Healthcare simulation has long been valued for its ability to authentically replicate a clinical scenario, with early emphasis placed predominantly on fidelity (physical, environmental and psychological) and the simulator itself [1–3]. In recent history, simulation was primarily used to develop procedural and technical skills in controlled environments. However, as the healthcare landscape has grown more complex, so too has the scope and purposes of simulation, transitioning into a multifaceted methodology – from education and professional development to cultural change, policy influence and systems-wide improvements.

This articulation is timely as healthcare grapples with tensions between education and training, performance and inquiry, and standardization and adaptability – each shaping simulation design and delivery.

This essay seeks to address that gap by examining two terms that together offer a robust and inclusive framing for simulation in healthcare: Simulation-Based Education (SBE) and Transformative Simulation (TfS). These concepts are grounded in distinct theoretical foundations and together span the broad spectrum of simulation applications in contemporary healthcare. By exploring their distinctions and intersections, this essay aims to provide greater conceptual clarity for a more intentional, theoretically informed use of simulation.

To support conceptual clarity across the spectrum, we draw on a wide but purposefully selected range of theories and concepts. These are not exhaustive, reflecting specific orientations of SBE and TfS – whether towards structured educational aims, cultural and systems-level intentions or both. This theoretical breadth is a necessary feature of the evolution of simulation, reflecting its expanding scope and complexity.

SBE and TfS stem from different philosophical orientations and theories. SBE is guided by an instructional or facilitative lens, informed by theories or educational concepts that together guide the design of a learning event for the participant to achieve specific outcomes. It is learner-centred, offering structured experiences designed to build competence and confidence through targeted learning activities and assessment.

TfS operates through a cultural and systems change-oriented lens, drawing on theories of change, safety, engagement and collective insight. It pursues broader, purpose-driven intentions in healthcare improvement, innovation, intervention, involvement, identification, inclusion and influence. Rather than focusing on learner(s), TfS is discovery-centred – prioritizing curiosity, collaboration and shared understanding among participants to surface insights that can enable and drive meaningful transformation in healthcare [41,42]. Unlearning is often an outcome.

Some forms of SBE prioritize clearly structured knowledge and skill acquisition, emphasizing clarity, consistency and measurable performance outcomes, with realism and replicability acting as core markers of effectiveness [43]. It is frequently utilized as an educational method across the learning continuum, from students to experienced practitioners, particularly where clearly defined objectives and standardized conditions are essential for building competence or ensuring safe practice [44].

A growing trend in contemporary SBE interventions is to acknowledge the limitations of standardization alone and actively seek to foster adaptive, reflective and systems-aware practitioners [34]. These approaches draw on transformative and constructivist theories, using simulation not just to develop competence and confidence but also to encourage deep engagement with uncertainty, complexity and change.

Within today’s dynamic and fast-evolving healthcare environments, certainty is increasingly problematic and adaptability has become critical. While SBE aims to enhance patient outcomes by improving individual or team performance, there is limited empirical evidence that these improvements consistently translate into clinical practice [45,46]. Some scholars have also noted that reduced exposure to variability in standardized learning environments may limit learners’ development of adaptive behaviours [47,48], and hinder transfer of training to clinical settings – where unpredictability, emotional complexity and systemic dynamics are more pronounced [49].

TfS, by contrast, relies heavily on the collective knowledge, expertise and contributions of those embedded within the healthcare system – whether through professional roles, lived experience or stakeholder influence. As such, it is often perceived as less accessible or applicable to those with limited exposure to healthcare, such as students or full-time educators. However, this perception may be shifting in light of the growing expectations placed on students to understand and shape systems, not just function within them [50,51].

TfS is inherently designed to have a direct and immediate impact on practice – through inclusive design, systems thinking and collaborative change-making through shared mental models and reciprocal illumination [52]. However, whilst relatively new in recognition yet with growing evidence, like SBE, it lacks robust empirical evidence demonstrating its long-term effectiveness or widespread implementation outcomes. Both approaches share the challenge of demonstrating sustained transformation beyond the simulation setting.

The literature suggests that SBE and TfS are often employed concurrently in healthcare settings, though their integration is not always conceptually or practically well-defined. For example, Lutgendorf and colleagues [53] developed a multidisciplinary in situ simulation for postpartum haemorrhage with multiple intentions: assessing existing hospital protocols (improvement), evaluating team performance (inclusion), shaping operational readiness (influence) and identifying opportunities for systems improvement (identification). Although these appear to address systems-level targets rather than educational objectives, SBE principles were used to strengthen competencies in managing obstetric emergencies, while TfS elements supported exploration of team dynamics, staff engagement and protocol development. Reported outcomes included increased team confidence, quicker preparation of simulated blood products, and a downward trend in postpartum haemorrhage cases. However, the systems-level improvement goals were ultimately reported as secondary to educational outcomes. This reflects a misalignment between the simulation’s broader transformative intent and the way its impact was evaluated, likely due to the absence of a clearly articulated theoretical framework distinguishing SBE from TfS.

This pattern is echoed in broader analyses. McGaghie and colleagues’ [54] seminal paper evaluating the impact of simulation on translational patient outcomes, recognized simulation’s potential to catalyse clinical change but concluded that such translation rarely occurs effectively. This is largely attributed to the absence of rigorous translational science methodologies embedded within simulation design and evaluation. Therefore, systems-level insights often emerge as incidental byproducts of instructional simulation, rather than as intentional drivers of design.

Despite considerable advancement in the field since 2011, this observation continues to hold weight. A literature review of TfS [23] reported simulation initiatives supporting cultural and systems-level change frequently lacked clear theoretical underpinnings or demonstrated misalignment between stated intentions, design approaches and reported outcomes. These findings are echoed in two further publications. A scoping review of simulation for latent safety threat identification found that ‘inconsistent application of systems theory and variable methodological transparency limit learning and generalisability’ p. 1, calling for more explicit theoretical foundations and closer alignment of simulation purpose with educational and organizational goals [55]. Similarly, a study exploring synergies between human factors and translational simulation concluded that much of the potential in this space remains unrealized due to persistent gaps in theory-practice integration [56]. These patterns suggest that, despite individual exemplars, the field still struggles to consistently embed robust cultural and systems-oriented frameworks in simulation design. As such, McGaghie’s assertion continues to offer a useful provocation – one that reinforces the need for conceptually and methodologically grounded approaches.

Furthermore, while simulation-derived data can inform practice change, particularly when interpreted by experienced practitioners, its transformative potential remains underutilized. In the context of quality improvement (QI), Brazil and colleagues [57] stated that identifying which simulation activities are more ‘focused on QI and which are more educationally focused’ p. 86 may be beneficial. Clarifying a simulation’s core intent is essential to ensure that opportunities for deliberate cultural and systems-level learning, as well as the empowerment and amplification of diverse voices, are recognized, prioritized and meaningfully acted upon, rather than being reduced to incidental or anecdotal insights, completely missed or not followed through.

More recently, Torres and colleagues [58] offered a student-centred perspective of TfS. They critically reviewed and interpreted each of the TfS SBIs through the lens of incremental levels of transformation, as summarized in Figure 2.

A recent study in Australia explored how senior healthcare leaders in a large metropolitan facility viewed simulation as a tool for organizational change and how it aligned with leadership priorities [59]. While leaders valued simulation for diagnostic functions, particularly its use in the identification of latent risks through realistic system testing, they placed even greater emphasis on its relational and cultural change power: enabling involvement and inclusion, building resilience and helping develop shared mental models across teams. However, the authors also observed that when a simulation’s intention isn’t aligned with its design or delivery, its ability to influence clinical practice is weakened – reinforcing a core TfS principle: coherence between intention and design. Clipperton et al. [59], concluded that their findings aligned strongly with the SBIs of TfS. This further supports TfS as a cultural and systems-level framework that explicitly connects purpose, intentions, theory and design, delivery, data and debriefing to enable meaningful and coherent transformation.

These examples illustrate a recurring pattern: simulation is frequently described as serving both education and cultural and systems-level purposes, yet the alignment between stated intention, theoretical grounding, design logic and reported outcomes remains inconsistent. Without an explicit, coherent articulation of purpose, simulation risks being evaluated through partial lenses that obscure its broader transformative potential.

While SBE typically articulates predefined learning outcomes to evaluate success, cultural and systems-level insights are often reported as secondary or unintended outcomes. In such cases, the Return on Investment (RoI) is primarily framed through learner achievement, rather than broader organizational or cultural outcomes – limiting recognition of its RoI and impact. This suggests that simulation for change is often not designed with change as its central intent – even when that potential exists. Consequently, the mechanisms needed to translate insights into action, such as stakeholder follow-up, policy dialogue or systems feedback loops, are often absent or recognized only after the opportunity for timely influence has passed.

SBE is well-established and highly effective for developing clinical competence and confidence, particularly in controlled environments. Contemporary SBE often incorporates adaptive and reflective elements, supporting learners to respond to complexity. TfS, meanwhile, places adaptive capacity and collective insight at the centre of its design logic but faces its own challenges in implementation often due to a lack of broader recognition. However, a recent publication by Weldon and colleagues [42] illustrated the potential of TfS as a governance-ready framework across an entire healthcare organization in Scotland with encouraging cultural and systems-level impact.

Rather than privileging SBE over TfS or vice versa, the question becomes: can these approaches be brought together in purposeful and complementary ways? If so, when, how and to what effect?

In this essay, we have argued that bringing SBE and TfS into an intentional relationship – grounded in transformative pedagogy – offers a compelling way to align individual learning with the urgent demands of cultural and systems-level change. This integrated model reframes simulation as both a site of skill development and a catalyst for critical reflection, social accountability and structural change. We have used the metaphor of a train on a bridge, able to travel on tracks in either direction with carriages comprising – Person, Organization/Context, Socio-cultural considerations and Health.

As AI increasingly shapes healthcare education and systems design, the need for coherent, ethically grounded simulation frameworks becomes even more pressing. Purpose-driven approaches such as TfS help ensure that technological advances support human-centred, culturally aligned progress rather than reinforcing existing limitations. Realizing the full promise of blended SBE and TfS models will require rigorous empirical study and thoughtful integration into training programmes so that transformative aims complement, rather than compete with, competency-based requirements. By adopting flexible, adaptive and change-oriented approaches to simulation, educators and institutions can prepare practitioners not only to navigate complex systems but also to reshape them – advancing patient care, equity and healthcare system resilience for the future.