Insights from Transformative Simulation over time: from replication to collective inquiry

Over the past two to three decades, healthcare simulation evolved from a practice focused on replicating clinical procedures to approaches that supported collective inquiry, system redesign and cultural change in complex healthcare systems. While this shift had been widely acknowledged, less attention had been given to the design experiments through which simulation’s purposes and epistemology were reconfigured. Drawing on 25 years of collaborative work, this conceptual essay synthesised developments in hybrid, distributed and sequential simulation, alongside the concept of circles of focus, to examine how simulation moved beyond fidelity-driven replication towards intentional representation, emergence and reciprocal illumination. Relaxation of realism, productive use of imperfection and deliberate movement between task, interaction and cultural and systems-level concerns enabled insights and shared understanding that were inaccessible to conventional educational or evaluative methods. These insights informed the subsequent formalisation of Transformative Simulation, distinguishing simulation designed to educate from simulation designed to support practice and cultural and systems-level change through collective sensemaking.