Behind the Simulator: What Nurse Educators Reveal About Teaching Critical Care in Norway

Simulation has quietly become one of the most powerful tools in modern healthcare education. Manikins that breathe, blink, and deteriorate on cue allow nursing students to rehearse the chaos of an intensive care unit without ever placing a real patient at risk. Yet while a large body of research has celebrated the learning gains that students take away from these high-fidelity scenarios, far less attention has been paid to the people standing at the front of the simulation room. A new qualitative study from Norway, published in BMC Nursing, turns the camera around and asks nurse educators what it actually feels like to design, facilitate, and sustain simulation-based learning in master’s-level critical care nursing programs.

The research team, led by Susanne Olesen of the University of South-Eastern Norway, interviewed nine educators drawn from eight different educational institutions across the country. Norway offers an unusually clear setting for such an investigation, because critical care nursing there is delivered at the master’s level, meaning the learners are experienced clinicians being pushed toward advanced judgment rather than novices memorizing basic procedures. Participants were selected specifically because they carried primary responsibility for simulation within their programs, and contextual information about each institution was gathered through a questionnaire before the interviews took place. The interview guide was anchored in the didactic relational model developed by Bjørndal and Lieberg, a framework that maps the relationships between learner, teacher, content, and context.

Methodologically, the study employed an exploratory qualitative design using reflexive thematic analysis, an approach in which researchers actively acknowledge their own perspectives while systematically coding interview data into patterns. From those patterns, three main themes emerged: complex competence, careful facilitation, and system barriers. Together, they sketch a portrait of a teaching role that is far more intellectually and emotionally demanding than the polished language of simulation pedagogy often suggests. The educators described simulation-based learning as simultaneously valuable and taxing, an activity whose success depends on a delicate interplay between individual expertise, learner-centered facilitation, and the organizational conditions surrounding both.

The first theme, complex competence, captures the sheer breadth of skills a simulation facilitator must hold in working memory at once. Educators described the facilitation of simulation as mentally demanding work that requires experience-based, pedagogical, professional, and technical competence all at the same time. In practical terms, this means that during a single scenario an educator may need to operate sophisticated manikin software, adjust the physiological storyline in real time as students make decisions, monitor group dynamics, and stay alert to whether the clinical content remains authentic to intensive care practice. The researchers found that educators built confidence in this demanding role through continuity, repeated opportunities to facilitate over time, and peer support from colleagues who understood the specific pressures of the simulation room.

This finding carries weight beyond Norway’s borders. Simulation-based learning is recognized internationally as an effective pedagogical approach, and professional bodies such as the International Nursing Association for Clinical Simulations and Learning have published standards that assume a skilled facilitator behind every scenario. What the Norwegian study adds is a grounded account of how that skill is actually assembled. It is not a single qualification but a layered competence, accumulated through clinical experience, pedagogical training, and technical fluency, and it appears fragile when continuity is broken or when educators are left to develop these abilities alone. The educators’ accounts suggest that institutions that rotate staff in and out of simulation roles, or that treat facilitation as an add-on to existing workloads, may be quietly undermining the quality of the learning experience.

The second theme, careful facilitation, describes what educators do to make simulation work pedagogically. Preparation emerged as central: scenarios and student roles were deliberately tailored to match the experiences of master’s-level students, who arrive with varied clinical backgrounds and different levels of prior simulation exposure. Educators spoke about creating psychologically safe environments, spaces where students could make mistakes, expose gaps in their knowledge, and practice difficult clinical judgments without fear of humiliation. They also described structuring learning progressively, so that challenges escalated in step with students’ developing confidence. This balancing act, between clinical authenticity on one side and pedagogical support on the other, was described as a constant negotiation rather than a formula.

The emphasis on psychological safety aligns with a broader shift in health professions education away from seeing simulation as a test and toward seeing it as a protected rehearsal space. For experienced critical care nurses, who are accustomed to being competent authorities at the bedside, admitting uncertainty in front of peers can be particularly uncomfortable. The educators in this study understood that dynamic and worked actively to manage it, adjusting scenario difficulty, assigning roles thoughtfully, and calibrating their own interventions during debriefing. Their accounts suggest that the artistry of simulation lies less in the technology than in this careful, responsive choreography around the learner.

The third theme, system barriers, is where the study becomes most pointed for educational leaders. The educators described a persistent misalignment between the strategic ambitions of their institutions and the actual time, resources, and technical support made available for simulation. High-quality simulation was sustained not primarily by institutional systems but by personal engagement, and by support from leaders who understood and championed the work. Where that support was present, educators could invest the preparation time that careful facilitation requires; where it was absent, the demanding nature of the role became a burden rather than a professional challenge. The researchers conclude that the implementation of simulation-based learning depends not only on individual competence but also on sufficient time, continuity, and organizational support.

This conclusion lands at a moment when nursing education systems worldwide are under strain. Workforce shortages, rising acuity in intensive care units, and rapid technological change, including growing interest in virtual reality and artificial intelligence in simulation, all increase pressure on educators to deliver more sophisticated training with fewer resources. The Norwegian findings imply that investments in manikins and software will underperform if the human infrastructure around them is neglected. A facilitator who lacks time to prepare, technical support when equipment fails, or colleagues to debrief with after a difficult session cannot deliver the learner-centered experience that the evidence base says simulation requires.

The study’s design, an exploratory qualitative approach with nine educators across eight institutions, cannot measure outcomes or generalize statistically, and the authors are careful to frame their findings as perceptions and experiences rather than effect estimates. But that is precisely the point of the research: before outcomes can be optimized, the conditions that make skilled facilitation possible must be understood. By documenting the mental load, the layered competencies, and the organizational frictions experienced by the people who run simulation in critical care nursing education, Olesen and her colleagues, including Ida Marie Bredesen, Lena Günterberg Heyn, Hilde Eide, Janet Mattsson, and Edda Johansen, have shifted the conversation from what simulation does for students to what simulation demands of educators. For faculties and hospital training programs everywhere, the message is clear: the simulator is only as good as the system that supports the person standing behind it.

Subject of Research: Nurse educators' experiences with simulation-based learning in master's-level critical care nursing education in Norway

Article Title: A qualitative study of nurse educators’ experiences with simulation-based learning in critical care nursing education in Norway

Article References: A qualitative study of nurse educators’ experiences with simulation-based learning in critical care nursing education in Norway. (n.d.). https://doi.org/10.1186/s12912-026-05493-z

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05493-z

Keywords: simulation-based learning, nurse educators, critical care nursing, nursing education, qualitative research, thematic analysis, facilitation, psychological safety, master's education, Norway, health professions education, organizational support