Into the light: the rise of shadowbox simulation to illuminate decision-making

Shadowbox simulation is an educational approach that utilises the ShadowBox method, originally developed in high-stakes fields such as firefighting and the military, adapted for healthcare education. Grounded in cognitive transformation theory and drawing heavily on naturalistic decision-making, shadowbox simulation makes expert reasoning visible and accessible, enabling learners to compare their decision-making with that of experts and develop complex cognitive and behavioural skills.

Early applications of shadowbox simulation in healthcare have demonstrated feasibility across diverse contexts. Building on these foundations, we describe the implementation of a hybrid shadowbox simulation format within Scotland's national Internal Medicine Training program. This model combines video vignettes of expert practice, structured decision-points, group discussion and procedural practice, all supported by expert facilitation. Evaluation across more than 40 sessions shows that learners value the safe learning environment, the opportunity to embrace uncertainty and explore multiple perspectives, and the balance of reflective discussion with procedural refreshers. Feedback indicates that the format may foster deeper engagement, greater knowledge retention, and broader participation compared with traditional immersive simulation, while requiring fewer resources. By synthesising evidence from outside healthcare, reviewing recent adaptations, and presenting the principles and outcomes of national implementation, this article positions shadowbox simulation as a theory-informed, resource-efficient, and scalable method that advances simulation practice.

We argue that shadowbox simulation offers particular promise for developing non-technical or behavioural skills, supporting reflective learning, and widening access to simulation-based education. Future potential applications extending to leadership, delegation, and induction training across healthcare professions are discussed.