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Standards are paramount for any practice specialty trying to improve performance. Setting a standard provides a benchmark from which to measure progress. Prior to entering clinical practice, medical professionals must demonstrate through testing and performance that they have acquired the knowledge and skills to meet a set of expected actions and abilities for their specialty. This is what helps to define each specialty, and the profession creates the assurance that care will be uniform and follow the guidelines put forth by its accrediting bodies. Now, given the work done by the Association for Simulated Practice in Healthcare (ASPiH) and others, simulation-based education (SBE) is better able to demonstrate to all who rely on it—students, educators, employers and patients—that consistency and quality can be achieved in this educational delivery and methodology.
Leaders from the ASPiH should be applauded for their comprehensive review of simulation-based education practice and expected norms for its use in their constituent regions of the United Kingdom. Having accepted and supported reference points provides guidance for the development and sustainability of programmes. While much of what was explored in the process of writing and defining both the standards and the accompanying guidelines reiterates the work conducted by other organisations around the world, the information from this independent review supports and narrows the diversity of independent practice in simulation around the globe and moves one step closer to the revolution predicted by Gaba.1
SimGHOSTS is an affiliated non-profit membership association that focuses specifically on the technical operations in simulation. As a reviewer of the International Nursing Association for Clinical Simulation and Learning (INACSL) standards and contributing author to INACSL’s Simulation Operations standard (released in 2017),2 I can attest to the difficulty of achieving consensus in such a diverse field of practice. Similarly, and spanning the same time course as ASPiH (2014–2016), SimGHOSTS worked for 2 years to better define the roles and expectations of the Healthcare Simulation Technology Specialist, only achieving a unifying standard after working jointly with representatives from two other professional groups: Society for Simulation in Healthcare (SSH) and INACSL.
The cautionary tale of standards lies in the name itself. A standard is only good if it is in fact that: standard. A standard is defined as ‘an idea or thing used as a measure, norm, or model in comparative evaluations’.3 In practicality, this definition requires two things: first, that the metric used for measurement does not change, and second, that a sufficient number of individuals or groups use the same information for measurement or comparison so that disparate groups have a common and accepted definition of success. While in fact the standards written by ASPiH appear to meet this need as a measurement tool and were supported through survey by the very people they were designed to serve, it is important to use the tool only within its designed scope. These ASPiH standards for simulation were written to meet the need ‘for nationally agreed standards to inform the development of SBE’.4 Similarly, other groups have developed standards and published them, as shown in the diagram demonstrating the overlap between ASPiH’s work and that of other groups including SSH and INACSL (reproduced in figure 1). A problem may arise if too many standards are published, particularly if there are conflicting ideas or expectations. If, however, the standards independently show the same information, they can validate each other. In the latter case, an effort should be made by all parties to cross-reference and connect standards to reduce divergence except when necessitated by local or regional need, such as has been suggested by ASPiH in their needs assessment. Their work was performed to create a ‘national’ standard for simulation. Showing congruency with other international organisations gives credence to their findings. However, application of ASPiH’s standards outside of the UK should not be undertaken except to support standards developed by other recognised international groups. Expansion without consensus undermines the process of establishing standards for all groups involved.
Standards are meant to be unifying concepts that support current and future practice. If used correctly, they can improve the quality and credibility of healthcare SBE, and I hope this is the goal. An additional concern is the money-making associated with requiring accreditation or certification in the standards. Some groups are using standards and the accompanying accreditation as revenue-generating avenues to support their organisations. While it is important to encourage, support and demonstrate quality and standards, requiring time and personnel for verification; monetisation of this process can interfere with the true goal, especially when more than one group exists to serve a similar goal. Several groups already provide accreditation of simulation centres, including the SSH, the American College of Surgeons and the American Society of Anesthesiologists.5–7 All of these groups strive to improve the quality of SBE. Even though some groups appear specialty specific, the bulk of the accreditation standards and application of SBE for most centres are not. These accreditation criteria can be appropriately applied to diverse centres. In 2010, the Society for Academic Emergency Medicine (SAEM) reviewed the process and ramifications of offering their own accreditation of simulation centres.8 While they found a benefit in offering accreditation, the group chose to support simulation through training and consultation without offering accreditation. Part of the rationale cited was that the required infrastructure for faculty development and other support mechanisms were not robust enough to promote the appropriate adoption and growth of simulation that would be expected.8 The SAEM evaluation discussed a potential move by the American College of Obstetrics and Gynaecologists to provide simulation accreditation in a pilot form, but what is still currently offered by this group is support, review and validation of curricula, not accreditation of the centre or staff specifically.9 10
Each group’s standards build a strong foundation for supporting and promoting the advancement of simulation programmes both in the UK and globally, but as stated by the authors, simulation is not just a technology—it is a technique—and one that is still evolving. Now it is evolving with an established framework on which to build, and multiple groups have been able to delineate expected actions by faculty, administrative and technical support for simulation, and the maintenance and provision of resources by institutions, all with the goal of supporting and sustaining SBE activities. With the support of ASPiH and other global entities working to define standards, simulation will be able to achieve its full potential and complete the healthcare education revolution for which Dr Gaba predicted it was destined.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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