Transformative Simulation as an Ontology for AI in Health Systems: From Fluent Tools to Coherent Reasoning

Artificial intelligence (AI) is increasingly applied to healthcare decision-making; however, many persistent patient safety risks arise from sociotechnical conditions such as communication breakdowns, coordination failures, and organisational culture rather than diagnostic or decision error alone. While simulation can engage these dimensions of care, AI-supported simulation remains limited by heterogeneity and a lack of explicit conceptual structure. This study presents a narrative and conceptual review of the healthcare simulation and AI literature to identify structural barriers to coherent AI reasoning about simulation. Drawing on this synthesis, we introduce Transformative Simulation (TfS) as an intentional framework that can be formalised as an ontology for AI-supported simulation focused on cultural and systems-level change. TfS structures simulation through explicit Simulation-Based Intentions, an aligned design–delivery–data–debrief process, and foundational considerations of purpose, perspective, power, preparation, and possibility. Framed in this way, TfS enables AI systems to interpret simulation artefacts in relation to declared intent, sociotechnical context, and ethical boundaries. We further describe an Intentionality–Simulation–Intelligence triad and a continuous learning loop that align human values, simulation structure, and AI reasoning. The findings of this review suggest that an important challenge in applying AI to healthcare simulation may be ontological as well as technical, and that explicit representation of intention and context is necessary to support coherent, context-sensitive, and system-aligned AI reasoning in healthcare.