, and uncertainty avoidance, all of which influence how feedback is given and received.^{18,19,21,22,62,65,67} Yet, no studies directly examined these influences in SP feedback. Research in this area is needed to design culturally sensitive and ethically sustainable SP programs, ensuring authentic representation of diverse populations and safeguarding SP well-being in emotionally demanding roles.^22,66,68 Fifth, virtual and technology-mediated SPs: Emerging innovations in digital and virtual SPs^69–71 offer opportunities for scalability, accessibility, and new pedagogical approaches. Future studies should compare traditional and virtual SPs to assess their impact on learner engagement, SP workload, and authenticity of interaction, thereby guiding effective integration of technology into SBE.

Strengths and Limitations of the Study

A strength of this review is its comprehensive scope, covering emotional, cognitive, and logistical factors across international studies. Our theoretical framing (cognitive load theory) provides coherence to a complex topic. We also transparently reported our methods and appraisal outcomes. This thorough approach provided a detailed exploration of how SPs enhance learning environments, which is crucial for a holistic understanding of their roles. Additionally, recommendations for future research are clearly articulated, offering actionable insights to optimise simulation programs and ensure the well-being of SPs.

Despite its comprehensive scope, the review has several limitations that affect its generalisability and applicability. Variability in the design, methodology, and demographics of the reviewed studies, which, while broadening the review’s scope, also complicates the direct comparison of SP programs. There is significant heterogeneity among the included studies poses challenges for effective synthesis and comparison, thereby limiting both the depth of interpretation and the broader relevance of the conclusions. The predominance of qualitative over quantitative research further constrains the scope and diminishes the overall strength of the evidence base. Additionally, the review’s limitation to English-language publications introduces language and publication biases, potentially excluding significant international research and skewing the global understanding of SP practices. A further limitation of this review is that 63% of the included studies were rated as medium quality, reflecting variability in study rigour, methodology, and reporting standards. This uneven evidence base limits the strength and generalisability of the findings, as methodological weaknesses such as inconsistent application of theory, limited use of mixed methods, and small sample sizes reduce the robustness of conclusions. While our synthesis offers useful insights, these quality constraints mean the results should be interpreted with caution and underscore the need for more rigorously designed, high-quality studies in this field. Selection biases may also exist due to the subjective nature of study inclusion and the focus on literature from only the past decade, potentially overlooking foundational studies and historical perspectives critical to the topic of SBE involving SPs.

Conclusion

Simulated patients are essential contributors to high-quality medical education, benefiting both students and SPs. This review shows that SP authenticity enhances learning, but highlights that emotional strain, cognitive load, and practical constraints can limit SP effectiveness. To optimize SP use, educators should focus on structured training, supportive feedback systems, and attention to SP cognitive and cultural needs. Research must address key gaps, especially the measurement of SP cognitive demands and long-term effects to inform these efforts. By integrating insights on SP experiences, programs can design more realistic and sustainable simulations. This, in turn, supports curriculum and faculty development initiatives that prepare both students and SPs for collaborative, effective learning in healthcare.