Simulation-based learning (SBL) is a technique that simulates the conditions of the professional arena for the purpose of learning and practicing specific skills (Chernikova et al., 2020; Liu and McFarland, 2021), particularly skills for effective communication (Gaffney and Dannels, 2015). One of the models of SBL is the clinical model, which involves professional actors who play specific roles, simulating situations experienced in the professional field (Jack et al., 2014).

The simulation technique was developed in the military and medical fields and the outcomes of SBL have been comprehensively documented in the literature, using a variety of research scales (Hofmann et al., 2021). However, in the field of teacher education, the development of simulations began only two decades ago (Kaufman and Ireland, 2016; Theelen et al., 2019) consequently, the outcomes of SBL in this field have yet to be addressed. Moreover, there is no validated scale for measuring these outcomes in the teacher-education arena and especially in the case of clinical simulations (Dotger, 2013).

The focus of the current study is on the process of developing and validating a scale to measure outcomes of clinical SBL workshops conducted with preservice and inservice teachers. To this end, we used a mixed methodology. This is part of a broader effort to identify the theoretical and practical value of using simulations in the field of teacher education (Badiee and Kaufman, 2014; Dotger, 2015; Ferguson, 2017).

SBL is an active learning experience, in which the learner acts out a professional scene, the focus of which is a problem or a conflict; this is followed by a reflective debriefing session (Manburg et al., 2017), during which the participants, guided by the simulation instructor, engage in a peer discussion of ways to improve their future performance in similar situations (Levin and Flavian, 2022).

Learning through simulations is grounded in theoretical constructionist learning theories (Orland-Barak and Maskit, 2017). Specifically, Vygotsky (1978) conceptualized the learning process as grounded in socially based experiences, inherently mediated by others, and collaborative in nature. In accordance with Vygotsky’s ideas of social constructivism, SBL imitates a social environment (Frei-Landau et al, 2022), wherein participants engage in peer learning (Levin and Flavian, 2022). However, although SBL is anchored in a strong theoretical foundation (Ferguson, 2017), its practical learning outcomes have yet to be fully assessed, particularly in the teacher-education arena.

The current study is based on the clinical simulation model, in which scenarios are enacted by a learner and a professional actor in real-time and video-recorded. The goal of clinical SBL workshops is to deepen the reflective abilities of educators while strengthening their interpersonal skills within conflictual situations (Ran and Nahari, 2018). A clinical SBL workshop involves four consecutive generic stages: (1) An opening phase for the instructor to introduce the workshop’s framework and activities. (2) A “simulated experience,” i.e., a five-minute scenario enacted by a professional actor who interacts in real-time with a group-member-learner (the actor responds according to predefined schemes written into the scenario). (3) Following each enacted simulation, a debriefing phase is led by the instructor. The core structure of the SBL debriefing is based on universal learning models (Kolb, 1984). During the debriefing, participants examine the facts (“what happened here?”), decipher the causes and motives behind the events (“why did this happen?”), and deduce general lessons to be learned from the experience (“what will we choose to do next time?”). The debriefing ends with the actor’s feedback to the workshop participants. (4) Each workshop ends with a summary phase, wherein participants are asked to share their insights and draw possible conclusions. Although all workshops are comprised of the same four generic stages, they are diverse in terms of their contents (different scenarios). In this study, we examined the outcomes of standardized four-hour SBL workshops, held over a period of five sequential semesters, at the simulation center at the Be simulation center at Achva Academic College. Each workshop included three scenarios and involved 15 participants.

The clinical simulation model was originally borrowed from the field of medical education (Hallinger and Wang, 2020). In 1963, Howard Barrows, a medical educator, began utilizing local actors to prepare future physicians (Barrows and Abrahamson, 1964). Using Barrows’ framework, Benjamin Dotger adapted the pedagogy of clinical simulations for use in teacher education (Dotger, 2013). There are differences between the medical and educational clinical simulations in terms of the goals, scopes and procedures, which together determine the differences in learning outcomes. Clinical simulations in medicine are used to practice routine and extreme techniques in a protocol manner, as well as to gain non-technical skills (Goolsarran et al., 2018). In medical simulations, learners perform a task involving a binary outcome of either success or failure; hence, in medicine, simulations are also used to test and evaluate learners’ performance and knowledge (Hofmann et al., 2021). The clinical simulation in teacher education, however, mainly focuses on soft skills used in routine conflictual situations. During the debriefing phase, the focus is on elements that were present and those that could have been used during the scenario and their influences on what was achieved or could be achieved next time. Thus, in the fields of medicine and nursing, many comprehensive and validated scales have been developed; some are used to assess the various simulation outcomes (Franklin et al., 2014), others examine attitudes regarding the simulation experience (Sigalet et al., 2012; Pinar et al., 2014), and yet others measure participants’ satisfaction with the use of simulations (Chernikova et al., 2020). There is also abundant literature evaluating these simulation scales (Hofmann et al., 2021).

By contrast, in the field of teacher education, there is no single comprehensive scale that addresses the wide variety of simulation outcomes. Rather, studies that have examined the value of SBL have focused on the relationship between participation in a simulation and one specific and known variable, such as self-efficacy (De Coninck et al., 2020) or leadership (Shapira-Lishchinsky, 2015). To date, no research scale for examining the numerous SBL outcomes in a comprehensive and integrative manner has been devised—not to mention—validated. This absence is not surprising, given that SBL research in this field is still in a fledgling state (Theelen et al., 2019; Levin et al., 2023).

Whether simulations are conducted face-to-face or virtually (Tang et al., 2021; Frei-Landau and Levin, 2022), there are currently three types of outcomes that are the focus of SBL-related research in teacher education. One of these emphasizes the practical outcomes, i.e., the acquisition of practical behaviors and skills needed to perform professionally in this field (e.g., effective management of the conflicts that arise between a teacher and a student’s parent). It was found that simulations provide the context in which cognitive knowledge can be translated into operational knowledge (Theelen et al., 2019; Dalinger et al., 2020). As compared to traditional methods of study, the SBL has a greater potential for inducing behavioral changes and improving performance (Theelen et al., 2019; Cohen et al., 2020). When the emphasis is on communication skills as the required practice, SBL was found to assist in the development of these skills as well (Dotger, 2015).

Another type of SBL outcome that is being investigated in teacher-education research pertains to the domain of social cognition. Social cognition is categorized as the mental procedures used to decipher and encode social cues; it involves the processing of information about everyone, including the self, as well as about social norms and practices (Fiske and Taylor, 1991). SBL was shown to be associated with the promotion of social skills in both interpersonal and team contexts (Shapira-Lishchinsky et al., 2016; Levin et al., 2023). SBL was also found to successfully cultivate learners’ reflective abilities (Levin, 2022), including their critical reflection skills (Tutticci et al., 2018; Codreanu et al., 2021). Furthermore, the collaborative aspect of SBL was found to lead to a high level of collaboration and to promote critical thinking, with an emphasis on a supportive rather than a judgmental environment (Manburg et al., 2017).

The third SBL-related outcome that is examined in teacher-education research is the emotional process and its resulting emotional outcomes when using SBL. In this framework, studies have found that because the SBL process provides a safe environment for learning and making mistakes (Bradley and Kendall, 2014; Dieker et al., 2017), SBL may result in decreased levels of anxiety as well as a balanced emotional experience (Levin and Flavian, 2022), as compared to practice conducted in the classroom. Thus, it ultimately enables a balanced reflection on one’s practice, which in turn increases preservice teachers’ sense of self-efficacy (Theelen et al., 2019). However, it is important to note that studies have also indicated that SBL could also lead to negative emotional experiences and outcomes. For instance, during the SBL process, learners can experience negative feelings such as embarrassment due to peers’ critique or demotivation due to learning overload, emotions which can undermine their self-confidence (Bautista and Boone, 2015; Dalgarno et al., 2016; Frei-Landau and Levin, 2023). Given these seemingly contradictory findings, the efficacy of SBL in the field of teacher education requires further study.

To summarize, in the field of teacher education, the existing knowledge about the outcomes of SBL is decentralized and there is a need for a comprehensive scale that can provide an integrative description of the learning outcomes. To this end, the current study describes the process of formulating and validating a scale for comprehensively assessing SBL outcomes, based on SBL workshops conducted over five sequential semesters with preservice and inservice teacher participants.

The objective of the study was to systematically develop a scale to measure SBL outcomes in teacher education. As the knowledge available about SBL outcomes in this field is limited, developing such an instrument could not begin with the traditional method of conducting a literature review. Instead, we determined that the most suitable way to gain insights about SBL’s possible outcomes was to consider participants’ reported feedback collected immediately following their participation in an SBL workshop, regarding the insights they gained through the SBL experience. Hence, a mixed-methods sequential exploratory design was implemented, to develop the Simulation-based Learning Outcomes in Teacher Education (SLOTE) scale, according to the recommended psychometric standards and criteria (Benson and Clark, 1982).

This mixed-methods sequential exploratory design consisted of a qualitative phase followed by a quantitative one (Creswell and Clark, 2017). Generally, mixed-method designs are well-suited for scale development (DeCuir-Gunby, 2008), as collecting qualitative and quantitative data allows the researcher to gain both a broad and profound understanding of the topic of study. Furthermore, the mixed-method design maximizes the scale’s reliability, strength, and appropriateness (Leech and Onwuegbuzie, 2010).

We first collected and analyzed qualitative data from 518 participants’ answers to open-ended questions, presented as an end-of-workshop task. These data were collected during workshops conducted during the first two of the five sequential semesters. Then, building on the exploratory results, we developed a quantitative survey scale measuring SBL outcomes. The quantitative phase included systematic quantitative data collection using a postworkshop survey of SBL participants, to assess the overall prevalence of these SBL outcomes. Finally, a psychometric analysis of the scale was performed to interpret the results and gain a better understanding of the SBL outcomes. Figure 1 displays the full design procedure.

The ethics committee of the college where the simulation center is located approved the entire study. Furthermore, every effort was made to meticulously maintain the rights, privacy, anonymity, and confidentiality of the participants throughout the research process, by upholding professional ethical standards. The participants were given a clear explanation of the purpose of the research, the framework in which it would be carried out, and the voluntary nature of their participation. Only then were they asked to indicate their agreement by signing an informed consent form.

The following sections describe the qualitative and quantitative phases utilized to empirically develop and validate the SLOTE scale.

The most significant contribution of this study is in addressing SBL’s multifaceted learning outcomes as revealed through participants’ perceptions. Thus, this study enhances our ability to theoretically and practically examine the use of SBL in teacher education, by providing a validated tool for assessing these outcomes. The SLOTE scale is a first in this subfield of teacher education, where the use of SBL is still being developed (Dotger, 2015; Theelen et al., 2019). In contrast to previous studies, which examined the effects of SBL in terms of a single outcome, such as teaching reading (Ferguson, 2017) or conflict management (Shapira-Lishchinsky, 2015), the current study’s innovation lies in conducting a comprehensive examination of the multifaceted simulation outcomes. Hence, the study’s contribution is in providing a theoretical conceptualization of SBL outcomes and examining these among preservice and inservice teachers. These outcomes are manifested in three dimensions: a cognitive dimension (communication skills), a behavioral dimension (collaborative learning-related insights) and an emotional dimension (emotional self-awareness).

The findings related to the first factor of communication skills echo those of previous studies in teacher education, which found that SBL helps nurture communication skills (Dotger, 2015). The current study not only confirms this finding but also demonstrates that SBL participants, regardless of their age, teaching experience, or level of education, indicated the development of communication skills as an SBL outcome. This added facet underscores the importance of the simulation activity (Theelen et al., 2019; Dalinger et al., 2020). Moreover, the numeric scores indicate that preservice teachers benefitted more—in terms of the acquisition of communication skills—from the SBL experience than did their more veteran colleagues. This finding echoes those of earlier studies that examined the benefits of the simulation experience in the context of participants’ professional development stage, whether in the field of medicine (Elliott et al., 2011) or in a paramedical field such as speech therapy (Tavares, 2019). A possible explanation for this finding is related to the assumption that preservice teachers have had less experience in the field, as compared to veteran teachers who have had more opportunities to acquire communication strategies (Symeou et al., 2012).

The finding that communication-skills outcomes for the simulation observers and the simulation actor-participants did not differ significantly confirms that significant learning occurs regardless of the role (observer or participant) of the SBL participant (Frei-Landau et al., 2022). It also corresponds to findings from studies in the field of medicine that compared the perceived outcomes expressed by observers vs. those expressed by participants, although these findings were not definitive (Bong et al., 2017; Zottmann et al., 2018). However, medical simulations are used to practice techniques as well as communication skills; consequently, every learner must actively experience a simulation (Goolsarran et al., 2018). Thus, the finding of the current study provides an empirical anchor to the rationale for using SBL in teacher education in a manner that does not require every participant to take an active role in the simulation.

The outcome of collaborative learning is another relevant aspect of the SBL experience (Manburg et al., 2017; Levin and Flavian, 2022), which corresponds to the growing tendency seen in higher education study programs to emphasize the development of collaborative learning skills (Curşeu et al., 2018). Furthermore, in the current findings, the number of collaborative-learning-related insights reported by participants who acted in the simulations was greater than the number reported by their counterparts who observed the simulations. This may be because the acting participants were involved in the workshop both actively, as actors in the simulation, and passively, as observers of simulations enacted by others, which by definition increased their opportunity to benefit from collaborative learning. Of note, there are various levels of collaborative learning (Luhrs and McAnally-Salas, 2016); hence, future studies ought to compare the observers’ and participants’ SBL outcomes in terms of the various levels of collaborative learning in SBL.

The study found that one of the major outcomes of SBL consists of emotional self-awareness. This is an awareness of the emotions that were elicited when contending with the challenges inherent in the SBL process, such as the critiquing element. This finding is in line with previous studies, which indicated that the SBL experience elicited negative—as well as positive—emotions among its participants (Bautista and Boone, 2015; Dalgarno et al., 2016). Not surprisingly, the preservice teachers in this study mentioned emotional self-awareness more frequently than did the experienced inservice teachers. This may be explained by earlier studies, which have shown that emotional self-awareness enables openness toward learning, which is greater when one is more professionally grounded and hence has also had more positive experiences (Govender and Grayson, 2008; Levin and Muchnik-Rozanov, 2023). An interesting finding was that the women mentioned the emergence of both positive and negative emotions in reaction to challenges encountered. This finding is in line with a previous study that found that women who participated in SBL reported on positive emotions, such as relief and confidence, as well as negative emotions, such as stress and self-criticism (Levin and Muchnik-Rozanov, 2023). However, the finding that the women mentioned emotional self-awareness more frequently than did the men in this study may suggest a relationship between emotions and gender in SBL. This can be explained by the findings of a previous study, according to which women who reported participating in SBL less frequently also indicated lower levels of satisfaction, and did not feel a sense of belonging (Engel et al., 2021).

A surprising finding was the absence of a significant difference between the observers and the active participants in terms of the outcome of emotional self-awareness. We expected to find that actively participating in the simulation would involve a sense of greater exposure and consequently would elicit more instances of emotional self-awareness, as was found in other studies concerning SBL in the field of teacher education (Bautista and Boone, 2015; Dalgarno et al., 2016). In the same vein, it was found that active participants in medical simulations were under a greater amount of stress than were the observers (Bong et al., 2017). The novelty of the current findings is that they suggest that active participation is not inherently more emotionally demanding and, consequently, participants in both roles are apt to benefit equally from the experiential learning afforded by the SBL process. Additional studies could compare the SBL experience as perceived by the simulation observers vs. the acting participants in relation to other SBL outcomes.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee of Achva Academic College. The patients/participants provided their written informed consent to participate in this study.

OL: conceptualization, data curation, funding acquisition, investigation, methodology, project administration, resources, validation, and writing. RF-L: conceptualization, formal analysis, funding acquisition, investigation, methodology, resources, validation, and writing. CG: conceptualization, statistical analysis, investigation, methodology, resources, validation, visualization, and writing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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