Abstract
BACKGROUND: Simulation-enhanced education (SEE) is increasingly integral to neurosurgical training, yet the mechanisms underpinning effective skill to clinical practice remain under-explored. This study, grounded in the Four-Component Instructional Design (4 C/ID) model and principles of deliberate practice investigates key variables influencing the translational impact of SEE on neurosurgical competence. METHODS: A sequential explanatory mixed-methods design was employed. Quantitative data were collected via a 17-item questionnaire administered to neurosurgical residents and experts (n = 57), capturing domains such as instructional design, fidelity, skill transfer and assessment. Descriptive statistics, internal consistency (Cronbach’s alpha), and exploratory factor analysis were used to identify prevailing trends and subscales. These findings informed semi-structured interviews (n = 13), which probed underlying factors affecting skill transfer. Interview data were analysed using inductive thematic analysis, with themes mapped to quantitative constructs. Triangulation was achieved by integrating both data strands, and multiple researchers contributed to coding and analysis to enhance credibility. RESULTS: Participants reported that SEE improved procedural confidence, technical competence, and task fluency. However, concerns persist around the realism of simulation, it’s applicability to complex clinical scenarios, and engagement among senior residents. Integration of quantitative and qualitative findings highlighted the value of simulation for procedural readiness and objective assessment, particularly when training design aligned with cognitive learning theory. Triangulation confirmed the robustness of emerging themes and provided a comprehensive understanding of the factors influencing translational impact. CONCLUSION: SEE supports the development of neurosurgical competence, particularly when grounded in robust instructional design and deliberate practice. Addressing challenges related to fidelity, transferability, and engagement will further the predictive validity and adaptive realism of neurosurgical simulation curricula. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12909-025-07814-3.