Implementing simulation-based education at scale: A realist evaluation of an institution-wide strategy

Background Simulation-based education (SBE) is widely embedded in health professions education; however, institution-wide implementation and sustainability remain challenging, particularly in large, multi-campus universities. While pedagogical effectiveness is well established, less is known about how organizational strategies function in practice. This study aimed to explain how an institution-wide SBE strategy was implemented using a realist evaluation lens. Methods A realist evaluation–informed mixed-methods design was employed. Organizational readiness data (simulation culture and organizational readiness survey; SCORS), document analysis, ethnographic observations, and stakeholder discussions were synthesized using context–mechanism–outcome (CMO) logic. Results Organizational readiness demonstrated strong normative support for simulation but low structural readiness for coordinated delivery. Seven CMO configurations explained how centralization, governance, curriculum integration, faculty development, and sustainability planning generated outcomes through mechanisms including legitimacy, accountability, psychological safety, confidence in simulation practice, and future-oriented motivation. Conclusion Implementation outcomes were shaped by interactions between organizational context and staff reasoning rather than strategy alone. These findings provide transferable, theory-informed explanations to support sustainable SBE implementation in complex higher education settings.