Local (e.g. access to professional actors), institutional (e.g. amalgamation of schools, funding models, commitment to simulation, innovation in education), discipline/profession (e.g. uni-, multi- or inter-professional) and national (e.g. assessments, scale) contexts have profoundly influenced the development of the SP programs. The four programs have emerged in different educational 'eras' and to meet different needs. Although highly contextualised, there are similarities between programs. These include their shared goal to provide high quality educational opportunities for trainees. Recent sharing of resources between programs has facilitated standard setting and perceived enrichment of programs. However, funding models constrain the extent to which resources can be freely shared.
While each program faced similar challenges the nature and direction of challenges differed. For example, in synthesizing key challenges for SPs, recruitment proved an issue. Two programs had difficulty recruiting SPs (Gippsland and Lausanne) while two programs were oversubscribed (Imperial and Toronto). This led to different recruitment strategies and selection processes. However, all programs were challenged by recruitment of special populations (e.g. ethnic groups, different age groups, males). Similarly, with performance and training, there were differences in the nature of challenges. The amount and type of training was strongly influenced by program resources and the volume of SP work.
In the synthesis of key challenges for faculty in SP programs, faculty development was highly valued and well supported for academic leads but there was less evidence of development opportunities for other faculty. For key challenges in the organisational structure of SP programs, clarity in the relationship with the host institution was critical and influenced several facets of the programs. The programs differed in relation to the type of leadership. That is, academic or professional management. The nature of the leadership in part reflected the funding models for each program. In this case study, only Toronto had a cost-recovery model. That is, they are self-funded charging for all services. In contrast, the three other programs were funded through university curriculum budgets. Additional differences between programs related to the role of union membership. Again, only Toronto had a union presence.
We hypothesise that the program 'culture' is influenced by their core business and scale. For example, the 'program' at Gippsland does not have an identity independent of its host institution while the program at Toronto has an international profile. The culture of the SP program at Toronto is highly 'professional'. The program sustains many SPs in work on a weekly basis. In contrast, at Gippsland and Lausanne no individual SP works on a weekly basis. This reduces opportunities for development and advancement of the methodology because there are fewer opportunities to practice, Further, undersubscribed programs are more likely to be challenged by quality assurance issues associated with the limited pool of SPs. It is also apparent that SP programs take time to 'mature' as SPs develop expertise through practice, feedback and mentoring  and are able to take on more sophisticated tasks.
In this analysis, national assessments and scale are interrelated. In our case study, only Canada has national health professional exams at the undergraduate level. This strongly influenced the size and focus of SP programs. Identity was also influenced by the location of the program in the University - in a small medical school, as an independent SP program, in specialist education unit and in a surgical department.
Terminology between SP programs varied and this created confusion and misunderstanding in cross-institutional comparisons. Notable differences in programs include their longevity, the consequent level of experience of SPs, numbers of registrants, funding models, pay rates, research profile and challenges. Research activity was partially influenced by funding models. However, local champions and expertise in educational research was also important.
The SP programs at Gippsland, Imperial and Toronto support the development of patient-centred communication and other professional skills in medical students and doctors. Lausanne differs in its target group working almost exclusively across professional disciplines. Toronto also works extensively across health professional groups. Imperial and Toronto cater to large numbers of trainees. In each program, strong academic and administrative leadership was considered critical for embedding SP-based education in curricula and for seeking new opportunities.
The literature offers little guidance on recruitment although qualities of SPs are regularly reported [11, 24]. Quality assurance was highly valued but an area for significant development in each program.
The Gippsland and Imperial programs are co-located with clinical skills simulation centres. Broader trends in the 'accreditation of simulation centres' are likely to impact SP programs. SPs in these programs were perceived as core to such centres rather than separate.
SP programs need to be responsive to local needs. Although larger and more established programs can offer a suite of educational activities, they were also constrained by instructional and regulatory issues. They have the ability to offer large-scale examinations while smaller programs focused on meeting specific local needs. The scale of the program seems to create different types of challenges.
Limitations of the approach
The authors were all involved in the research process and so it is possible that responses were biased. However, the extended period over which the study occurred and the multiple authors provided repeated opportunities for validation. Further, it is possible that as a self-selected group of academics sharing a similar philosophy to SP methodology there is bias in our reporting. The cases do not represent all types of SP programs. We acknowledge the highly contextual nature of each SP program and like much qualitative research we do not make claims for generalisability.