Latvia’s National Strategy for Simulation-Based Healthcare Education

Abstract

This policy insight outlines Latvia’s national strategy for integrating simulation-based education into all levels of medical and healthcare education by 2027. It is framed as a direct response to the 2024 Global Consensus Statement on Simulation-Based Practice in Healthcare, operationalizing its recomme ndations within a national policy context for Latvia. Grounded in international and national standards—including WHO guidance, EU directives, and principles of healthcare safety and education quality—the strategy promotes simulation as a transitional and indispensable phase between theoretical instruction and clinical practice. The strategy emphasises structured collaboration among universities, professional associations, healthcare providers, and government bodies. It sets out a governance and resource model for simulation-based learning environments, ensuring quality, sustainability, and alignment with ethical and professional standards. By embedding simulation-based education into undergraduate, postgraduate, and continuing medical education, Latvia aims to enhance healthcare professionals’ clinical competence, reduce preventable medical errors, and improve patient outcomes. The approach supports deliberate practice, facilitates safe and realistic training conditions, and strengthens the preparedness of healthcare workers for both routine and complex clinical scenarios. The strategy also calls for standardised quality-assurance mechanisms, accreditation procedures, and integration into national regulatory frameworks. This national roadmap aims to establish Latvia as a regional leader in simulation-based healthcare education, improving not only the safety and efficiency of healthcare services but also public trust and professional development. As such, the strategy serves both as a practical implementation plan and a model for countries pursuing similar goals.

1. Introduction

Ensuring high-quality and safe healthcare requires a well-educated, competent, and confident workforce. In response to global challenges and the growing demand for effective healthcare services, Latvia has prioritised the integration of simulation-based education into medical and healthcare training. Simulation offers a structured, safe, and ethically sound learning environment where students and professionals can develop, refine, and assess both technical and non-technical skills without putting patients at risk. This approach aligns with international strategies and policy frameworks—including the WHO Global Strategy on Human Resources for Health and EU directives on patient safety and professional qualifications—highlighting the essential role of education in strengthening health systems and improving patient outcomes.

Following the cooperation memorandum signed on 7 December 2023 by the Ministry of Health of the Republic of Latvia, Rīga Stradiņš University, University of Latvia, the Latvian Medical Association, the Latvian Junior Doctors Association, the Latvian Nurses Association, the Latvian Union of Professional Organisations of Medical Practitioners, and the Emergency Medical Service—titled “National Strategy for the Development of Simulation-Based Education in Medical and Healthcare Education”—the document “Strategy for the Development of Simulation-Based Education in Medical and Healthcare Education in Latvia” (hereinafter referred to as the Strategy) has been developed.

The development of this Strategy acknowledges the importance of integrating a simulation-based approach into medical and healthcare education, as well as reflects the commitment of the Strategy’s development partners to collaborate and involve a broader range of stakeholders. This effort aims to enhance the quality of education for current and future professionals in the medical and healthcare fields, as well as to improve the quality of healthcare services, encompassing aspects of safety for both patients and healthcare providers.

Simulation-based education in medicine and healthcare represents a modern pedagogical approach that prepares learners for clinical practice by immersing them in environments that closely replicate real-world physical settings and by employing scenarios that mirror actual clinical situations. This approach is founded on methodology, environments, and technologies tailored to the specifics of medicine and healthcare. Together, they enable the acquisition, development, and enhancement of knowledge and skills, strengthening professional competence, and developing the ability and readiness to act in real work environments without subjecting patients to risks or harm and significantly minimising the possibility of errors in the provision of healthcare services.

These Strategy should be noted that the feasibility and sustainability of implementing this Strategy depend on factors such as political will, allocated resources, and the willingness of experts and enthusiasts to embrace the challenge and take responsibility for turning this Strategy into reality.

When deciding on the integration of a simulation-based educational approach into medical and healthcare education programmes at all levels, it is crucial to establish a comprehensive, structured, and coordinated governance framework for this field. The integration of simulation-based approaches into all levels of medical and healthcare education aims to provide learners—whether in undergraduate studies, residency, or continuing professional development—with the opportunity to acquire new skills or enhance existing ones, clinical decision-making algorithms, and practical actions in clinical situations, all within a safe, controlled, and realistic environment. The primary objective of such a framework is to implement this Strategy while ensuring the sustainable management and long-term development of the simulation-based medical and healthcare sector, in response to the evolving conditions of work and life.

1.1. Quality Education—The Foundation of Quality Healthcare

Quality of care is one of the most frequently quoted principles of health policy, and it is currently high up on the agenda of policy-makers at national, European and international levels (Busse et al., 2019b). Furthermore, this issue will remain relevant in the future, as evidenced by one of the United Nations Sustainable Development Goals—Good Health and Well-Being, which aims to ensure access to high-quality essential healthcare services (The Global Goals, n.d.; United Nations, n.d.).

Delivering quality health services requires competent—that is, well-educated, trained and skilled—healthcare professionals and the cornerstone of building competence for healthcare professionals is education and training (Kreutzberg et al., 2019).

When developing and implementing educational programmes tailored to the specifics of the medical and healthcare fields, it is essential to ensure that their content is evidence-based, up-to-date, and aligned with contemporary practice standards. Moreover, these programmes must adhere to one of the most important principles of medical ethics within the concept of healthcare safety—First, do no harm!

However, according to recent studies, almost one billion people are adversely affected by a lack of access to effectively trained health workers, resulting in illness or death (WHO, n.d.-c).

1.2. Statistical Data Indicates

• Each year, approximately 3.2 million patients in the EU experience adverse events while receiving medical care. It is estimated that 20% to 30% of these cases are preventable (European Union, n.d.).
• Each year, 8% to 12% of hospitalised patients suffer complications related to the care they receive in European Union (EU) hospitals (European Union, 2020).
• Both the World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD) highlight the following in their reports:

  ○

  Globally, unsafe healthcare results in more than 3 million deaths annually.

  ○

  Around 1 in 10 patients are harmed in healthcare.

  ○

  In OECD countries, approximately 15% of inpatient expenditure is consumed by treating the effects of hospital-acquired harm (OECD, 2022; World Health Organization, 2023).

• In Latvia, over €1 million is paid annually from the Medical Risk Fund for harm caused to patients (LIKUMI.LV, n.d.-c).

1.3. General Aspects Justifying the Need for Integration of Simulation-Based Approach in Medical and Healthcare Education

• Quality is the optimal balance between implemented opportunities and the system of norms and values. It arises from the interaction between participants who agree on standards (norms and values) and components (opportunities) (Mitchell, 2008).
• The norms and values of the 21st century in the context of healthcare are reflected in the aspects outlined by the WHO’s concept of “healthcare quality”—safe, effective, people-centred, timely, efficient, equitable and integrated (World Health Organization, 2018).
• Notably, patient safety has long been seen as an entry point for efforts to improve quality of care, and safe care can be seen as a barometer of the success of basic systems to improve quality (World Health Organization, 2018).
• Safety is the foundation upon which all other aspects of quality care are built (Mitchell, 2008). All aspects characterising healthcare quality influence or can influence patient safety, which justifies the belief that patient safety is the starting point for efforts to improve care quality.
• Patient safety is a framework of organised activities that creates cultures, processes, procedures, behaviours, technologies and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce impact of harm when it does occur (World Health Organization, 2021).
• Health systems can only function with health workers (WHO, n.d.-b), and the quality of healthcare services is directly linked to the performance of healthcare professionals, which largely depends on their competence (knowledge, skills, and attitudes). The cornerstone of competence development is education (Busse et al., 2019a).
• To ensure the production of skilled and confident future doctors, students, and residents must be given ample opportunities to practice and refine their abilities before engaging with real patients (Agrawal et al., 2023). Simulation is increasingly being used in healthcare education to teach cognitive, psychomotor, and affective skills to individuals and teams (Motola et al., 2013).

1.4. Breadth of Simulation-Based Medical Education and Justifying Aspects of Simulation-Based Educational Approaches in Medical and Healthcare Education

With the evolution of the healthcare safety concept, which encompasses both patients’ rights to quality and safe care (WHO, n.d.-d) and healthcare professionals’ rights to a safe working environment (WHO, n.d.-a), the approach to teaching and learning for medical and healthcare professionals has also undergone a transformation. As a result of this transformation, the modern process of medical and healthcare education is now inconceivable without the integration of a simulation-based educational approach.

• By applying an appropriate methodology in the implementation of simulation-based medical and healthcare education, and integrating simulation-specific technologies and solutions in a suitable environment, it is possible to acquire new skills, enhance previously learned ones, and practise rarely used technical and non-technical skills, ultimately improving patient safety and clinical outcomes (Elendu et al., 2024).
• The integration of simulations into medical and healthcare education programmes enables preparation for both common daily practice scenarios and rare, complex clinical situations, encountered in daily practice (Elendu et al., 2024).
• One of the most significant advantages is the opportunity for deliberate practice, where learners can repeatedly perform tasks and refine their skills without risk to patients (Motola et al., 2013). This repetition is crucial for developing proficiency and ensuring that skills are retained over time (Barry Issenberg et al., 2005).

Key benefits of integrating simulation into medical and healthcare education:

• No risk to patients.
• Many scenarios can be presented, including uncommon but critical situations in which a rapid response is needed.
• Participants can see the results of their decisions and actions; errors can be allowed to occur and reach their conclusion (in real life a more capable clinician would have to intervene).
• Identical scenarios can be presented to different clinicians or teams.
• The underlying causes of the situation are known.
• With mannequin-based simulators clinicians can use actual equipment, exposing limitations in the human–machine interface.
• Full recreations of actual clinical environments allow to explore complete interpersonal interactions with other clinical staff and provide training on teamwork, leadership and communication.
• Intensive and intrusive recording of the simulation session is feasible, including audio taping and videotaping, there are no issues of patient confidentiality–the recordings can be preserved for research, performance assessment or accreditation.
• Offers opportunities to work with equipment and tools used in real clinical settings within simulation scenarios, identifying and evaluating limitations in human-technology interaction (World Health Organization & WHO Patient Safety, 2011).
• Simulation provides a safe environment for learners to make and learn from mistakes, essential for effective learning (Elendu et al., 2024).
• Fosters clinical reasoning, decision-making, and critical thinking skills while enhancing communication, leadership, and teamwork abilities. It also provides opportunities to test administrative problem-solving skills (Saleem & Khan, 2023).
• Supports adaptation to evolving demands in the healthcare system (Diaz-Navarro et al., 2024a).

Simulation can also serve as a method for studying aspects such as the interaction between human factors and the work environment (both narrowly and systemically), which influence or may influence the quality and safety of patient care. By using simulations as a research method, existing or new processes can be investigated, the simplicity of checklist usage can be evaluated, and preparation for the use of new equipment or devices can be facilitated (Diaz-Navarro et al., 2024b).

Numerous studies have demonstrated that Simulation improves clinical skills, enhances patient safety, and leads to better clinical outcomes compared to traditional training methods. For example, a meta-analysis of simulation-based education in medical schools found that students trained in Simulation performed significantly better in technical and non-technical skills assessments than those who received traditional training (World Health Organization, 2013).

1.5. Challenges to Implementing Simulation-Based Educational Approaches

Despite its many advantages, SBE faces several challenges. One of the primary barriers is the high cost associated with purchasing and maintaining simulation equipment and the need for specialised facilities and trained personnel. This can be a significant financial burden for educational institutions, particularly those in resource-limited settings. Furthermore, while advanced, the realism of simulations still cannot fully replicate the complexities and unpredictability of real-life clinical situations. This raises concerns about transferring skills acquired through Simulation to actual patient care. Another challenge is the need for faculty training and development. Effective SBE requires instructors to be proficient in the technical aspects of Simulation and skilled in facilitating debriefing and providing constructive feedback. This necessitates ongoing professional development and support for educators, which can be resource-intensive. Despite these challenges, the evidence supporting the effectiveness of SBE is compelling (Elendu et al., 2024).

2. Methods

2.1. Conceptual Framework for the Development Strategy of Simulation-Based Medical and Healthcare Education

2.1.1. Vision

Modern education for current and future medical and healthcare professionals—for quality and safe healthcare.

2.1.2. Mission

Develop a simulation-based education approach and integrate it into medical and healthcare education at the levels of undergraduate studies, residency training, and professional development (hereinafter—“all levels of education”), covering all stages of healthcare (pre-hospital care, primary healthcare, secondary healthcare, tertiary healthcare) to enhance the quality of healthcare and ensure the safety of patients and healthcare professionals.

2.1.3. Values

• Safety at various levels:

  1.1.

  Safety aspects in healthcare in the broadest sense.

  1.2.

  Safety of healthcare professionals and patients.

  1.3.

  Physical and psychological safety of simulation participants and simulation professionals.

• Simulation activities as a sustainable resource in the educational process (ensuring compliance with specific requirements regarding content, design, and implementation, as well as effective resource utilisation, considering the ecological impact across all aspects of simulation practices, while supporting the growth and development of the field.
• Promoting excellence is rooted in the improvement and advancement of all aspects of simulation practice.
• Mutual respect is a key factor in fostering and maintaining positive collaboration, which is fundamental to the success of any simulation-based education activity.
• Collaboration is driven by a shared commitment to achieving a common goal: providing the best possible experience for learners while upholding the highest standards of practice.

2.1.4. Overarching Goal

To establish a development and management model for simulation-based medical and healthcare education, strengthening the competence, skills, and readiness of current and future professionals in the medical and healthcare sectors.

A detailed map of the strategic objectives and a comprehensive outline of the strategy’s scope are provided in Figure 1 and

Table 1. Scope of the strategy.

Stakeholders Involved in the Implementation of the Strategy						Benefits of Implementing the Strategy
Ministry of Health						Enhanced safety for patients and healthcare professionals. Improved quality of medical and healthcare education and healthcare services. Needs-based management of healthcare human capital (knowledge and skills). Coordinated management of the quality, processes, and required resources for the simulation-based education phase—practice in simulation-based learning environments *
Implementers of medical and healthcare education at all levels						Needs-based content for simulation-based learning environments (skills, algorithms, clinical scenarios) ** has been identified and aligned with the specifics of each educational programme and level of education. Implementation of simulation-based learning environments is promoted in accordance with unified quality standards. Necessary resources for implementing practice in simulation-based learning environments (infrastructure, technology, and human resources, with priority given to certified instructors) are ensured. Ability to share information is provided, including: ○ catalogue of content implemented in simulation-based learning environments (skills, algorithms, and clinical scenarios), ○ relevant methodological materials (descriptions, simulation scenarios, checklists, assessment criteria, video materials, etc.), ○ quality policies, ○ Information on accredited simulation structures, simulation instructors, simulated patients, etc. Targeted clinical practice is promoted, ensuring the required level of preparedness for practising in clinical environments.
Undergraduate studies		Residency		Professional development
Lecturers. Healthcare Professionals Qualified to Provide Training Instructors.
Sectoral Educational Institutions Healthcare Institutions (as part of clinical placement)		Sectoral Educational Institutions University Hospitals Regional Hospitals specialised Healthcare Institutions		Sectoral Educational Institutions University Hospitals Regional Hospitals Specialised Healthcare Institutions Emergency Medical Service Sectoral Professional Associations
Recipients of medical and healthcare education at all levels						Improved accessibility for implementing simulation-based practice in medical and healthcare education programmes at all levels. Facilitated acquisition, development, and objective structured assessment of skills, algorithms, and clinical scenarios in safe, realistic, and controlled conditions—in accordance with the skills levelling model *** Enhanced professional capacity and quality of healthcare and support staff (including both technical and non-technical skills such as critical thinking, communication, leadership, and teamwork). Strengthened readiness and ability to perform in real work environments, encompassing both common clinical scenarios and rare, complex, and interdisciplinary situations.
Students		Residents		Healthcare professionals Healthcare support persons (with priority given to perfusionists and emergency medical vehicle operators)
Healthcare service providers						Better-prepared healthcare professionals for work in clinical environments. Opportunity to influence the content implemented in simulation-based learning environments, based on data from patient safety incidents, patient feedback and experiences, and clinical case studies.
Healthcare institutions Healthcare professionals and healthcare support persons
Pre-hospital phase	Primary healthcare		Secondary healthcare		Tertiary healthcare
Recipients of healthcare services—patients and their relatives						High-quality and safe healthcare services. Fewer adverse events, medical errors, and reduced risk of unnecessary harm. Fewer complications, improved treatment outcomes, and faster improvement in quality of life. Increased trust and confidence in the healthcare process.
Society
The integration of simulation-based education into medical and healthcare education is an investment in the availability of high-quality and safe healthcare services.
Comments: * The Cabinet of Ministers Regulation of Latvian Republic No.617 “Regulations on the Competence of Medical Practitioners and Students Studying Medical Education Programmes in Medical Practice and the Scope of Theoretical and Practical Knowledge of Medical Practitioners and Students Studying Medical Education Programmes” stipulates that: A simulation-based learning environment is a physical space (surroundings or conditions) replicating aspects and elements of a real-world setting. It facilitates controlled simulation-based educational activities, ensuring participants’ physical, emotional, and psychological safety to support learning, assessment, or testing LIKUMI.LV (n.d.-b). ** Technical skills—skills that are required for the accomplishment of a specific task (Lioce, 2020). Non-technical skills—the cognitive (decision-making, situation awareness) and interpersonal (communication, teamwork, leadership) skills that underpin technical proficiency, and are considered particularly important for preventing errors. Non-technical skills include communication, leadership and followership, decision-making, situation awareness, and task management (Lioce, 2020). Clinical algorithm—A standardised description of sequential actions, where each subsequent action depends on the outcome of the previous one, serving to address a healthcare problem (SPKC, n.d.). Clinical scenarios—A medical condition or context in which patient assessment, diagnosis, and treatment are carried out (based on the NHS understanding of the term “clinical scenario”) (Clinical Situation, n.d.). *** The skills levelling model for practical skills should be considered in the context of the theory-based and workplace-based learning phases. Levels of practical skill acquisition: Level A (Beginner Level): The learner possesses theoretical knowledge of the skill, its purpose, and application. Level B1 (Basic Level): The learner has the ability to practically execute the skill using simulation resources within the simulation environment. Level B2 (Intermediate Level): The learner has understanding, abilities, and practical skills to apply the skill in a simulation environment as part of a simulation scenario (a simulation scenario consists of a clinical algorithm and clinical situation). Level C1 (Advanced Level): The learner has understanding, abilities, and practical skills to apply the skill in a real work environment under the direct supervision of a qualified instructor or certified healthcare professional. Level C2 (Expert Level): The learner has understanding, abilities, and practical skills to independently analyse situations and apply the skill in a real work environment under the guidance of a qualified instructor or certified healthcare professional LIKUMI.LV (n.d.-b).

, respectively.

2.2. 1st Strategic Direction: Recognition of Practice in Simulation Learning Environments

By investing in the integration of simulation-based educational approaches into the medical and healthcare education curriculum, the quality of healthcare, as well as the safety of patients and healthcare personnel, are actually enhanced (Slavinska et al., 2024). However, simulation-based education should not be an extra-ordinary activity but must be grounded in the ways learner performance is evaluated and should be built into learners’ normal training schedule. Effective medical learning stems from learner engagement in deliberate practice with clinical problems and devices in simulated settings in addition to patient care experience. Medical education using simulations must be a required component of the standard curriculum (Motola et al., 2013).

The Global Consensus Statement on Simulation-Based Practice in Healthcare encourages policy-makers and managers to formally recognise and harness the benefits of simulation in healthcare practice and education, which ultimately improves patient outcomes (Diaz-Navarro et al., 2024a).

2.2.1. Objective

To structure the medical and healthcare education process into three sequential phases: (1) theory-based learning phase; (2) simulation-based learning phase (practice in a simulation learning environments); (3) work-based learning phase (practice in a work environments). Practice in simulation-based learning environments (phase 2) should be distinguished as a separate part of the medical and healthcare education process—a transitional phase between theory and practice.

2.2.2. Aspects Supporting the Objective

The need to integrate a simulation-based approach in medical and healthcare education is justified by the need to ensure:

• Healthcare quality and safety.
• Quality of education in the medical and healthcare fields.

2.3. Healthcare Quality and Safety Within the Scope of Legal Regulations

• Article 6 of the Treaty on the Functioning of the European Union (TFEU) stipulates that Union shall have competence to carry out actions to support, coordinate or supplement the actions of the Member States, including in the field of protecting and improving human health (European Union, 2012).
• The EU Regulation (EU) 2021/522 of the European Parliament and Council sets a general objective to improve and promote health across the Union, while one of its specific objectives is to enhance access to quality, patient-centred, outcome-based healthcare and related care services, with the aim of achieving universal health coverage (European Parliament, 2021).
• The Directive 2011/24/EU of the European Parliament and Council emphasises that, regardless of the opportunities for patients to receive cross-border healthcare, Member States are obligated to ensure safe, high-quality, effective, and quantitatively sufficient healthcare within their own territory (European Parliament, 2011).

2.4. Quality of Education in the Medical and Healthcare Fields Within the Scope of Legal Regulations

• Education quality refers to the educational process, content, environment, and management that provide inclusive education and opportunities for individuals to achieve excellent outcomes aligned with the objectives set by society and defined by the state (LIKUMI.LV, n.d.-a).
• The Bologna Process, initiated with the Bologna Declaration in 1999 (signed by Latvia) (European Higher Education Area and Bologna Process, n.d.), is one of the key initiatives at the European level, establishing a unified European Higher Education Area (EHEA) (European Higher Education Area and Bologna Process, n.d.).
• One of the purposes of the Bologna Declaration (1999) was to encourage European cooperation in quality assurance of higher education with a view to developing comparable criteria and methodologies. The European Ministers of Education adopted in 2005 the “Standards and Guidelines for Quality Assurance in the European Higher Education Area (ESG)” drafted by the European Association for Quality Assurance in Higher Education (ENQA) in co-operation and consultation with its member agencies and the other members of the “E4 Group” (ENQA, EUA, EURASHE and ESU). A new version was adopted in 2015 at Yerevan (Bologna Process, n.d.-b).
• A key goal of the Standards and Guidelines for Quality Assurance in the European Higher Education Area (ESG) is to contribute to the common understanding of quality assurance for learning and teaching across borders and among all stakeholders. The ESG considers the frameworks for qualifications and the European Credit Transfer and Accumulation System (ECTS), contributing to transparency and mutual trust in higher education within the EHEA (AIC, n.d.):

  ○

  A qualifications framework encompasses all the qualifications in a higher education system—or in an entire education system if the framework is developed for this purpose. It shows what a learner knows, understands and is able to do on the basis of a given qualification—that is, it shows the expected learning outcomes for a given qualification (Bologna Process, n.d.-a).

  ○

  The European Credit Transfer and Accumulation System (ECTS) reflects learning based on specific learning outcomes and the associated workload (European Education Area, n.d.).

• Learning outcomes are statements regarding what a learner knows, understands and is able to do on completion of a learning process. The definitions and descriptions of learning outcomes as used in qualifications frameworks; qualification standards and curricula are statements and expressions of intentions. They are not outcomes of learning, but desired targets. Achieved learning outcomes can only be identified following the learning process, through assessments and demonstration (European Centre for the Development of Vocational Training, 2022).

The challenge is how to ensure that the intended learning outcomes (the acquisition and assessment of practical skills) are achieved and evaluated without compromising safety and quality standards in healthcare (without exposing either the patient or the professional to safety risks).

Tasks to Achieve the Objective

• Develop a glossary of terms in the national language that defines the concepts characterising the simulation-based approach in medical and healthcare education.
• Enshrine in national legal regulations the provision that the simulation-based approach in all levels of medical and healthcare education is classified as a distinct part of the educational process (a phase between theory and practice), incorporating aspects specific to this field (in the context of 2nd and 3rd Strategic Directions).

2.5. 2nd Strategic Direction: Establishing a Management Model for Practice in Simulation-Based Learning Environments

Although simulations are widely integrated into medical and healthcare education, additional challenges reported include insufficient standardisation of simulation training programmes and inadequate quality assurance of practices, particularly related to assessment and faculty development (Cristina et al., 2024). The effectiveness of simulation, like all educational modalities, depends on how well it is used. Simulation should be utilised as an adjunct to patient care experiences, and its integration into the curriculum should be well-planned and outcome driven (Motola et al., 2013).

The implementation process for simulations must align with evidence-based quality assurance approaches and recognised standards of practice, such as the Healthcare Simulation Standards of Best Practice (INACSL) (Charnetski & Jarvill, 2021), The ASPiH Standards—Guiding Simulation-Based Practice in Health and Care (ASPiH) (Lewis et al., 2017), The ASPE Standards of Best Practice (ASPE) (Lewis et al., 2017), and Standards for Organisations that Deliver Simulation-Based Education (NHS) (Standards for Organisations That Deliver Simulation-Based Education, n.d.). Additionally, the process must adhere to an ethics code tailored to the specific requirements of the field (Code of Ethics, n.d.). It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognised standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification (Cristina et al., 2024).

Key organisations driving the development of simulation-based education in medicine and healthcare:

• Society for Simulation in Healthcare (SSH) (Society for Simulation in Healthcare, n.d.).
• Society in Europe for Simulation Applied to Medicine (SESAM) (SESAM, n.d.).
• International Nursing Association for Clinical Simulation and Learning (INACL) (INACL, n.d.-a).
• Association for Simulated Practice in Healthcare (ASPiH) (ASPiH, n.d.).
• The Association of Standardized Patient Educators (ASPE) (Association of SP Educators, n.d.).
• International Network of Simulation Experts “EuSim” (EuSim, n.d.).
• Swedish Association for Clinical Training and Medical Simulation “KlinSim” (KlinSim, n.d.).

2.5.1. Objective

To develop a management and organisational model for ensuring practice in simulation-based learning environments, based on internationally recognised practice standards.

2.5.2. Aspects Supporting the Objective

• The European Economic and Social Committee in its opinion highlights that strong and resilient healthcare systems can only be built on an educated, qualified, and motivated healthcare workforce. This workforce is a critical factor in implementing successful health policies and, consequently, improving people’s health (WHO, 2022).
• The OECD in its report states that the foundations for system resilience and a capacity to minimise harm are found in strong safety governance, a 21st century information infrastructure, and sufficient staffing with a workforce skilled in handling safety risks in complex, dynamic environments, working in a supportive and just safety culture that values continuous learning and improvement (OECD, 2022).
• World Health Organization (WHO):

  ○

  Educational and training institutions for healthcare professionals should utilise simulation methods with a fidelity level appropriate to the context (high-fidelity methods in resource-rich settings and lower-fidelity methods in resource-limited settings) (World Health Organization, 2013).

  ○

  The Global Patient Safety Action Plan 2021–2030 provides specific recommendations on healthcare workforce education, skill development, and safety, including promoting the use of simulation methods in professional education for medical and healthcare professionals at all levels (World Health Organization, 2021).

• Adoption of the Healthcare Simulation Standards demonstrates a commitment to quality and implementation of rigorous evidence-based practices in healthcare education to improve patient care (INACL, n.d.-b).

2.5.3. Tasks to Achieve the Objective

1. 

Identify and manage the content implemented in practice in simulation-based learning environments (skills, algorithms, and clinical scenarios), which includes:

1.1.

Define criteria to identify which skills, algorithms, and clinical scenarios should be acquired, developed, and/or assessed in simulation-based learning environments, specifying the educational programme and level.

1.2.

Create a shared database that provides access to the content (skills, algorithms and clinical situations) to be learned in the simulation learning environment.

1.3.

Develop an operational model (processes and technical solutions) for organising the acquisition, development, and assessment of content implemented in simulation-based learning environments (skills, algorithms, and clinical scenarios).

2. 

Establish a quality policy to ensure the acquisition, development, and assessment of content implemented in practice simulation-based learning environments, which includes:

2.1.

Develop a model for the accreditation of organisations implementing simulations or determining the rights to conduct practice in simulation-based learning environments.

2.2.

Develop a certification and recertification model for simulation-implementing personnel (with priority given to simulation instructors).

2.3.

Develop a quality assurance model specifying requirements for the design, implementation, and evaluation of practice in simulation learning environments.

2.4.

Develop and approve a quality policy for recruiting and engaging role players in simulation activities.

2.5.

Develop and approve an ethics code tailored to the specifics of the field, considering recommendations and best practices from leading organisations in simulation-based medical and healthcare education.

3. 

Establish an ecosystem for the structures implementing practice in simulation-based learning environments, which includes:

3.1.

Establish a structure based on principles of interinstitutional collaboration, involving practising professionals with appropriate expertise (hereinafter referred to as domain experts);

3.2.

Develop a system to ensure the acquisition, development, and assessment of content implemented in practice in simulation-based learning environments.

4. 

Establish a funding model to support practice in simulation-based learning environments, which includes:

4.1.

Create a funding calculation model for ensuring the content implementation (skills, algorithms, and clinical scenarios) in simulation-based learning environments, based on previously identified content and considering the resources required for its implementation: technologies, environment, human resources.

4.2.

Develop an interinstitutional shared financial responsibility model for supporting practice in simulation-based learning environments, which includes defining goals and needs, identifying the involved institutions, determining funding sources.

2.6. 3rd Strategic Direction: Integration of Practice in Simulation-Based Learning Environments into All Levels of Medical and Healthcare Education Programmes

The Global Consensus Statement on Simulation-Based Practice in Healthcare emphasises the need to ensure equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, adhering strictly to the principles of equity, diversity, and inclusion (Cristina et al., 2024).

Tasks to Achieve the Objective

1. 

Develop a digital shared platform for key topics in simulation-based medical and healthcare education, including:

1.1.

Educational materials,

1.2.

A database of accredited organisations authorised to implement simulation-based learning environments,

1.3.

A database of certified and recertified simulation instructors,

1.4.

A database of simulation-based medical and healthcare education programmes, etc.

2. 

Educate and inform the creators and implementers of medical and healthcare education programmes about:

2.1.

The simulation-based education approach in medical and healthcare education, its concepts, and associated terminology.

2.2.

Legal regulatory aspects in the context of simulation-based medical and healthcare education.

2.3.

The management and organisational model of practice in simulation-based learning environments.

3. 

Ensure the availability and integration of simulation learning environment infrastructure and technologies in the implementation of simulation-based educational programmes.

Detailed description of the tasks is available in

Table 2. Action plan for the implementation of the simulation-based strategy for the development of medical and healthcare education in Latvia 2025–2027.

No	Action. Tasks and Sub-Tasks	Performance	Performance Indicator	Responsible Authority
1st STRATEGIC DIRECTION: RECOGNITION OF PRACTICE IN SIMULATION LEARNING ENVIRONMENTS
1.1.	Develop a glossary of terms in the national language that defines the concepts characterising the simulation-based approach in medical and healthcare education.	A glossary of terms has been developed, encompassing the concepts and terminology that characterise simulation-based medical and healthcare education to promote a unified understanding of the field and facilitate the precise formulation of legal regulations	A glossary containing 100–150 terms has been created, published, and made available in electronic format.	Sectoral Educational Institutions
1.2.	Enshrine in national legal regulations the provision that the simulation-based approach in all levels of medical and healthcare education is classified as a distinct part of the educational process	(1) A rationale and proposals for amendments to legal regulations have been developed, stipulating that practice in simulation-based learning environments constitutes a distinct phase of the educational process (between theoretical learning and practice in clinical environment). These amendments include specific requirements for implementing practice in simulation-based learning environments within medical and healthcare education programmes	A rationale and proposals for amendments to legal regulations have been developed to establish practice in simulation-based learning environments as a distinct part of the educational process, and these have been submitted for consideration to the Ministry of Health of the Republic of Latvia.	Sectoral Educational Institutions
		(2) Relevant legal regulatory documents requiring the integration of the proposals formulated in Subparagraph 1.2.1 have been identified and are being advanced for inclusion in legal acts.	Necessary amendments have been made to the legal framework, classifying practice in simulation-based learning environments within medical and healthcare education programmes as a distinct part of the educational process with clearly defined requirements and procedures.	The Ministry of Health of the Republic of Latvia The Ministry of Education and Science of the Republic of Latvia
2nd STRATEGIC DIRECTION: ESTABLISHING A MANAGEMENT MODEL FOR PRACTICE IN SIMULATION-BASED LEARNING ENVIRONMENTS
2.1.	Identify and manage the content implemented in practice in simulation-based learning environments
2.1.1.	Define criteria to identify which skills, algorithms, and clinical scenarios should be acquired, developed, and/or assessed in simulation-based learning environments, specifying the educational programme and level See explanatory comment below.	(1) Criteria have been established to determine which skills, algorithms, and clinical scenarios must be acquired, refined, or assessed within simulation-based learning environments, aligned with the specificity and level of designated medical and healthcare education programmes. This ensures a unified approach to implementing medical and healthcare education programmes.	Criteria for identifying content to be implemented in simulation-based learning environments have been developed and submitted for review to the Ministry of Health of the Republic of Latvia.	Sectoral Educational Institutions
		(2) Relevant regulatory documents requiring the integration of proposals formulated in Subsection 2.1.1 of Point 2.1 have been identified and are being submitted for inclusion in legal acts.	Necessary amendments have been made to the regulatory framework to establish criteria for identifying the content (skills, algorithms, and clinical scenarios) to be implemented in practice in simulation-based learning environments.	The Ministry of Health of the Republic of Latvia The Ministry of Education and Science of the Republic of Latvia
2.1.2.	Create a shared database that provides access to the content (skills, algorithms and clinical situations) to be learned in the simulation learning environment	A database prototype has been developed that: (1) Contains information on the content to be implemented in simulation-based learning environments (skills, algorithms, and clinical scenarios), providing up-to-date data for the development and updating of professional standards. (2) Facilitates the sharing of relevant methodological materials (descriptions, checklists, assessment criteria, video materials, etc.) among medical and healthcare education institutions and sector specialists, promoting standardisation in the medical and healthcare field.	A shared database prototype (Version 1.0) has been developed, providing educational institutions and industry professionals with access to standardised information on the content implemented in simulation-based learning environments, as well as methodological materials.	Sectoral Educational Institutions
2.1.3.	Develop an operational model (processes and technical solutions) for organising the acquisition, development, and assessment of content implemented in simulation-based learning environments (skills, algorithms, and clinical scenarios). See explanatory comment below.	A prototype operational model has been developed and implemented, defining processes and technical solutions to ensure the effective organisation and monitoring of the identification, acquisition, enhancement, and assessment of content (skills, algorithms, and clinical scenarios) implemented in simulation-based learning environments. This model also facilitates data collection and management to establish individual skills portfolios and institutional skills portfolios for healthcare facilities.	The developed process and technical solution prototype have been adapted and implemented in at least three undergraduate education programmes, three residency-level programmes, and three professional development programmes within the field of medical and healthcare education.	Sectoral Educational Institutions
2.2.	Establish a quality policy to ensure the acquisition, development, and assessment of content implemented in practice simulation-based learning environments
2.2.1.	Develop a model for the accreditation of organisations implementing simulations or determining the rights to conduct practice in simulation-based learning environments.	A model for accreditation and granting rights to implement practice in simulation-based learning environments has been developed and implemented. This model includes clear criteria and procedures for organisations to obtain the rights to conduct practice in simulation-based learning environments within medical and healthcare education programmes.	At least one organisation has obtained accredited organisation status/three additional organisations have acquired the rights to implement practice in simulation-based learning environments. Information about these organisations is publicly available.	Sectoral Educational Institutions
2.2.2.	Develop a certification and recertification model for simulation-implementing personnel (with priority given to simulation instructors).	A certification and recertification model for simulation instructors has been developed and implemented, outlining the requirements and procedures for obtaining and maintaining the status of a simulation instructor.	At least 10 simulation instructors have been certified, and this information is publicly available, ensuring transparency and accessibility for all stakeholders	Sectoral Educational Institutions
2.2.3.	Develop a quality assurance model specifying requirements for the design, implementation, and evaluation of practice in simulation learning environments.	A quality assurance model for practice in simulation-based environments within medical and healthcare education programmes has been developed and implemented, defining the requirements for the design, implementation, and evaluation of simulation-based practice environments.	The quality assurance model for practice in simulation-based environments has been implemented in at least 10 medical and healthcare education programmes of varying scope (undergraduate studies, residency, and professional development) in accordance with the requirements defined in the guidelines.	Sectoral Educational Institutions
2.2.4.	Develop and approve a quality policy for recruiting and engaging role players in simulation activities.	A quality policy for the recruitment and participation of role players involved in simulation activities (e.g., simulated patients and other simulation participants) has been developed and implemented. This policy includes clear guidelines for the selection, training, and involvement of participants in simulations to achieve educational objectives and ensure reliable simulation outcomes.	A database of trained role players for simulation activities has been established and maintained, ensuring transparency and accessibility for all stakeholders. The database includes at least 20 trained simulation participants who meet the established policy requirements and are ready to participate in simulation sessions.	Sectoral Educational Institutions
2.2.5.	Develop and approve an ethics code tailored to the specifics of the field, considering recommendations and best practices from leading organisations in simulation-based medical and healthcare education.	An ethics code has been developed and approved, tailored to the specifics of simulation-based medical and healthcare education, and aligned with the recommendations and best practices of SSH, INACSL, and ASPiH. This ensures the implementation of high ethical standards in practice simulation-based learning environments	The developed and approved ethics code is publicly accessible, officially recognised, and practically integrated into all accredited organisations and those granted the rights to implement practice in simulation-based learning environments.	Sectoral Educational Institutions
2.3.	Establish an ecosystem for the structures implementing practice in simulation-based learning environments
2.3.1.	Establish a structure based on principles of interinstitutional collaboration, involving practising professionals with appropriate expertise (hereinafter referred to as domain experts)	A structure has been established based on interinstitutional collaboration principles, engaging field experts to ensure comprehensive development and management of practice in simulation-based learning environments in accordance with unified quality standards.	A structure has been established to lead, coordinate, and ensure the implementation of practice in simulation-based learning environments following a unified approach,	The Ministry of Health of the Republic of Latvia The Ministry of Education and Science of the Republic of Latvia
2.3.2.	Develop a system to ensure the acquisition, development, and assessment of content implemented in practice in simulation-based learning environments See explanatory comment below.	An ecosystem of organisations implementing practice in simulation-based learning environments (Phase 1) has been established, ensuring the acquisition, development, and assessment of content across all levels of medical and healthcare education programmes.	An ecosystem of structures implementing simulation-based learning environments (Phase 1) has been established, ensuring that all organisations and institutional units related to the field (educational institutions, university hospitals, regional hospitals, specialised medical institutions) operate in accordance with defined requirements.	The Ministry of Health of the Republic of Latvia The Ministry of Education and Science of the Republic of Latvia
2.4.	Establish a funding model to support practice in simulation-based learning environments
2.4.1.	Create a funding calculation model for ensuring the content implementation (skills, algorithms, and clinical scenarios) in simulation-based learning environments	A prototype for funding calculation has been developed to determine the costs of implementing and maintaining practice in simulation-based learning environments. The calculations prioritise necessary simulation technologies, learning infrastructure, and human resources (instructors, technical specialists, administrative staff) to ensure consistent and accurate cost planning	The developed funding calculation prototype has been integrated into the core operations of at least one accredited simulation-based organisation.	Sectoral Educational Institutions
2.4.2	Develop an interinstitutional shared financial responsibility model for supporting practice in simulation-based learning environments	A model for interinstitutional shared financial responsibility has been developed to support the maintenance of the simulation-based learning environment ecosystem, defining clear principles and procedures for financial accountability and resource allocation among the participating institutions.	Investments are being made in the establishment and maintenance of the simulation-based learning environment in accordance with the chosen model.	Sectoral Educational Institutions
3rd STRATEGIC DIRECTION: INTEGRATION OF PRACTICE IN SIMULATION-BASED LEARNING ENVIRONMENTS INTO ALL LEVELS OF MEDICAL AND HEALTHCARE EDUCATION PROGRAMMES
3.1.	Develop a digital shared platform for key topics in simulation-based medical and healthcare education	A digital shared platform has been established, providing up-to-date information relevant to the specific needs of the field.	One digital shared platform has been established, ensuring access to up-to-date information.	The Ministry of Health of the Republic of Latvia The Ministry of Education and Science of the Republic of Latvia
3.2.	Educate and inform the creators and implementers of medical and healthcare education programmes	A comprehensive plan has been developed to strengthen the competence of medical and healthcare education programme developers and implementers regarding the concept of simulation-based medical and healthcare education, with secured funding for its implementation.	Trained personnel for implementing practice in simulation-based learning environments.	The Ministry of Health of the Republic of Latvia The Ministry of Education and Science of the Republic of Latvia
3.3.	Ensure the availability and integration of simulation learning environment infrastructure and technologies in the implementation of simulation-based educational programmes	Infrastructure necessary for implementing practice in simulation-based learning environments has been established.	Make initial financial investments.	The Ministry of Health of the Republic of Latvia
Comments: 2.1.1. In accordance with the Cabinet of Ministers Regulation of Latvian Republic No.617 “Regulations on the Competence of Medical Practitioners and Students Studying Medical Education Programmes in Medical Practice and the Scope of Theoretical and Practical Knowledge of Medical Practitioners and Students Studying Medical Education Programmes”—the skills (practical manipulation) in medical and healthcare education programmes must be acquired in a simulation environment, as defined by the relevant occupational standard and the professional qualification requirements contained therein (hereinafter referred to as the occupational standard). The learning of skills (practical manipulation) in a simulation environment shall be expected at least in the following cases: ○ There is limited or no learning, refinement and evaluation of skills, algorithms, clinical situations during practice in a healthcare institution. ○ Learning, developing and evaluating skills, algorithms, clinical situations in a healthcare institution can limit a patient’s right to receive treatment that is appropriate to their condition, of good quality and competence. ○ Learning, developing and evaluating skills, algorithms, clinical situations cannot be done in any other way for practical, ethical and legal reasons LIKUMI.LV (n.d.-b). ○ It should be foreseen that the existing criteria defining which skills, algorithms, clinical situations are to be learned, refined and/or assessed in a simulation-based learning environment can be complemented data that demonstrates the existence or likelihood of patient safety harms. Potential sources of data: ○ Data from the Patient Safety Case Reporting and Teaching System, ○ Patient feedback and experience data, ○ Research and statistics, ○ Clinical cases. 2.1.3. Potential Operating Model should: Identify the skills, algorithms, and clinical scenarios to be acquired, enhanced, and evaluated within specific simulation-based educational activities (based on point 1.1). Specify the particular skills, algorithms, and clinical scenarios and the level *** at which they are to be acquired, enhanced, or evaluated within specific simulation-based educational programmes (based on point 1.2). Collect and monitor data: ○ Individual skills portfolios for students in medical and healthcare study programmes, residents, and professionals undergoing professional development. ○ Institutional skills portfolios for medical and healthcare institutions, based on the individual skills portfolios of their human resources (Grigorovica et al., 2024). 2.3.2. To develop a mutually coordinated system of institutions implementing simulation-based learning environments, it is necessary to: Establish a Centre of Excellence for simulation-based medical and healthcare education and research, which will: ○ Ensure the acquisition, development, and assessment of content implemented in simulation-based learning environments across various medical and healthcare fields, thereby providing broad expertise. ○ Design, implement, and evaluate highly complex, multidisciplinary, interdisciplinary, and interinstitutional simulations. ○ Promote the development of methodologies aligned with simulation-based medical and healthcare education. ○ Train and prepare simulation instructors and other personnel involved in simulation-based activities. ○ Test, evaluate, and implement the latest simulation technologies and solutions. ○ Provide testing and evaluation for professionals returning to work after extended absences. ○ Conduct scientific and research activities specific to the field. ○ Support the operations of universities and other simulation centres. Establish simulation-based learning organisations (structures) in all educational institutions offering medical and healthcare programmes or develop collaboration models with existing simulation organisations (structures) to ensure the acquisition, enhancement, and assessment of skills, algorithms, and clinical scenarios tailored to the specifics of each educational programme. Establish simulation centres in university hospitals, regional hospitals, and specialised healthcare institutions to: ○ Enable the renewal and maintenance of skills, algorithms, and clinical scenarios learned during undergraduate studies. ○ Facilitate the acquisition, development, and readiness to address situations specific to each hospital during postgraduate and professional development stages. Develop a rational and sustainable collaboration model between the Centre of Excellence for simulation-based medical and healthcare education and research, simulation-based learning organisations (structures) in educational institutions, university hospitals, and specialised healthcare institution simulation centres, which will: ○ Implement a unified practice approach. ○ Facilitate resource sharing. The internal functioning system of organisations (structures) implementing practice in simulation-based learning environments consists of: Human resources: domain experts, simulation instructors, simulation specialists, simulation technicians, engineers, administrative, and support staff. Simulation learning environment. Simulation technologies and resources.

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Progress report on the implementation of the simulation-based action plan for the development strategy for medical and health education in Latvia 2025–2027 as of (1) 1 March 2026; (2) 1 March 2027; (3) 1 March 2028.

2.7. Concept for the Implementation of the Strategy for Simulation-Based Medical and Healthcare Education Development in Latvia for 2025–2027

Implementing simulation-based education remains challenging globally. Strategic leadership and government support are crucial in determining its scope and integration into training programmes (Elendu et al., 2024; Nayahangan et al., 2024). Achieving its full potential requires coordinated action among healthcare and academic stakeholders, along with substantial financial investments, specialised equipment, trained faculty (Cristina et al., 2024), and a robust governance model (Figure 2).

3. Conclusions

The document “Strategy for the Development of Simulation-Based Medical and Healthcare Education in Latvia for 2025–2027” underscores the significance of this field and provides a detailed vision for systematically, sustainably, and thoughtfully developing and integrating a simulation-based educational approach at all levels of medical and healthcare education.

The integration of simulation-based education into all levels of medical and healthcare education is pivotal for strengthening the competencies, capabilities, and readiness of current and future professionals in the field. This, in turn, represents a crucial step toward achieving high-quality education and, consequently, ensuring high-quality and safe healthcare services.

It is essential not to delay the implementation of the Strategy and to initiate the necessary changes to the legal framework. This includes formalising the simulation-based learning phase as a distinct part of the medical and healthcare education process, situated between theory and practice, establishing a management model for practice in simulation-based learning environments, and ensuring the integration of such practices into educational programmes at all levels.

The successful implementation of the Strategy requires:

• Robust and sustainable collaboration among institutions delivering medical and healthcare education programmes, healthcare institutions, domain experts, and national health policy planners and implementers.
• The involvement and support of public administration.
• Long-term resource availability.
• Regular analysis, evaluation, and timely improvements based on the Strategy’s implementation outcomes.

The implementation of the Strategy and its action plan will be an important contribution to the development of simulation-based medical and healthcare education at national level. It should be recognised that Latvia has the potential to become one of the first countries where this area is managed on the basis of clearly defined conditions and regulated by law. Moreover, if successfully implemented, the Strategy has the potential to become a model or prototype for implementation in other countries.