Social Learning Theory and Social Cognitive Theory in Healthcare Simulation – A Narrative Review

Abstract

Background

Social learning theory (SLT) and social cognitive theory (SCT) are frequently invoked in simulation-based education (SBE), particularly when explaining observational learning and the educational value of observer roles. However, the theories are often treated as interchangeable, and conclusions about the superiority of one theory over the other have occasionally exceeded the available evidence.

Methods

Foundational theoretical texts and empirical literature relevant to healthcare simulation were identified through purposive literature searches of PubMed, Scopus, CINAHL, ERIC, and Google Scholar, supplemented by citation chaining. Literature was selected for conceptual relevance to modelling, observer roles, self-efficacy, self-regulation, debriefing, and performance transfer.

Results

SLT and SCT share an observational-learning lineage but are not identical. SLT most clearly explains modelling, imitation, and reinforcement during early behaviour acquisition. SCT extends this account by incorporating self-efficacy, forethought, self-regulation, and reciprocal determinism, making it especially useful for understanding how observers interpret, monitor, and transfer learning in SBE. Available empirical work supports the educational value of directed observation, observer tools, structured debriefing, collaborative interpretation, and explicit discussion of errors. Nevertheless, no head-to-head trials directly compare SCT-informed with SLT-informed simulation designs.

Conclusion

SCT appears theoretically well aligned with contemporary healthcare simulation, particularly for observer roles and learner agency, but current evidence supports it as a promising framework rather than a demonstrated default or superior theory. Comparative, theory-driven studies are now needed.

Introduction

Healthcare simulation is an established educational strategy in medical and health professions training, providing learners with opportunities to rehearse clinical skills, decision making, teamwork, and communication in a controlled environment before or alongside patient-facing practice. ¹ As simulation has expanded, so too has the need for explicit theoretical justification for how learning occurs within different simulation roles and formats.

One area of continuing pedagogic interest is the observer role. Earlier assumptions within simulation pedagogy often privileged direct, hands-on participation and implied that observers were educationally disadvantaged. That assumption has since been challenged. ² Systematic and theoretical work suggests that observers can achieve meaningful learning, particularly when their role is structured, their attention is directed, and their perspective is incorporated into debriefing. This is highly relevant to current simulation-based education (SBE) practice, where faculty constraints, growing class sizes, and limited scenario time often require some learners to observe while others enact the scenario. ³

Social learning theory (SLT) and social cognitive theory (SCT) are often used to explain how learners benefit from observing others in simulation. Because the theories are historically related and share core assumptions about modelling and social learning, they are sometimes used interchangeably. ⁴ Yet they do not make identical claims. SLT is primarily concerned with how behaviour is acquired through modelling, imitation, and reinforcement, whereas SCT adds a more explicit account of human agency, self-efficacy, forethought, self-regulation, and reciprocal determinism.^5,6 The purpose of this narrative review is therefore not simply to restate the classical descriptions of the 2 theories, but to compare their explanatory value for healthcare simulation, provide concrete SBE examples, synthesise the available evidence more critically, and identify theory-aligned educational and research implications.

Methods

This article was revised as a narrative review rather than a systematic review because its main aim is conceptual comparison and theory-informed synthesis rather than effect estimation. Narrative reviews are appropriate when foundational texts, conceptual papers, and heterogeneous empirical studies must be integrated, provided that the search and selection approach is made explicit. ⁷

An iterative, purposive literature search was undertaken using PubMed, Scopus, CINAHL, ERIC, and Google Scholar. Search terms included combinations of ‘social learning theory’, ‘social cognitive theory’, ‘healthcare simulation’, ‘simulation-based education’, ‘observer role’, ‘observational learning’, ‘vicarious learning’, ‘self-efficacy’, ‘debriefing’, and ‘clinical skills’. Citation chaining of key papers was used to identify additional foundational and empirical sources.

Eligibility was broad and included: (1) foundational texts required to define SLT and SCT; (2) conceptual and review papers relevant to simulation pedagogy; and (3) empirical studies in health professions education that examined modelling, directed observation, self-efficacy, instructor-modelled learning, observer roles, or transfer from observed to enacted performance. English-language papers were prioritised. Studies were excluded when they were unrelated to health professions education or when SCT/SLT were invoked only superficially without pedagogic relevance. Because this was a narrative review, no formal risk-of-bias tool or meta-analysis was applied; instead, studies were appraised qualitatively for conceptual relevance, design, and interpretive limits.

Positioning SLT and SCT Within the Broader Theory Landscape of Simulation

Simulation is a theoretically plural field. Experiential learning emphasises the transformation of experience through reflection, ⁸ reflective practice foregrounds reflection in and on action, ⁹ sociocultural and constructivist traditions emphasise mediated learning and participation in socially organised activity,^10,11 self-determination theory highlights autonomy, competence, and relatedness as drivers of motivation, ¹² and cognitive load theory reminds educators that instructional design can either support or overwhelm limited working-memory resources. ¹³ In parallel, simulation has also been described as a social practice rather than a pedagogy in itself, which means its educational power depends on how activities, roles, interactions, and meaning-making processes are organised. ¹⁴

SLT and SCT deserve focused attention within this broader landscape because they directly address a central question in SBE: how learners acquire and adapt behaviour through watching other people perform. That question is especially salient in observer roles, video-assisted simulation, peer modelling, faculty demonstration, error observation, and debriefing. The present review therefore focuses on SLT and SCT not because they are the only theories relevant to simulation, but because they are especially pertinent when the educational problem is learning from others’ performance.

SLT and SCT: Overlap, Tension, and Added Explanatory Work

In classical SLT, learning occurs in a social context through attention to a model, retention of what was observed, reproduction of the behaviour, and motivation to perform it. Reinforcement may be direct, vicarious, or self-generated, and the instructional emphasis falls on modelling, imitation, and the consequences attached to behaviour. ⁴ In simulation terms, SLT is highly useful when the desired learning outcome is accurate reproduction of an observable behaviour: for example, a procedural sequence, a communication script, or a visible team behaviour such as closed-loop communication.

SCT preserves these observational mechanisms but moves beyond them. In SCT, learners are not merely reactors to models and consequences; they are agents who anticipate outcomes, judge their own capabilities, regulate their behaviour, and act within a dynamic interplay of person, behaviour, and environment. ⁵ Self-efficacy is central to this shift. Bandura's self-efficacy theory describes perceived capability as a task-specific belief that influences whether a learner will initiate action, how much effort will be invested, and how persistently the learner will continue despite difficulty. ⁶ Burke and Mancuso applied these ideas to nursing simulation, arguing that simulation design and debriefing can actively cultivate intentionality, forethought, self-reactiveness, and self-reflectiveness. ¹⁵

The relationship between SLT and SCT is therefore best understood as refinement rather than rupture between the 2. They are not wholly separate paradigms, yet neither are they conceptually identical. SLT gives a strong account of how modelled behaviour becomes available for enactment; SCT gives a fuller account of how learners interpret, monitor, and transfer that learning. In epistemological terms, an SLT-dominant reading privileges observable performance and reinforcement, whereas an SCT-informed reading assumes that internal appraisal, agency, and contextual interpretation are also legitimate educational targets. This distinction matters in SBE because the theory one privileges will shape what is designed, what is debriefed, and what is assessed.

For this reason, hierarchical framing should be avoided. SLT is not ‘wrong’ or obsolete. When the educational task is narrow and behaviourally defined – for example, reproducing an aseptic sequence, a standardised handover, or a physical examination manoeuvre – SLT may be entirely adequate and even pragmatically preferable because it keeps the instructional focus on modelling and rehearsal. SCT offers added explanatory power when the learning task involves observer roles, adaptation, confidence calibration, coping with stress, self-monitoring, or transfer to a novel clinical situation. The issue is therefore not whether SCT should replace SLT wholesale, but which theory better matches the educational mechanism of interest. Table 1 illustrates this discussion.

Specific Manifestations of SLT and SCT in Healthcare Simulation

Concrete SLT-informed examples in SBE extend well beyond simply ‘watching a video’. A faculty member may demonstrate a deteriorating-patient assessment using an ABCDE structure and an SBAR escalation call, after which learners reproduce the same sequence in the next scenario. A senior resident may model sterile central-line preparation or correct donning and doffing of personal protective equipment, with novices subsequently imitating the same sequence on a task trainer. A communication station may use a standardised-patient demonstration of empathic opening questions, agenda setting, and signposting, followed by repeated learner rehearsal with immediate corrective reinforcement. These are SLT-dominant designs because their primary logic is model, attend, imitate, and reinforce.^4,16

By contrast, SCT-informed examples involve not only modelling but guided interpretation and self-regulation. An observer in a sepsis or postpartum haemorrhage simulation may be given a structured tool to identify patient cues, anticipate the next decision, note environmental pressures, and record how the team maintains or loses situational awareness. The observer then rates task-specific self-efficacy before and after debriefing, articulates one strategy for future performance, and later re-enters a related scenario with an explicit action plan. Another SCT-informed design might ask learners to identify which coping strategies preserved performance under pressure, which contextual features constrained the team, and how they would adjust their own behaviour in a future case. These activities are not about imitation alone; they target forethought, self-monitoring, self-efficacy, and reciprocal determinism.^5,6,15

For conceptual clarity, self-efficacy is an SCT construct rather than a classical SLT construct. Accordingly, when simulation studies measure learners’ perceived capability to perform a specific task, manage a scenario, or lead a team, those outcomes align primarily with SCT. This also means that the commonly reported outcome of ‘confidence’ should be interpreted cautiously: generic confidence is broader and less precise than self-efficacy, whereas task-specific perceived capability is theoretically closer to SCT. In response to the reviewer query, self-efficacy beliefs about learners’ confidence in performing a future task should therefore be interpreted as SCT rather than SLT.

Evidence From the Literature: What Is Supported and What Remains Uncertain

The literature supporting observer learning and theory-informed simulation is meaningful, but it should not be overstated. Roberts’ review of vicarious learning in nursing challenged the idea that only first-hand experience produces learning and highlighted multiple examples of students learning from others’ experiences. ¹⁷ At the same time, Roberts also noted that the educator's role in structuring this learning remained unclear, which is an important caution against assuming that observation by itself is educationally sufficient.

Burke and Mancuso provided one of the clearest SCT-oriented interpretations of simulation. Their paper did not compare SCT against SLT experimentally; rather, it argued conceptually that simulation can be designed to foster symbolic coding, metacognition, self-efficacy, and self-regulation, especially when the level of challenge is matched to learner readiness and debriefing helps learners interpret what occurred. ¹⁵ This remains an important contribution, but it is best read as a theory-building paper rather than comparative proof.

Hober and Bonnel similarly do not establish theoretical superiority, but they provide useful empirical detail on what observers report learning. In their descriptive study, observers described the learning experience in terms of conceptualising the case, capturing the big picture, and connecting with the team. The study supports the claim that observers are not merely passive onlookers and that observer learning spans the whole simulation event. However, the study was small, observational, nursing-based, and heavily dependent on self-report, so its conclusions are better understood as supportive rather than definitive. ¹⁸

Islam et al offer a different form of evidence. Their scoping review examined SCT-based health promotion interventions in primary care and found that self-efficacy was the most frequently used SCT construct and that included studies generally reported positive outcomes. ¹⁹ This is useful because it shows that SCT constructs travel well across health-education and behaviour-change contexts. However, these were not simulation studies, so the review strengthens the plausibility of SCT in healthcare education rather than proving that SCT outperforms SLT in SBE.

Comparative simulation studies also warrant a more synthetic reading than simple citation listing. Kaplan et al reported no significant difference in content-test performance between student participants and student observers when both groups took part in debriefing, suggesting that observation can yield cognitive learning comparable to active participation under some conditions. ²⁰ LeFlore et al, in contrast, found that instructor-modelled learning may outperform self-directed learning on some behavioural and self-efficacy outcomes, which is relevant when the instructional task depends on a clearly modelled target performance. ²¹

Other studies indicate that the quality of observational design matters. Grierson et al showed that collaborative feedback during observational practice improved clinical skill acquisition, suggesting that social interaction during observation strengthens learning rather than distracts from it. ²² Domuracki et al found that observing flawed as well as flawless demonstrations improved global performance when learners were explicitly told that the observed performance contained errors, indicating that observers benefit from being asked to interpret, not merely copy, what they see. ²³ Bong et al reported that directed observers achieved non-technical performance equivalent to repeatedly active learners while experiencing lower stress, and Lai et al similarly found that an observational role can support crisis resource management learning when paired with debriefing.^24,25 Reime et al reported broadly similar outcomes for observers and participants on several measures, while also noting that learners still valued hands-on participation for professional confidence and role consolidation. ²⁶

Taken together, the evidence suggests that observer learning in SBE is real but conditional. The active ingredient is not passive viewing; it is structured attention, interpretive work, guided discussion, and opportunity for future enactment. These mechanisms are compatible with both SLT and SCT, but they map particularly well onto SCT because they depend on metacognition, self-regulation, self-efficacy, and future-oriented planning. Nonetheless, the evidence base remains methodologically limited. Much of the literature is single-centre, nursing-dominant, small-sample, and focused on self-report or short-term outcomes. Most importantly, the literature compares roles or instructional formats, not theories. That is why SCT can be argued to have broader explanatory reach in simulation without claiming that it has already been empirically proven superior to SLT.

Educational Implications, Theory-Specific Interventions, and Future Research

A theory-specific educational intervention can now be articulated for each framework. An SLT-specific simulation intervention would organise learning around expert modelling, focused attention to visible behaviours, rehearsal, and reinforcement. For example, in a sepsis escalation session, faculty could first demonstrate a target performance comprising structured assessment, escalation language, and closed-loop communication; learners would then reproduce that behaviour in a closely matched scenario and receive feedback focused on fidelity to the model. This approach is most defensible when the educational aim is accurate reproduction of a recognisable routine.

An SCT-specific intervention would extend that design by making internal regulation and future application visible. Observers could be given a structured observation guide, asked to identify key cues and anticipate decisions, rate their task-specific self-efficacy before and after debriefing, articulate contextual barriers and coping strategies, and formulate a written action plan for the next related scenario. Debriefing would move beyond what happened to also explore why the team acted as it did, how the environment shaped behaviour, and how the learner's own perceived capability changed. This is especially relevant for observer roles because it converts observation from a passive assignment into an agentic learning task.

The most useful next step would be direct comparative research. One pragmatic design would be a randomised or cluster-randomised trial comparing an SLT-informed observer condition with an SCT-informed observer condition, while holding scenario content, faculty time, and debrief duration constant. The SLT arm would emphasise model fidelity and reinforced rehearsal; the SCT arm would add self-efficacy calibration, structured observation, reflection on contextual determinants, and explicit transfer planning. Outcomes should include not only immediate checklist performance, but also non-technical skills, task-specific self-efficacy, cognitive load, stress, observer satisfaction, and delayed transfer to a novel scenario. Table 2 demonstrates some theory aligned interventions and suggested study designs.

From a practice perspective, adopting SCT more explicitly would not mean discarding modelling. Rather, it would change 3 features of simulation design. First, the observer role would shift from passive watching to guided noticing through observer tools, prediction tasks, or cue-identification prompts.^2,3 Second, debriefing would include observer perspectives and explicitly explore expectations, coping strategies, contextual pressures, and future action plans rather than focusing only on enacted behaviour.^15,27,28 Third, assessment would become more aligned with the theory: educators would combine behavioural checklists with task-specific self-efficacy ratings, reflective products, and transfer tasks, rather than treating performance on a single scenario as the only relevant endpoint.

Conclusion

SLT and SCT are both relevant to healthcare simulation, but they do different explanatory work. SLT remains highly useful for understanding modelling, imitation, and reinforcement during early or tightly specified skill acquisition. SCT extends this by accounting for self-efficacy, self-regulation, forethought, and reciprocal determinism, which makes it especially valuable when simulation learning depends on observer roles, adaptive performance, and transfer across cases.

The present synthesis does not justify a categorical claim that SCT has already been shown to be superior to SLT in SBE. No direct theory-to-theory comparative studies were identified. A more defensible conclusion is that SCT is a promising and theoretically congruent framework for contemporary healthcare simulation, particularly where observers must actively interpret, regulate, and later apply what they have learned. Future studies should test that proposition directly through theory-driven intervention design rather than assuming it in advance.

Table 1.

Analytical Comparison of SLT and SCT in Healthcare Simulation.

Dimension	SLT in Simulation	SCT in Simulation	Pedagogic Implication
Primary explanatory focus	Acquisition of observable behaviour through modelling, imitation, and reinforcement.	Acquisition plus interpretation, self-regulation, self-efficacy, and person-environment interaction.	Use SLT for behavioural reproduction; use SCT when transfer and agency matter.
View of learner	Learner is primarily a recipient of modelled behaviour.	Learner is an active agent who anticipates, monitors, and adjusts performance.	SCT justifies goal-setting, reflection, and self-monitoring activities.
Role of reinforcement	Central for motivating reproduction of modelled behaviour.	Still relevant, but mediated by efficacy beliefs, expectations, and self-regulation.	Feedback in SCT should address both behaviour and interpretation.
Observer learning	Observer learns by attending to a model and reproducing what was seen later.	Observer learns by interpreting actions, evaluating capability, anticipating outcomes, and planning future action.	Directed observer tools align more strongly with SCT than passive viewing.
Debriefing emphasis	Correctness of observed and enacted behaviour.	Reasoning, appraisal, contextual pressures, future strategy, and self-efficacy calibration.	Debriefing may be theory-neutral in form but SCT-rich in function.
Best fit in SBE	Procedural rehearsal, communication scripts, standardised behavioural routines.	Observer roles, adaptive performance, non-technical skills, transfer across cases.	Neither theory is universally superior; fit depends on the educational mechanism.
Limitation if used alone	May under-explain agency, metacognition, and transfer.	May become conceptually broad without tightly specified instructional mechanisms.	Hybrid designs may often be most educationally realistic.

Abbreviations: SCT, social cognitive theory; SLT, social learning theory.

Table 2.

Theory-Aligned Interventions and Suggested Comparative Study Designs.

Theory	Example Simulation Intervention	Core Design Elements	Possible Study Question	Suggested Outcomes
SLT	Faculty model a deterioration scenario, then learners reproduce the same assessment, escalation, and communication sequence in a matched case.	Attention cues; expert demonstration; imitation; repeated rehearsal; corrective reinforcement.	Does an explicit model-first design improve immediate procedural accuracy compared with unstructured exposure?	Checklist performance; communication behaviour; short-term retention.
SCT	Directed observers track cues, predict next actions, rate task-specific self-efficacy, contribute to debriefing, and enact a personal action plan in a subsequent scenario.	Observation tool; forethought; self-efficacy calibration; reflective debriefing; self-regulation; transfer task.	Does an SCT-informed observer package improve transfer, self-efficacy, and adaptive performance compared with an imitation-focused observer package?	Self-efficacy; non-technical skills; transfer to a novel case; delayed retention; learner stress.

Abbreviations: SCT, social cognitive theory; SLT, social learning theory.