Abstract Background Simulation facilitation models have developed predominantly in Western educational settings. The ways in which cultural norms, particularly kreng-jai and deference to authority, shape nursing student participation in high power-distance contexts have received limited empirical attention. Objectives This study examined how stress, role positioning, and facilitator feedback timing and tone interact to shape participation and culturally safe learning in simulation-based nursing education in Thailand. Methods Semi-structured interviews were conducted in Thai with 24 third- and fourth-year nursing students in Eastern Thailand between August and October 2024. Interviews lasted 45–60 min and were analysed using reflexive thematic analysis. Results Four themes were developed. Entering a New Space positioned simulation as a threshold where visibility intersected with kreng-jai-patterned restraint; students’ reluctance to speak was culturally rational rather than disengagement. Stress as a Double-Edged Sword in Simulation showed that pressure could sharpen recall and prioritisation but could also narrow participation when abrupt feedback arrived mid-scenario. Learning Across Participation, Observation, and Debriefing identified distinct but complementary learning routes: active scenario participants acted under time pressure, whereas observers developed an analytic perspective, with both perspectives converging during debriefing. Facilitation and Cultural Safety found that calm guidance kept kreng-jai compatible with engagement, whereas abrupt correction rendered silence a response to relational risk. Conclusion Participation and psychological safety in simulation were not inherent features of instructional design but were interactionally and culturally mediated through facilitation, role positioning, and hierarchical norms.
Abstract Background Healthcare simulation training faces significant barriers due to the “clinician-developer gap,” where educators lack programming expertise to create customized digital simulators. Natural Language-Driven Development (NLDD) is an emerging paradigm that enables clinicians to develop educational technology through conversational artificial intelligence interfaces. Methods We implemented NLDD methodology to develop Open Vent Sim , a comprehensive mechanical ventilation simulator designed to replace anesthesia machines and ventilators in educational contexts lacking dedicated equipment. A multidisciplinary team comprising anesthesiologists, residents, a research nurse, IT, and biomedical engineers collaborated using Google AI Studio to iteratively create a web-based application through natural language prompts. Development proceeded through conversational cycles in which clinical requirements were translated into functional code via large language model assistance. Results Open Vent Sim was successfully developed in about 40 h over two weeks, featuring three simulation environments: anesthesia workstation, ICU ventilator, and high-flow oxygenation systems. The simulator incorporates physiological patient profiles (normal, ARDS, COPD) with dynamic compliance calculations and realistic waveform generation. Clinical validation was achieved through the integration of continuous resident feedback during iterative development. The application was successfully implemented in SimZone 1 as an interactive skill trainer and in SimZone 2 for team-based clinical scenarios during formal anesthesia and critical care education. Significant technical adaptation was required to transform the AI-generated prototype into a production-ready application. Conclusions NLDD demonstrates the potential to democratize the creation of educational technology by empowering clinical domain experts to develop sophisticated simulation tools without traditional programming expertise. This approach addresses resource limitations while maintaining clinical authenticity, though professional technical oversight remains essential for production-ready implementations.
Simulation-based education is widely recognised as a key strategy in health professions training, yet the quality and sustainability of simulation initiatives depend heavily on the preparation of faculty responsible for facilitation, scenario design, and debriefing. While international standards provide guidance for simulation practice, implementing faculty development programs can be challenging in institutions characterised by limited resources, high teaching workloads, and heterogeneous faculty experience. Detailed accounts of how such programs are designed, implemented, and sustained within real institutional constraints remain limited. This paper describes the design, implementation, and reflective analysis of a hybrid faculty development architecture for simulation facilitators developed within a Brazilian higher education institution. The program was informed by experiential learning theory, adult learning principles, and implementation science perspectives, and was developed following an institutional needs assessment. The architecture combined asynchronous preparatory learning, synchronous online discussions, and experiential in-person workshops focused on scenario design and debriefing practice. A six-month responsive longitudinal support component was incorporated to facilitate transfer of learning into authentic teaching contexts. Communication and reinforcement mechanisms were integrated into institutional digital platforms already used by faculty in order to minimise participation barriers. Implementation indicators demonstrated feasibility and high participant acceptability within the institutional context. Implementation revealed both strengths and tensions. The structured experiential phase proved operationally stable and aligned with faculty learning needs. However, utilisation of the optional mentorship component remained limited, highlighting the challenges of sustaining engagement in contexts characterised by competing professional demands. Descriptive readiness profiles suggested developmental progression among participants, although the architecture was not designed as a formal competency assessment framework. Reflective analysis of the implementation process allowed the identification of design principles related to feasibility, contextual adaptation, reinforcement strategies, and institutional integration. This practice-based account illustrates how simulation faculty development initiatives can balance pedagogical rigour with contextual feasibility. Rather than proposing a new competency framework, the architecture offers an implementation-oriented approach for supporting faculty development in resource-constrained educational environments. The experience suggests that foundational experiential training, flexible reinforcement strategies, and integration within existing institutional ecosystems may offer transferable insights for institutions seeking to expand simulation capacity under similar structural constraints. The study was registered in the Brazilian Registry of Clinical Trials (ReBEC), number RBR-4dqtygd.
The simulation community has invested heavily in educational rigour (validated debriefing methods, high-fidelity technology, faculty development), yet evidence linking simulation to sustained clinical improvement remains limited. We propose this gap exists not because simulation is ineffective, but because it is poorly positioned within organisational systems. Drawing on a decade of programmatic experience at a non-academic hospital, including multiple initiatives that did not produce sustained outcomes and subsequent methodological pivots, we argue that simulation achieves sustainable impact only when embedded within quality improvement infrastructure. Using the Donabedian model as a conceptual framework, we demonstrate that process-focused interventions (education, training) without corresponding structural supports (equipment, systems, protocols) produce transient change at best. Integrated approaches, where simulation serves as a quality improvement tool to identify system threats and monitor interventions through Plan-Do-Study-Act cycles and the SAFER-Matrix, produce measurable, sustained improvements. Evidence from in situ programmes across emergency departments and cardiac catheterisation laboratories, multi-site collaboratives, and AI-powered telehealth simulation demonstrates that this integrated approach succeeds where education alone falls short. We have formalised these principles in the Simulation-Quality Integration (SIM-QI) Framework, currently submitted for independent peer review, which provides a practical blueprint for embedding simulation within QI infrastructure. We present actionable implications for simulation educators, institutions, and researchers seeking to bridge the gap between educational excellence and clinical translation.
