Beyond the Checklist: How Different Prebriefing Tools Influence Simulation Outcomes—A Systematic Review and Meta-Analysis

Technical Summary: Beyond the Checklist: How Different Prebriefing Tools Influence Simulation Outcomes

Problem Statement
Simulation-based education (SBE) relies heavily on the prebriefing phase to align learners with objectives, reduce anxiety, and establish psychological safety. Despite its recognized importance, prebriefing implementation suffers from significant variability, conceptual ambiguity, and a lack of standardized, evidence-based frameworks. While previous systematic reviews have examined the general presence of prebriefing, they have failed to differentiate interventions by the type or innovation level of tools employed. Furthermore, existing literature has largely overlooked the specific impact of emerging technologies (e.g., AI, Virtual Reality) and has not quantitatively synthesized effects on psychological safety as a distinct outcome. This gap limits the ability of educators to optimize prebriefing design in contemporary practice, particularly as high-technology tools become more prevalent.

Methodology
This study is a systematic review and meta-analysis conducted in accordance with PRISMA 2020 guidelines.

• Search Strategy: Four databases (ScienceDirect, Embase, Medline, Web of Science) were searched from inception to August 6, 2025.
• Eligibility Criteria: The review included Randomized Controlled Trials (RCTs) and quasi-experimental studies comparing structured prebriefing interventions against standard or no prebriefing in healthcare SBE. Outcomes were limited to simulation performance, psychological safety, and simulation experience.
• Classification Framework: Interventions were categorized using the Substitution, Augmentation, Modification, and Redefinition (SAMR) model to stratify tool innovation levels:
  • Group 1 (Substitution): Standard structured outlines or checklists without additional interactive components.
  • Group 2 (Augmentation): Checklists supplemented with interactive elements (e.g., facilitated peer discussion or instructor dialogue).
  • Group 3 (Modification): Novel digital tools enabling new forms of engagement (e.g., Virtual Reality, AI chatbots).
• Statistical Analysis: A random-effects model was used to calculate pooled Standardized Mean Differences (SMDs) with 95% Confidence Intervals (CIs). Heterogeneity was assessed using $I^2$ and $\tau^2$. Publication bias was evaluated via Egger's test and Duval and Tweedie's trim-and-fill method. Sensitivity analyses were conducted using a leave-one-out approach.

Key Results
Fifteen studies (6 RCTs, 9 quasi-experimental) comprising 16 study arms for performance, 15 for psychological safety, and 6 for experience were included.

• Simulation Performance: Innovative prebriefing significantly improved simulation performance overall (SMD = 1.04, 95% CI [0.73, 1.36]). This result remained robust after trim-and-fill adjustment (SMD = 0.98). Subgroup analysis showed consistent positive effects across all SAMR groups, though Group 2 (Augmentation) demonstrated the lowest heterogeneity ($I^2$ = 58.2%).
• Psychological Safety: The initial pooled analysis suggested a significant benefit (SMD = 0.84). However, Egger's test indicated significant publication bias ($P < 0.0001$). After trim-and-fill adjustment, the effect was attenuated to non-significance (adjusted SMD = 0.47, 95% CI [-0.49, 1.43]). Group 2 showed a statistically reliable effect on safety, whereas Group 3 (Modification) failed to demonstrate a significant benefit (SMD = 0.51, 95% CI [-3.53, 4.55]).
• Simulation Experience: No significant overall improvement was found (SMD = 0.22, $P$ = 0.32), and this null finding persisted after bias correction.
• Heterogeneity: High heterogeneity was observed across all domains ($I^2$ ranging from 71.6% to 82.0%). Group 3 interventions exhibited extreme heterogeneity ($I^2$ = 88.0% for performance), likely due to uncontrolled institutional factors such as hardware infrastructure and facilitator proficiency.

Key Contributions

1. Granular Stratification: This is the first meta-analysis to systematically classify prebriefing interventions by tool innovation level (SAMR framework), moving beyond binary comparisons of "presence vs. absence" of prebriefing.
2. Differentiated Outcomes: The study provides distinct quantitative evidence that while structured prebriefing consistently enhances objective performance, its impact on psychological safety is highly sensitive to publication bias and tool type.
3. Evidence for "Augmentation": The analysis identifies Group 2 interventions (structured worksheets combined with facilitated interaction) as the most reliable strategy, offering the best balance of effectiveness, consistency, and lower heterogeneity across outcomes.
4. Caution on High-Tech Tools: The findings challenge the assumption that higher technological novelty (Group 3) yields superior results, noting that such tools introduce extreme variability and may fail to improve psychological safety without additional scaffolding.

Significance and Claims
The paper claims that the application of different prebriefing tool types is significantly associated with varying SBE outcomes, but these effects are outcome-specific. The authors assert that higher technological novelty does not uniformly yield superior results and may introduce extraneous cognitive demands that hinder psychological safety.

The central conclusion is that moderate-innovation approaches incorporating facilitated interactive elements (Group 2) represent the most reliable, evidence-supported strategy for prebriefing design. The study argues that prebriefing should prioritize instructional stability and contextual feasibility over novelty alone. While digital tools like VR and AI show promise, the current evidence is too heterogeneous to support their routine preference over simpler, human-guided interactive formats. The authors emphasize that prebriefing should be viewed as a context-sensitive preparatory process rather than a fixed content package, with core elements adapted to learner levels and institutional settings.