Why is simulation important for improving healthcare quality, and how does it address challenges?

Learning is a process that might involve several tools and different learning situations. It is important to apply the appropriate tool to the right situation. Simulation can be a valuable tool when you want to apply skills, test protocols, implement new equipment, protocols, and/or infrastructure. It is important that healthcare workers can apply their skills in complex situations, where they need to interact with other people, also under stress.  The root cause of medical errors and adverse events are often related to communication issues or other human factors that traditionally haven’t been included in our healthcare education.

Research has found that teams that perform well when it comes to human factors and non-technical skills are likely to also perform well in a clinical emergency. Simulation has proven to be an efficient way of training such skills. Research from the Safer Births Bundle of Care program has shown that simulation is needed to bridge training and real-life clinical work and clinicians' behavior, especially in critical situations.

Our approach to simulation methodology includes reflection-based debriefing, where successes and challenges are addressed in a safe learning environment, and in a non-judgmental way.   

Can you tell us about the Safer Births Bundle of Care program and the role of SAFER? How did involvement evolve from the initial implementation of the program to the current model? 

The Safer Births Bundle of Care (SBBC) program aims to reduce maternal and newborn mortality in a low-resource context through bundling of training innovations, clinical innovations, continuous quality improvement, and sustainability. It has been a collaboration between 12 international partners and was implemented in 30 hospitals in five regions in Tanzania, and has now been scaled up to 142 hospitals in the same regions.

SAFER was invited as a partner, responsible for training facilitators and for building a sustainable capacity for healthcare simulation in the five regions. Then COVID hit us, and we needed to come up with a plan of how to fulfil SAFER’s commitment to the program, without the possibility to travel. We needed to simplify things, and from that the SimBegin program was born.

Can you describe the faculty development program designed for new simulation educators, SimBegin, and why it was developed?

SimBegin is the result of many years of experience with other more traditional facilitator courses. In some contexts, we found these programs to be too advanced. Especially for people with no previous exposure to simulation. We also wanted to use the opportunity to make an evidence-based program that could support a sustainable system for high-quality simulation training.Our need to deliver in the Safer Births Bundle of Care program also coincided with a COVID driven increase in requests or facilitator training from low- and mid-resource countries. We joined forces and got funding from Innovation Norway to develop this novel faculty development program.

SimBegin was developed in close collaboration with Laerdal Medical and Laerdal Global Health. SAFER’s involvement was very hands-on in the start, as we trained SimBegin faculty educators and SimBegin mentors during the first phase of SBBC. During the scale-up the local faculty trained 90 mentors and 285 facilitators, really proving the potential for the model to be sustainable. During this phase SAFER’s involvement has been related to quality assurance, faculty development, and research activities.

What is a blended learning approach? And what are the benefits?

A blended learning approach means that we utilize several learning modalities: E-learning, digital training sessions, and traditional face-to-face interactions. The program has proven highly adaptable/flexible and can be integrated into existing training programs or even be delivered fully digital to areas that are beyond reach for travel. We can choose the most efficient modality to the different steps of the learning process. For example, there is no need to spend time and resources on teaching in a classroom what can be learned through e-learning and individual studies. This approach also reduces the time clinicians must spend on facilitator training, away from clinical work. People learn at different paces, and our blended approach takes this into consideration as well.

What role does mentoring play in simulation-based training?

This is an interesting question, as our experience is that it is highly important for new facilitators to receive guidance in their pathway of developing their facilitator skills. It is kind of logical, yet there has been almost no research conducted on this specific topic.

Why is reflection such an important part of simulation-based learning?

I think the short answer is that people learn more from what they figure out themselves than from being told how to do something. Reflection is a way of figuring out why things went well or not.

Over the past decade, what have you learned about what makes simulation training most effective? Are there 3 key things that you consider essential for success?

1. Create a safe learning environment for the learners

2.  Facilitators must be well-trained to conduct reflection-based debriefing. This requires time and resources.

3.  There needs to be a system for frequent simulation training. A one-time simulation event will probably not change anything. Repetition is key!

What specific outcomes have been observed from SimBegin implementation?

We have documented frequent and regular simulation activity after SimBegin implementation. We’ve also seen a strong shift from blame-oriented to non-blame cultures and fostering of safe learning environments in clinical and educational contexts. Healthcare workers report increased self-efficacy. Simulation training is used to prepare new staff. The results from the Safer Births Bundle of care were published in New England Journal of Medicine earlier this year and demonstrated a 45% reduction in newborn- and a stunning 75% reduction of maternal deaths. 

Do you have a personal story about how you’ve seen simulation training directly impact healthcare workers' ability to save lives?

I think this quote from a Tanzanian midwife is one of my favorites:

“ . . . , it was very scary, when you had a fresh stillbirth, you rush to hide the
case note where the matron cannot see it, you think what I will say about it, what have
I done wrong, what will happen to me and so on. So, it was very difficult. But nowadays if you get fresh stillbirth, your colleagues call you with love, and say, please come let us sit down and discuss the areas for improvement. We discuss, identify gaps and make them our objectives for training further that we aim at not repeating the same mistakes tomorrow.”

Where has the program been implemented? And are there plans for further expansion?

SimBegin has reached over 25 countries globally, including Tanzania, Norway, China, Brazil, to mention a few. From 2021, we have trained over 2500 facilitators across low-, mid-, and high-income countries. Almost 1000 of these have been trained in the first half of 2025. The course materials are available in multiple languages, and we are aiming to translate into 12 languages. We are close to a potential of reaching one million simulation participants annually with the facilitator capacity in the first four years of SimBegin implementation.

What do you think makes a simulation program both scalable and sustainable over time?

I think a couple of factors are critical. First, most simulation centers lack the “muscle” required to scale big.  Collaboration between industry partners like Laerdal and simulation expertise like SAFER combines simulation competency with a potential of global reach. Second, to make a program sustainable you need to build local capacity, robust enough to handle turnover with strong incentives to keep the program alive. And third, you need to connect the local simulation community to a larger network, that could be regional, national, or international.