The Østergaard Declaration: Advancing Simulation for Safer Healthcare

The Østergaard Declaration sets out a shared European vision for simulation-based education and training, placing patient safety at its core. We spoke with Professor Crina Burlacu, Chair of the ESAIC Simulation Committee, about the origins of the Declaration and its ambitions for the future of healthcare education.

1. What inspired the creation of The Østergaard Declaration, and why was now the right moment to launch it? 

At the beginning of my tenure as Chair of the ESAIC Simulation Committee on 1 January 2024, I sought to build upon the strong foundations already established by my predecessor, Professor Doris Østergaard, after whom the Declaration has been named. 

One of my principal objectives was to promote and support the wider dissemination across Europe of both the Utstein simulation-based education and training (SBET) curriculum, developed by our group in 2022, and the National Anaesthesia Simulation Training (NAST) model, successfully implemented in Romania in collaboration with SRATI. Through collective surveys, individual exchanges, and annual SimNet meetings held during Euroanaesthesia, we listened closely to the needs, expectations, and barriers surrounding the implementation of SBET across European jurisdictions.  

It became increasingly clear that advancing SBET required a ESAIC position statement to provide a common platform for educators, national societies, and regulators across Europe. With endorsement from the ESAIC Board and support from EBA and the NAS Committee, we developed The Østergaard Declaration to ensure both institutional legitimacy and broad European applicability. The timing is particularly important, as the forthcoming revision of the EBA ETR, together with the updated Helsinki Declaration on Patient Safety 2.0, has created momentum for a unified European position on SBET. 

2. The Østergaard Declaration describes simulation-based education as an ‘essential healthcare infrastructure’ rather than an optional educational tool. What does this shift in thinking mean in practice for hospitals and training institutions? 

This represents an important shift in mindset, moving away from the perception of simulation as an optional educational activity — something valuable only when resources, time, or local enthusiasm permit. The Declaration advocates for simulation to become a standard and expected component of healthcare education and clinical practice, rather than an exception. In practical terms, this means that regulators and training institutions should move beyond ad hoc or isolated simulation initiatives and instead embed SBET within educational frameworks. Healthcare organisations should also use simulation proactively to test clinical pathways, prepare teams for rare but critical events, identify latent safety threats before they harm real patients, and strengthen system resilience and organisational culture. 

Viewing simulation as infrastructure also implies accountability. Educational and healthcare organisations, training bodies, professional societies, and policy makers should work collaboratively to ensure equitable and sustainable access. 

3. Despite strong evidence supporting simulation-based education, implementation across Europe remains inconsistent. What are the biggest barriers that still need to be addressed? 

There is no doubt that strong scientific evidence supports SBET across all the domains I have mentioned. The barriers to implementation are largely structural, organisational, and cultural. 

From a structural perspective, there remains considerable heterogeneity in regulatory frameworks and educational governance across Europe. In some countries, SBET is embedded within national curricula and training requirements, whereas in others it remains optional or dependent on local initiatives. ESAIC surveys have demonstrated important disparities in access between regions, reflecting differences in educational investment, infrastructure, and institutional support. 

Organisationally, funding and protected time remain major barriers. High-quality simulation requires sustained investment in facilities, trained faculty, programme development, and dedicated educational time. Too often, simulation still depends on committed local champions working around clinical pressures rather than on stable institutional support and long-term planning. 

Finally, there is an important cultural challenge. Simulation is still sometimes regarded as desirable rather than essential, particularly during periods of workforce shortages and financial pressure. Yet if we truly recognise simulation as a core component of training and a patient safety intervention, it can no longer be treated as a discretionary educational activity. 

4. One of the central themes of The Østergaard Declaration is patient safety. How can simulation-based education directly improve outcomes for both patients and healthcare teams? 

Simulation is not merely an educational methodology; it is a patient safety strategy. At the individual and team level, it enables healthcare professionals to acquire, refine, and maintain technical, social, and cognitive skills, thereby supporting competency development and lifelong continuing professional development. Beyond education, translational simulation contributes to improving clinical systems by testing processes, evaluating care pathways, and identifying latent safety threats within real-world clinical settings. Transformative simulation operates at a broader level, helping to shape organisational culture, strengthen collaborative practice, and support long-term system change towards safer and more resilient healthcare. 

Ultimately, better-prepared professionals and safer systems contribute to improved outcomes for both patients and healthcare teams. 

5. The Østergaard Declaration also highlights the importance of psychological safety, feedback and debriefing. Why are these elements so critical in modern healthcare education? 

Psychological safety, feedback, and debriefing are essential because simulation is not merely about practising tasks; it is about how healthcare professionals learn, reflect, and improve together in a safe simulated environment. Effective learning occurs when participants feel safe to make mistakes, ask questions, and reflect honestly without fear of judgement or humiliation. This prepares learners for clinical practice, where reflection and speaking up about concerns can directly influence patient safety. 

Debriefing is particularly critical because much of the learning occurs after simulation. Structured feedback and reflective discussion enable participants to understand not only what happened, but also why it happened, by exploring decision-making, communication, teamwork, and system factors in a constructive manner. In this way, experience is transformed into meaningful behavioural and professional development. 

Psychologically safe learning environments can support professional wellbeing and reduce stress, while equitable access to simulation and high-quality feedback helps ensure that educational opportunities are not determined by geography, hierarchy, gender, or professional background. Ultimately, inclusive and reflective learning environments contribute to stronger teams and safer healthcare systems. 

6. Looking ahead, what would success look like for The Østergaard Declaration over the next five to ten years across European anaesthesiology and intensive care? 

Over the next five to ten years, I hope to see SBET more consistently embedded within anaesthesiology, intensive care, and perioperative training programmes across Europe, informed by the Utstein curriculum as a common educational reference point. While implementation should reflect national governance structures and cultural contexts, greater alignment in principles and simulation quality would support more equitable training. 

Success would also mean broader access to high-quality SBET and stronger engagement from regulators, professional societies, training institutions, and hospitals, with simulation increasingly recognised as an essential component of specialist education, workforce development, and patient safety. 

ESAIC will continue to support this process by promoting the adoption of the Utstein curriculum and encouraging thoughtful adaptation of the NAST model to national contexts. We also aim to align simulation curricula more closely with the competencies of the EBA ETR, helping integrate training and certification standards. Equally important is strengthening collaboration between simulation programmes through the sharing of educational content, scenarios, and faculty expertise to maximise efficiency and foster networks of excellence across Europe. Continued support with faculty development will remain essential to ensure educational quality, expert facilitation, and sustainable leadership in simulation. 

Anaesthesiology has long been a leader in SBET and is uniquely positioned to serve as a role model for the wider healthcare community, helping to drive broader adoption across specialties and healthcare systems while contributing to safer healthcare overall.