Operations in Healthcare Simulation Nursing Education: Rise of the Specialist

H. Michael Young explains the changing face of simulation for nursing and the evolving roles and experiences involved.

Simulation-based education is still evolving, and along with it the roles of those responsible for its implementation. For example, undergraduate, pre-licensure nursing programs have benefited from innovative educators’ early adoption of manikin-based simulation. However, today’s manikins are far more complex, technologically, relying on networks, integrated audiovisual and program management and other technology innovations. Many nursing education programs are short on qualified educators and without technical support from team members who understand the objectives of the educator, opportunities could be lost in using these expensive and complex technologies. But hiring an IT expert is not necessarily the right move; with so many nuances to implementing simulation best practices, many IT professionals may not have the temperament. In both academic and hospital-based education, information technology departments are more likely to restrict simulation technologies than they are to find innovative ways to support it.

Rebecca Burgess Wise, Standardized Patient – bleed out and amputee; ABIA, Akron Ohio; moulage is often the job of operations specialists. Image Credit: H. Michael Young.

Growing Pains

Nursing as a profession is experiencing ashortage of available qualified clinicians and by extension, a shortage ofnursing educators. Consequently, nursing educators’ responsibilities continueto grow even while working at maintaining course schedules, clinical activitiesand supervision of learners. Nursing simulation has grown rapidly, oftenstaffed with traditional faculty with full course loads. Considered advanced atthe time, the patient simulators of the early 2000s were relatively simple whencompared to current models; manufacturers of the early simulators were selling“systems” with everything included to implement simulation activities. Today’smanikin-based simulators are far more complex, although in some ways easier tooperate, but require more infrastructure to support operation. Simulationfacility design has also changed over the last two decades, with greaterrequirements due to diversity of simulation activities and technologies.Simulation technologies are often integrated with audiovisual systems, havededicated wireless and Ethernet networks, headwall integration, powerfulservers and institution compliant computers. As Electronic Health Records andmedication dispense technologies are integrated into simulation activities, newchallenges emerge. The many different technologies used in simulation are notcoming from one vendor, but many. Typically, venders do not cooperate with eachother to provide a better experience for their mutual customers.

With more complex infrastructure requirements more specialized skills and knowledge are also needed. From full-time simulation educators, simulation center directors, simulation operations directors/managers, coordinators, simulation researchers, IT specialists, audiovisual specialists, and so forth; the many roles in simulation continue to multiply, but the number of individual employees is not increasing fast enough to address the added responsibilities. Traditional educators, even if equipped to address all these roles simply do not have the time.

Mr. Atkinson teaching simulation specialists. Image Credit: S. Scott Atkinson of University of Akron Simulation Specialists Associates Degree Program.

Guidelines

State boards of nursing have been slow toprovide guidance in terms of who and how simulation would be delivered. TheNational Council of State Boards of Nursing (NCSBN) finally released itsguidelines in 2015, (published in the Journal of Nursing Regulation). Theseguidelines are the result of a ground-breaking multi-site study that attemptedto answer the question, “how much clinical time for nursing students could bereplaced or supplemented by simulation without sacrifice of competency?” TheNCSBN recommends to state boards of nursing that up to 50% of clinicals time couldbe satisfied using simulation.

The NCSBN Guidelines:

Implementation of these guidelines arevoluntary, flexible and open to interpretation. How is “commitment tosimulation programs” measured? How does anyone know if their facilities areappropriate for conducting simulation? Such questions are not intended to implythat simulation specialists do not have appropriate answers, but how eachsimulation program interprets these guidelines will be different and a lack ofstandardization creates confusion. In time, and with further research,standardization will occur.

Although the NCSBN permits up to 50%clinical time be satisfied with simulation, each state board has the last word.The International Nursing Association for Clinical Simulation and Learning(INACSL) has put together a map that shows where the NCSBN regulations havebeen applied, to a certain degree. The map discloses that application of theGuidelines is far from universal. Much of North America undergraduate nursingprograms have not yet formalized the percentage of clinical hours that can becompleted through simulation. Some states permit up to the recommended 50%,while others range from 15%, 25% and 30%.

22 States have applied the guidelines atvarious rates, but so much of North America remains unreported or undefined. Ifall 50 US States were to use simulation for 50% of student clinical hours, thedemand on nursing program educators and the demand for more simulation staffwould be enormous. Implementing simulation is not a time saving endeavor, noris it more convenient. The technology is complex, expensive and althoughpopular with students and many educators, the research, at best, supports thatsimulation is as good as traditional clinical experiences.

Each state has evaluated its ability toincorporate simulation into the development of competent nurses, andsurprisingly, of the 22 states that have reported and defined simulation usage,seven do not allow the full 50% suggested by the NCSBN.

Standards: Bridging the Gap(s)

INACSL Standards of Best Practice:Simulationsm published its latest complete version in 2016, but in 2017, INACSLadded its newest standard: Operations. Subject-matter experts were recruitedand tasked with writing the new standard. Prompted initially by SimGHOSTS’leadership, representatives from other simulation groups were invited to sharethe authorship. Early in the process, the “standard” appeared more like a jobdescription. However, it did not take long for the team to separate operationsfrom the roles that performed the tasks. The new Operations Standard provides abetter framework for understanding the scope of the field, while giving afoundation for defining existing, new and emerging roles.

SSH is trying to improve simulation programoutcomes through simulation program accreditation. The 2016 SSH AccreditationStandards provide a framework for establishing what a simulation program shouldbe. For simulation programs who are not ready for formal accreditation, theAccreditation Standards can still help simulation programs to develop andmature.

In Medical Training Magazine’s 2013 articleConnecting the Dots with Medical Simulation, Marty Kauchak wrote: “While theseindividuals [simulation technicians] often have impressive resumes, skill setsand experience, they collectively lack the rigor of certification,qualification and standards found in the technical workforces in otherhigh-risk industries.”

With no clear pathway for technicians’careers, further complicated by inadequate opportunities for formal educationin their chosen field, the role is nevertheless taking form. Healthcareeducation programs are recognizing that the role of simulation technicians, orOperations Specialists, as they have become known, are indispensable members ofthe simulation team, supporting educational programs with a diverse and variedset of skills. As simulation technicians, the expectations were simple: set upthe simulation activity space, take it down, clean up and operate the simulatoron behalf of an educator. The “technician” role has long been considered anentry-level position, but that has changed. Kauchak’s observation that medicalsimulation specialists “collectively lack the rigor of certification” was afair conclusion.

SimGHOSTS, an organization dedicated topromoting and supporting the role of the Healthcare Simulation TechnologySpecialist, has annual meetings around the world. It was the rise of SimGHOSTS,now an affiliate of SSH, that the Society for Simulation in Healthcare, theworld’s largest healthcare simulation education organization, began developingprofessional certification for those working in simulation operations,including sim techs.

In 2014, SSH established professional certification for simulation technicians: Certified Healthcare Simulation Operations Specialist (CHSOS). This certification came on the heels of SSH’s Certified Healthcare Simulation Educator (CHSE). The emergence of the CHSOS and the continued leadership of SSH have demonstrated a strong commitment for the professional development for all simulation roles, thus the operations specialist is born. Simulation Technician, Simulation Technology Specialists and other titles are still in use, but Operations Specialist has become an acceptable next step for this group.

Center for Clinical Simulation & Learning, Advanced Tech Lab, Tarleton State University. Image Credit: H. Michael Young

Formal Education

Universities, colleges and trade schoolshave explored the development of certificates and degrees for OperationsSpecialists, but currently there are only a few. In the 2013 Kauchak article,Scott Atkinson reported hopes of starting an associate degree or certificate.Scott Atkinson was successful developing the degree, and currently teachessimulation courses at the University of Akron. Mr. Atkinson prefers “simulationspecialists” as a title but recognizes the diversity and value of the variousoperational roles. At least three other colleges offer or will offer associatedegrees for this role. Discussion of establishing a bachelor’s degree forsimulation operations has been ongoing for about five years at severaluniversities, but concern arose that the high-cost of tuition placed unduefinancial burden on students, and that current salaries would not justify theinvestment. The CHSOS, like the CHSE does require a bachelor’s degree, orequivalent. And over the last few years, SSH continues to see CHSOS numbersrise.

The Operations Specialist can still earn abachelor’s degree in any number of fields and enjoy a successful career inoperations. However, a clinical education is required for advancement to amanager and administrator role. Some operations specialists have becomedirectors, but not many, and even less who do not have clinical credentials.Further specialization may improve options, but other models for a simulationprogram need to be explored.

Final Thoughts

Some simulation specialists believe thatthe model needed is the concierge model. The simulation program and its staffthen become service providers for traditional course faculty and theirstudents. Faculty still oversee the progress of their students, but simulationspecialists (simulation educators, operations specialists, mentors, etc.)develop and deliver simulation activities on behalf of faculty. This approachis becoming more accepted and appreciated, while some programs insist thatfaculty supervise all simulation activity. With responsibility for studentperformance still falling on course faculty, the concierge model still requiresa cooperative relationship between simulation staff and program faculty, andthe support of credentialing agencies.

Nevertheless, the healthcare simulation “community” is experiencing a quiet, but growing trend where programs are supported and administered by operations specialists. The ever-evolving role of operations specialists, at some point, will need its own career path, offering a full pallet of skills to implement the technologies, techniques and activities and a broader understanding of how simulation fits into the overall curriculum. While the technician was the job of a “doer”, the operations specialist is the job of a critical thinker with skills in communication, computers, network configuration, audiovisual technology, organizational skills, and professionalism.

About the Author

H. Michael Young works as a simulationeducation, technology and operations consultant for Level 3 Healthcare. As amember of SSH and INACSL, Mr. Young is at the forefront in promoting the roleof the Operations Specialist. A member of the SSH Certification Council, Youngchairs the CHSOS Sub-Committee and holds the Certified Healthcare SimulationEducator certification. In 2017, Young was invited, along with othersubject-matter experts, to contribute to the authorship of the INACSL Standardsof Best Practice: Simulationsm: Operations. In 2016, Mr. Young, with leadeditor and author Laura T. Gantt co-edited and authored Healthcare Simulation:A Guide for Operations Specialists. Young is a regular author for the companyblog, social media and is a presenter and contributor for webinars on subjectsrelated to simulation operations and technology.

References

1. Healthcare Simulation: A Guide for Operations Specialists: https://www.wiley.com/en-us/Healthcare+Simulation%3A+A+Guide+for+Operations+Specialists-p-9781118949436
2. Society for Simulation in Healthcare (SSH): Certified Healthcare Simulation Operations Specialists Exam Information: http://www.ssih.org/Certification/CHSOS/Exam-Information Blueprint: http://www.ssih.org/Portals/48/Certification/CHSOS_Docs/CHSOS%20Examination%20Blueprint.pdf SSH Accreditation Standards http://www.ssih.org/Accreditation
3. International Nursing Association for Clinical Simulation and Learning (INACSL)

Originally published in  Issue 4, 2018 of MT Magazine.