Table 1 Median and frequency distributions of responses from questionnaire items<\/p>\n
All questionnaire subscales demonstrated high internal consistency, with Cronbach\u2019s alpha values ranging from 0.86 to 0.89. Average inter-item correlations were between 0.51 and 0.54, suggesting good cohesion with some redundancy. Exploratory factor analysis supported unidimensionality for each subscale, with all items loading\u2009>\u20090.70 on the first factor and minimal secondary loadings. These findings indicate strong internal coherence of the questionnaire (Appendix 3).<\/p>\n
Qualitative themes<\/p>\n
Thirteen participants from the questionnaire round were invited for interview, all of whom agreed to take part. Participants classified as \u201cExpert\u201d (P1\u20139) were at consultant or fellowship level (n\u2009=\u20099), whilst participants categorised as \u201cResident\u201d (P10\u201313) were junior residents (years three and four of an eight year programme, n\u2009=\u20094). Participant demographics are outlined in Table\u00a02<\/a>. Interview times ranged between 16 and 59\u00a0min. Theoretical sufficiency was evident after the twelfth interview. Figure\u00a02<\/a> provides a graphic overview of the study\u2019s key results, visually summarising the main themes and their interconnections as identified through the integration of quantitative and qualitative data.<\/p>\n Table 2 Interview participant\u2019s demographical dataFig. 2 When cognitive load and fidelity are well-matched, performance in simulation becomes a strong predictor of operative competence-highlighting the key variables that influence skill transfer from simulation to neurosurgical practice.<\/p>\n Theme 1 \u2013 building technical confidence in a safe learning environment<\/p>\n Simulation was perceived as a powerful tool for developing foundational technical and cognitive skills, especially for junior residents. Participants highlighted how simulation helps reduce cognitive load by allowing procedural steps to become automated through repeated practice.<\/p>\n \u201cSimulation lets them build up muscle memory, so they\u2019re more fluent in theatre. It\u2019s not about the complexity of the task, but the familiarity of the tools.\u201d (P4, Expert). Consultants described simulation as preparing residents for more complex cases by isolating essential psychomotor skills from environmental stressors: \u201cIf residents have built up muscle memory of the technical steps from learning in the sim lab, then the only influential stressors are OR environmental factors.\u201d (P3, Expert).<\/p>\n Alongside skill acquisition, simulation was also seen to foster a psychologically safe learning environment. Coaches play an important role in this, guiding residents stepwise through procedures, normalising mistakes, and encouraging open dialogue. These coaching behaviours enable residents to attempt unfamiliar techniques without fear of judgment. As one resident shared, \u201cIn simulation, you have time, the consultant can go through all steps to the task with you, one by one\u201d (P10, Resident). Such practices helped co-construct a safe environment where residents could take risks, reflect openly, and receive targeted feedback\u2014conditions that underpinned growing confidence and technical proficiency. These insights elaborate on the \u2018effectiveness\u2019 construct from the survey, where the majority of respondents agreed that simulation improves procedural confidence (see Tables\u00a01<\/a> and Appendix 2).<\/p>\n Theme 2 \u2013 educational process: workflow and clinical reasoning<\/p>\n This theme explores how simulation serves as cognitive scaffolding, supporting the development of workflow understanding and clinical reasoning\u2014key elements of the \u201csupportive information\u201d component of the 4\u00a0C\/ID model. Participants emphasised that high-fidelity, immersive simulations are most effective when they mirror the entire clinical workflow, from patient preparation to procedural wrap-up, rather than isolating technical skills alone.<\/p>\n \u201cSimulation should be immersive, right from entering the OR to the final stitch. It\u2019s not just the technical part\u2014it\u2019s knowing how to think like a surgeon.\u201d (P10, Resident).<\/p>\n \u201cResidents sometimes miss steps [in theatre] because no one ever told them how to think through the full workflow.\u201d (P4, Expert).<\/p>\n Another participant described how simulation allowed for structured exploration: \u201cSet targets to find deeper anatomical structures\u2026 that\u2019s a learning in itself as you\u2019re not rummaging around looking for them on a real patient first and foremost\u201d (P6, Resident). Such reflections illustrate how coaching interactions\u2014characterised by clear goal-setting and the normalisation of uncertainty\u2014supports psychological safety and enables residents to engage with complexity without fear of error.<\/p>\n These insights elaborate on the \u2018effectiveness\u2019 and \u2018translational impact\u2019 constructs identified in the quantitative phase, where participants agreed that simulation supports not only technical proficiency but also broader clinical reasoning (see Tables\u00a01<\/a> and Appendix 2).<\/p>\n Theme 3 \u2013 systemic barriers & fidelity: challenges for advanced residents<\/p>\n This theme highlights the interplay between learner stage, simulation fidelity, and educational value. Senior residents reported that engagement with simulation declines unless the activities are highly realistic and tailored to advanced learning needs. Perceived educational value (\u201cyield\u201d) and relevance are critical motivators for participation at this level.<\/p>\n \u201cFor residents in later stages of training, there has to be a pull factor for them to attend\u2014there has to be yield.\u201d (P12, Resident).<\/p>\n \u201cOnly thing that\u2019s left are new surgical questions\u2026 and that can be difficult to simulate well.\u201d (P13, Resident).<\/p>\n These perspectives align with quantitative findings indicating lower perceived benefit of simulation among senior residents and highlight the need for ongoing innovation in simulation design to maintain engagement and educational effectiveness (see Table\u00a01<\/a> and Appendix 2).<\/p>\n Theme 4 \u2013 limits of simulation: crisis, stress, and risk<\/p>\n This theme illustrates the current boundaries of simulation\u2019s instructional reach, especially in replicating stress, error consequences, and decision-making under uncertainty\u2014elements critical to predictive validity. While simulation was broadly regarded as beneficial, participants acknowledged its limitations in replicating high-stakes elements such as crisis adaptation, anatomical variability, and the psychological pressures of real patient care.<\/p>\n \u201cSimulation doesn\u2019t have the same risk of complications such as managing excessive bleeding. You need the risk of things not going right so a resident learns to adapt.\u201d (P1, Expert).<\/p>\n These comments reinforce the quantitative finding that, while most participants value simulation for skill acquisition, there is scepticism about its ability to fully prepare residents for the unpredictable and high-risk realities of the operating room. This theme underscores the need for more immersive and scenario-based simulations that incorporate risk, unpredictability, and non-technical skills development (see Table\u00a01<\/a> and Appendix 2).<\/p>\n![\"figure](\"https:\/\/media.springernature.com\/lw685\/springer-static\/image\/art%3A10.1186%2Fs12909-025-07814-3\/MediaObjects\/12909_2025_7814_Fig2_HTML.png\")
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