Authentic roles matter: how in situ simulation influences fidelity, psychological safety, and learning transfer

In situ simulation (ISS) enables healthcare teams to test systems, identify safety threats, and strengthen interprofessional practice. Compared with off-site simulation (OSS), ISS may promote greater fidelity and transfer of learning. Cross-training, where participants adopt roles outside their profession, is widely used in healthcare education but remains controversial, with little evidence on how participants perceive its impact.

We conducted a qualitative study in a Danish teaching hospital intensive care unit, using ethnographic observations, field notes, and semi-structured interviews. Sixteen interviews with physicians and nurses, supported by audio recordings of debriefings, were thematically analysed using a phenomenological-hermeneutic approach with consensus coding.

Four themes were identified: fidelity, psychological safety, transfer, and cross-training. Participants described fidelity as multidimensional, including environmental, team, scenario, time, and resource aspects. ISS was perceived as more realistic and immersive than OSS, supporting deeper engagement and learning. PS was enhanced by familiarity with colleagues and environment, limited observation, and absence of cross-training. Facilitator competence at facilitating politely and creating room for all participants to speak up strongly influenced PS. ISS was viewed as promoting greater transfer of technical and social-cognitive skills to clinical practice, with some learning leading to organisational change. Cross-training was met with mixed reactions. Most participants, especially junior staff, preferred training in authentic roles, citing negative effects on PS and learning. More experienced clinicians occasionally valued cross-training for its reflective potential, though often only in less advanced roles.

In situ simulation promotes learning by aligning fidelity, psychological safety, and transfer within participants' authentic clinical roles and environments. Cross-training was frequently perceived as undermining both learning and psychological safety, particularly among less experienced staff, suggesting a misalignment between role substitution and learners' developmental needs. Careful scenario design emphasising authentic roles, realistic fidelity, and skilled facilitation may optimise simulation learning outcome, Cross-training should be applied selectively, with explicit attention to learners' experience levels, role authenticity, and potential impacts on psychological safety.