Enacting deliberate practice in simulation-based surgical training: a mixed-methods study

Introduction: Simulation-based surgical training (SBST) is increasingly used to address reduced operative exposure and patient safety concerns. However, access to simulation alone does not ensure effective learning. Deliberate practice (DP) provides a theoretical framework for structured skill acquisition, yet its enactment within everyday surgical training environments remains poorly understood, particularly in low- and middle-income countries.
Methodology: A sequential mixed-methods design was used. The quantitative phase involved 53 participants (38 trainees, seven trainers, eight expert surgeons) who completed a structured questionnaire examining SBST access, training practices, and alignment with DP principles. The qualitative phase included 22 semi-structured interviews exploring lived experiences of simulation use, feedback, and institutional influences on practice. Quantitative data were analysed using descriptive and non-parametric statistics. Qualitative data were analysed using systematic text condensation guided by the DP framework.
Results: Expert surgeons demonstrated greater alignment with DP  principles than trainees, particularly in goal setting, reflective self-monitoring, and feedback utilisation. Trainees reported more opportunistic use of simulation, limited task progression, and weaker alignment between task difficulty and competence level. Although most centres had simulation access, its use was inconsistent and rarely embedded within longitudinal curricula. Qualitative findings identified institutional barriers including limited protected training time, heavy clinical workload, absence of structured progression pathways, inconsistent faculty training in feedback delivery, and lack of scheduled simulation sessions.
Conclusion: Effective enactment of deliberate practice in SBST depends on curricular integration, structured feedback processes, and institutional support. Strengthening these elements may enhance the educational impact of simulation in resource-constrained training environments.