In this blog we shine a spotlight on ‘Transformative Simulation’ and the role it can play in healthcare quality and safety. We are absolutely delighted to be joined by Professor Sharon Weldon (Professor of Healthcare Simulation and Workforce Development at the University of Greenwich and President of the Association for Simulated Practice in Healthcare, ASPiH) and Dr Julie Mardon (Clinical Director of Integration and Director of the Scottish Centre for Simulation and Clinical Human Factors, NHS Forth Valley, Scotland), who share their fascinating insights with us.

I think most healthcare professionals have experience of simulation in some form but may be less familiar with the concept of Transformative Simulation. What is Transformative Simulation and what makes it different to other forms of simulation?

Transformative Simulation (TfS) emerged from a growing recognition that many of the challenges facing healthcare systems today cannot be addressed through education, training, or technical improvement alone. While simulation has matured significantly over the past three decades, its use has largely remained tethered to educational paradigms or discrete improvement activities.

Transformative Simulation (TfS) builds on this foundation but reframes simulation as a method for collective understanding, insight, and learning. Rather than asking, “What do individuals need to learn?”, TfS begins with a different question: “What does the system, and the people within it, need to understand about itself in order to change?”

This shift matters because contemporary healthcare challenges – from workforce wellbeing and integration to safety culture and governance – are relational, emotional, and deeply contextual. TfS therefore integrates insights from multiple lenses including human factors, improvement science, social science and participatory practice into a coherent design and process framework. It positions simulation not as an adjunct to education, but as a strategic tool that can support collective sensemaking, surface hidden dynamics, and inform governance-level decision-making and organisational direction. Through shared enactment and reflection, simulation helps teams develop shared mental models and organisational insight – often through a process of reciprocal illumination.

It sounds like there are significant opportunities for Transformative Simulation in healthcare. Where do you think it has the most potential?

Many established simulated approaches continue to make important contributions to quality improvement and patient safety^1-5. TfS does not replace these approaches; rather, it situates them within a meta-framework that makes design intention explicit through a categorisation of purpose, helping teams align simulation activity with broader cultural and systems-level change^6-8.

TfS asks simulation designers to declare why simulation is being used before deciding how it is designed and delivered. The TfS framework articulates seven Simulation-Based Intentions (such as Identification, Inclusion, Influence, and Improvement), each aligned with distinct theoretical traditions and design logics, shaping different forms of cultural and systems-level impact.

This matters because simulation is never neutral. Every scenario selectively foregrounds certain behaviours, relationships, and system dynamics while obscuring others. TfS provides a shared language and design logic that helps teams choose the right “lens” for the kind of change they are seeking – whether that is revealing latent safety threats, influencing culture, engaging patients, or supporting leadership decision-making.

In doing so, TfS helps avoid a common pitfall: conflating learning outcomes with cultural or systems-level change, or assuming that educational success automatically translates into organisational impact.

Can you give an example of how you have used Transformative Simulation to facilitate systems transformation or improvements in patient safety?

NHS Forth Valley in Scotland offers a powerful example of TfS applied at cultural and systems-level. During a period of significant organisational challenge, including escalation within the NHS Scotland Support and Intervention Framework, the health board adopted simulation not as a training intervention but as a leadership and governance tool.

Senior leaders, clinicians, and staff participated together in carefully designed simulations that explored emotionally charged and systemically complex issues – such as interprofessional trust, decision-making under pressure, and the lived experience of staff and patients. These simulations were conducted in a range of environments, from clinical settings to ordinary rooms using basic equipment and props, demonstrating that meaningful simulation does not depend on a dedicated simulation facility. This flexibility also enables participation from groups who may not normally engage with simulation – such as organisational leaders, operational staff, patients, and members of the public.

This work was not episodic. A monthly “Simulation Safety Club,” informed by the organisation’s evolving risk profile, provided a structured forum for surfacing tensions alongside latent system issues and testing improvement ideas. In parallel, smaller targeted simulation projects were used to examine and refine specific pathways and service interfaces.

One such project focused on how small pieces of equipment were ordered in community care. The simulation was conducted in a home-style setting with a patient scenario at its centre, using everyday equipment such as raised toilet seats and mobility aids to recreate the practical realities of care at home.  Through mastery-based simulation of real-world scenarios, home care staff and allied health professionals examined how traditional referral pathways delayed independence and increased demand. By shifting decision-making to the point of care, teams collaboratively developed a shared, person-centred approach that empowered frontline staff to act directly.

The impact has been both human and measurable. People now receive timely support that enables them to remain independent – as one person reflected, “The girl ordered and fitted a raised toilet seat for me and the difference it has made is amazing. I manage myself now.” Sustained into its third year, the initiative saves the equivalent of 165 years of waiting time annually, demonstrating how simulation-enabled redesign of everyday decision-making can generate durable, cultural and systems-level benefit and directly support Scotland’s Shifting the Balance of Care policy⁹.

These simulations were not designed to test technical competence or rehearse protocols. Instead, they were structured to surface cultural assumptions, relational dynamics, and unintended consequences of existing ways of working. Over time, this approach supported cultural healing, strengthened integration across services, and informed governance-level conversations about safety, workforce wellbeing, and system renewal⁷.

What impact has Transformative Simulation had, and what further research is needed?

TfS enables forms of insight and learning that are often difficult to access through traditional improvement methods alone. By creating psychologically safe spaces for collective enactment and reflection, simulation can reveal how culture, power, and informal norms shape everyday practice – often more powerfully than data or policy alone.

This has been demonstrated across a range of applications, including approaches that support public and patient engagement in pathway redesign, experiences of care, diagnostic innovation, and service design and development^4-5,10-12, as well as collaborative healthcare remodelling initiatives that use staged enactment to surface relational and system-level barriers^1,11-15. In these contexts, shared immersion enabled co-construction of knowledge between clinicians, patients, operational staff, and leaders – generating insights that would not have emerged through conventional consultation or audit-based approaches.

When designed intentionally, TfS supports:

• earlier identification of systemic risks
• deeper engagement with lived experience
• more honest leadership conversations
• and more sustainable change grounded in shared understanding

Rather than producing predefined solutions, TfS helps organisations see themselves more clearly. This clarity is often what enables meaningful, locally owned transformation to follow.

To strengthen the evidence base further, ongoing collaborative research is needed to examine how specific design choices shape outcomes, and what may be distinctive about simulation compared to other improvement methods – including concepts such as reciprocal illumination¹⁶.

I am sure many of our readers are now thinking about how they could use Transformative Simulation in their organisations. What advice do you have for them?

The most important advice is not to start with scenarios or technology, but with values and purpose. Ask first: What kind of change are we trying to enable? and what does the system need to understand that it currently cannot see?

Simulation for cultural and systems-level change requires different design choices, different facilitation skills, and different expectations of outcome than simulation for education. It also requires leadership courage – particularly a willingness to participate, listen, and act on what emerges.

Finally, TfS works best when it is embedded over time, aligned with governance structures, systems-level priorities, and treated as part of the organisation’s learning infrastructure rather than a one-off intervention.

For organisations wondering where to begin, one practical entry point is the creation of a regular, risk-informed “simulation safety club” – a structured forum in which leaders and frontline teams can explore live system challenges through simulation and reflective dialogue. Such forums help normalise simulation as a governance tool rather than an educational event.

The team at NHS Forth Valley would be pleased to share their experience of developing this approach and welcome opportunities for dialogue and shared learning.

As healthcare systems continue to face complexity, uncertainty, and constraint, simulation has an opportunity to evolve. Transformative Simulation offers a way of using this powerful method not to train individuals, but to help systems learn, reflect, and change together.

Further resources, case examples, and opportunities to engage with Transformative Simulation are available through the Association for Simulated Practice in Healthcare (ASPiH): https://aspih.org.uk/

References

1. Weldon SM, Kneebone R, Bello F. (2016). Collaborative healthcare remodelling through sequential simulation: a patient and front-line staff perspective. BMJ Simul Technol Enhanc Learn. 2(3):78-86. doi: 10.1136/bmjstel-2016-000113
2. Nickson, C.P., Petrosoniak, A., Barwick, S. et al. Translational simulation: from description to action. Adv Simul 6, 6 (2021). https://doi.org/10.1186/s41077-021-00160-6 
3. Huddy JR, Weldon SM, Ralhan S, Painter T, Hanna GB, Kneebone R, Bello F. (2016). Sequential simulation (SqS) of clinical pathways: a tool for public and patient engagement in point-of-care diagnostics. BMJ Open. 6(9): e011043. doi: 10.1136/bmjopen-2016-011043.
4. Dubé, M., Hron, J.D., Biesbroek, S. et al. (2025). Human factors and systems simulation methods to optimize peri-operative EHR design and implementation. Adv Simul 10, 23. https://doi.org/10.1186/s41077-025-00349-z
5. Shultz J, Rickson M, McGarva J, Reynolds P, Risling E, Wiley K. (2026) Simulation-based mock-up evaluation to inform the design of a complex continuing care centre. Healthc Manage Forum. 39(1):40-44. doi: 10.1177/08404704251348375
6. Weldon, S., Buttery, A., Spearpoint, K., & Kneebone, R. (2023). Transformative forms of simulation in health care – the seven simulation-based ‘I’s: a concept taxonomy review of the literature: International Journal of Healthcare Simulation. from 10.54531/tzfd6375
7. Weldon SM, Mardon J, Tallentire V, et al. (2026). From escalation to emergence: NHS Forth Valley and the quiet power of Transformative Simulation. BMJ Leader. doi: 10.1136/leader-2025-001408
8. Weldon, S. (2026). Transformative simulation. Journal of Healthcare Simulation. from 10.54531/RGSR2310
9. Scottish Government. (2025). NHS Scotland operational improvement plan. Retrieved from: https://www.gov.scot/publications/nhs-scotland-operational-improvement-plan/pages/4/ ISBN 9781836914556
10. Korkiakangas, T., Weldon, S. M., & Kneebone, R. (2021). ‘Let me take care of you’: what can healthcare learn from a high-end restaurant to improve the patient experience? Journal of Communication in Healthcare, 14(3), 225–240. https://doi.org/10.1080/17538068.2021.1877602
11. Kronfli, M., Weldon, S. M., Kneebone, R., & Bello, F. (2017). Sequential simulation: a new approach to sharing challenges, opportunities and learning in maternity service delivery. BMJ Stel. 3 (Suppl 2) A13-A14; https://access.portico.org/stable?au=phzprkgcgpr
12. Geis GL, Pio B, Pendergrass T, Moyer M, Patterson M. (2011). Simulation to Assess the Safety of New Healthcare Teams and New Facilities. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare 6(3):p 125-133. DOI: 10.1097/SIH.0b013e31820dff30
13. Weldon SM, Korkiakangas T, Kneebone R. (2020). How simulation techniques and approaches can be used to compare, contrast and improve care: an immersive simulation of a three-Michelin star restaurant and a day surgery unit. BMJ Simul Technol Enhanc Learn. 6(2):65-66. doi: 10.1136/bmjstel-2018-000433
14. Imran A, Holden B, Weldon SM, Boak D, Klaber B, Kneebone R, Watson M, Bello F. (2020) ‘How to help your unwell child’: a sequential simulation project. BMJ Simul Technol Enhanc Learn. 6(2):127-128. doi: 10.1136/bmjstel-2018-000432
15. Weldon SM, Ralhan S, Paice L, Kneebone R, Bello F. (2016). Sequential simulation of a patient journey. Clin Teach. 14(2):90-94. doi: https://doi.org/10.1111/tct.12549
16. Kneebone R. (2015). When I say … reciprocal illumination. Med Educ. 49(9):861-2. doi: 10.1111/medu.12743.