Author: Dr. Michael Weldi, MSc MBA, Managing Director, Med-STA GmbH
A patient becomes agitated and breathless during a CT scan. Oxygen saturation falls and cyanosis develops. The CT team calls for help and the medical emergency team is alerted. Shortly before it arrives, the patient loses consciousness. Resuscitation must begin among the CT table, console, narrow routes and uncertain equipment access, with a team suddenly working outside its routine.
The clinical scenario is familiar, but organisationally more complex than it appears in a classroom.
This illustrates simulation’s educational and safety roles. A simulation centre can train knowledge, skills and communication very effectively. In-situ simulation adds the actual team, equipment, routes and disruptions of the environment where critical situations occur.[1]
For hospital leaders, medical and nursing directors, quality teams and patient safety leads, the practical question is where simulation can contribute most to everyday care.
What in-situ simulation means
In-situ simulation takes place in the actual working environment: a ward, resuscitation room, operating theatre, outpatient clinic, delivery suite, intensive care unit or Medical practice.[1]
The change involves more than location. Simulation reveals the real care system and its interacting elements.
Who leads? Where is equipment kept? Do role allocation and handovers work under time pressure? Does every profession know the alerting pathways? Which interfaces become fragile during an emergency?
A simulation centre recreates a clinical setting and can address these questions only to a limited extent. In-situ simulation tests the actual setting.[2]
Why simulation centres remain important
Simulation centres remain well suited to standardised education, repeated technical practice, protected first exposure and work with complex simulators. These objectives can often be achieved more easily, or more effectively, in a centre.[2]
For beginners, invasive procedures or highly standardised course formats such as structured emergency response training a simulation centre may be educationally appropriate and organisationally more efficient.
Neither setting is universally better.
Choose according to the objective. A centre may suit knowledge acquisition and individual skills. In-situ simulation offers particular advantages when the aim is to improve existing teams and real processes.[2]
The actual system becomes part of the training
Critical events often involve several interacting factors: unclear responsibilities, communication breakdowns, missing equipment, restricted space, concurrent tasks and unspoken assumptions.[3]
These factors may remain hidden when training takes place outside the system. In-situ simulation makes them visible.
A team may discover that not everyone can locate the defibrillator; some professions are unfamiliar with internal alerting; a medicine is available but dosing support is missing; a ward–intensive care handover point is undefined; or a new layout creates emergency bottlenecks.
These findings provide information about the system.
In-situ simulation tests the interaction of people, environment, equipment, processes and organisation alongside individual learning.[3]
Identifying latent safety threats before harm occurs
The literature calls these hidden system weaknesses “latent safety threats”: problems that may remain unnoticed in routine work but emerge under pressure.[3]
Examples include missing or misplaced equipment, unclear responsibilities, inconsistent alerting pathways, technical barriers and ambiguous handovers.
In-situ simulation can reveal such risks before they affect real patients.[3]
This is particularly valuable during refurbishment, new service development, process changes and team formation. A workflow that sounds logical in a meeting needs testing under time pressure, across professions and in the actual space.[7]
For leaders, in-situ simulation is therefore also a tool for assessing the clinical organisation.[7]
What the evidence shows, and its limits
Research generally indicates benefits, particularly when in-situ simulation forms part of structured training and quality programmes. Reviews describe positive effects on clinical workflows, team performance and identification of latent safety threats.[4]
However, universal superiority would be an unjustified claim. Direct comparisons sometimes show similar knowledge and observed team-performance outcomes. A randomised obstetric anaesthesia study found similar individual and team outcomes with in-situ and off-site training. Participants rated in-situ training as more authentic, and qualitative findings suggest potentially greater organisational learning in the actual environment.[5][6]
Its particular strength is therefore not necessarily a better knowledge-test score. It lies in practice transfer, identifying system weaknesses and training existing teams under realistic conditions.[2]
Teamwork develops within its working context
Resuscitation, trauma care, obstetric emergencies, airway problems, critical transfers and perioperative complications all require teamwork.
Teams need to develop a shared picture, clarify roles, prioritise, voice information clearly, escalate in time and apply standards, alongside individual clinical competence.[8]
These are non-technical skills: communication, leadership, situational awareness, decision-making and coordination.
Simulation-based team training in situ has the advantage of involving the actual team in its actual context, closer to clinical care than an unfamiliar group at an external course.[2]
Established teams can benefit too. Alongside strengths, they develop blind spots and unspoken assumptions that may become problematic with new colleagues, infrequent events or unfamiliar disruptions.
Simulation alone does not resolve problems
In-situ simulation does not succeed automatically.
Poor preparation can unsettle teams, disrupt care or yield superficial findings. Effective sessions need clear learning and system objectives, good prebriefing, psychological safety, stop rules, structured debriefing and a clear distinction between learning and assessment.[9]
Follow-up matters just as much. When a threat is identified, someone needs to record, assess, prioritise and address it. Otherwise, teams may become frustrated as problems remain unchanged.[10]
The literature identifies this limitation: simulation can reveal latent safety threats, but their resolution depends on governance, leadership and resources.[10]
Simulation takes place in the room; improvement takes place across the organisation.
When in-situ simulation is particularly useful
It is especially useful when the working environment substantially influences care quality.[2] Examples include resuscitation rooms and emergency departments, operating theatre and anaesthesia teams, intensive care, obstetric emergencies, paediatric and neonatal acute care, ECMO and other high-risk care, outpatient clinics, day units, medical practices and primary care units.
Our article provides an example of preparing a primary care unit for a safer launch: Launching a primary care centre safely: lessons from the Austrian Patient Safety Award 2025.
In-situ simulation can also test resilience at professional or departmental interfaces, in new spaces and care models, or after major restructuring.
Our ECMO article explains why training needs to extend beyond technical skills: ECMO training: why technical skills alone are not enough.
What hospitals should clarify before implementation
A strategic approach begins with clear questions: which clinical risks need attention? Is the objective training, systems testing or both? Which professions need to participate? Which leaders need to be involved to ensure action? How will findings be documented, actions decided and changes reassessed?
These organisational arrangements enable simulation to contribute to an ongoing safety and improvement process, beyond a single training day.[7]
Resources and benefits
A common concern is that in-situ simulation is harder to organise because it interacts with routine operations.
That can be true. It requires coordination, realistic scenarios, experienced facilitators and a clear safety plan. It also avoids travel to an external venue, includes actual interfaces directly and identifies problems relevant to the team’s own workplace.[1]
It may be less convenient, but often brings teams closer to the problem they need to address.
Our article examines training frequency and an evidence-informed model: How often should an emergency team train?.
Conclusion
In-situ simulation reduces the distance between training and clinical care.[2]
It shows how teams function under realistic conditions, whether equipment, spaces, alerting, roles and communication fit together, and which weaknesses remain hidden in classroom training.[3]
Simulation centres remain important for standardised education, technical skills and protected learning. When the objective is improving actual workflows and specific local safety risks, in-situ simulation often offers a more direct approach.[2]
The choice should follow the problem being addressed and the setting that best supports that objective.
How this relates to Med-STA
Med-STA delivers simulation in the working environments of hospitals, medical practices, primary care units and ambulance services. The emphasis is on actual workflows, teamwork, human factors, debriefing and feasible improvements.
Depending on the objective, in-situ simulation can provide training, systems assessment or a starting point for Process development . Combined with debriefing, SimLean360° or consultancy can turn training into a practical improvement process. Our Lean article explores this connection: Lean in hospitals: why simulation is the missing component.
Our medical practice article provides a practical example: Emergencies in medical practices: why preparation matters more than routine.
References
- Sørensen JL, Østergaard D, LeBlanc V, et al. Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation. BMC Medical Education. 2017;17:20. doi:10.1186/s12909-016-0838-3
- Calhoun AW, Cook DA, Genova G, et al. Educational and Patient Care Impacts of In Situ Simulation in Healthcare: A Systematic Review. Simulation in Healthcare. 2024;19(1S):S23–S31. doi:10.1097/SIH.0000000000000773
- Fent G, Blythe J, Farooq O, Purva M. In situ simulation as a tool for patient safety: a systematic review identifying how it is used and its effectiveness. BMJ Simulation & Technology Enhanced Learning. 2015;1(3):103–110. doi:10.1136/bmjstel-2015-000065
- Goldshtein D, Krensky C, Doshi S, Perelman VS. In situ simulation and its effects on patient outcomes: a systematic review. BMJ Simulation & Technology Enhanced Learning. 2020;6:3–9. doi:10.1136/bmjstel-2018-000387
- Sørensen JL, van der Vleuten C, Rosthøj S, et al. Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial. BMJ Open. 2015;5:e008344. doi:10.1136/bmjopen-2015-008344
- Sørensen JL, Navne LE, Martin HM, et al. Clarifying the learning experiences of healthcare professionals with in situ and off-site simulation-based medical education: a qualitative study. BMJ Open. 2015;5:e008345. doi:10.1136/bmjopen-2015-008345
- Diaz-Navarro C, Armstrong R, Charnetski M, et al. Global consensus statement on simulation-based practice in healthcare. Advances in Simulation. 2024;9:19. doi:10.1186/s41077-024-00288-1
- Martin A, Cross S, Attoe C. The Use of in situ Simulation in Healthcare Education: Current Perspectives. Advances in Medical Education and Practice. 2020;11:893–903. doi:10.2147/AMEP.S188258
- INACSL Standards Committee. Healthcare Simulation Standards of Best Practice. International Nursing Association for Clinical Simulation and Learning. inacsl.org
- Lounsbury O, Tomlinson A, Wakeling J, Bowie P, Higham H. The use of healthcare simulation to identify and address latent safety threats: a scoping review. Frontiers in Health Services. 2025;5:1682629. doi:10.3389/frhs.2025.1682629