Healthcare Simulation: A Guide for Operations Specialists

1

INTRODUCTION

Laura T. Gantt

East Carolina University College of Nursing, Greenville, NC, USA

Readers may recall the terms digital native and digital immigrant and the year(s) that they first became common vernacular. A digital native is typically one for whom technology has always existed; a digital immigrant, on the other hand, has migrated toward the use of technology out of necessity or a desire to integrate it into their lives (Prensky, 2001, p. 3). In this same way, it seems there are those of us who are simulation immigrants and others who are simulation natives. While I consider myself a native, I stop short of calling myself an expert. My background in emergency and flight nursing means that I have taken every type of certification course, many of which were simulation based, long before they were called that. This gave me an unexpected edge in obtaining a position in the healthcare simulation field at a time when incredible financial resources were dedicated to developing simulation labs, even though few people knew much about them.

I did not, however, have an edge in finding the educational resources I needed to build a successful team of professionals for a simulation program in a large nursing college with diverse undergraduate and graduate degrees. Nevertheless, with limited resources, I set about the task of educating myself in healthcare simulation. At first, I attended simulator training and simulation conferences, and read the few books and journals available.

After a few years of blind searching, I got smarter in my hunt for resources. Indeed, in some fields of study, simulation really has been around a very long time. I looked at how other disciplines conducted simulation-based training. This proved to be helpful in determining best practices for teaching with simulation, since other fields, such as aviation and gaming, have overlapping characteristics with healthcare.

However, when it came to training those who had to put it all together in the healthcare simulation lab, I learned the hard way that trying to apply lessons from other fields often does not work. Never was this clearer to me than when I encountered a new employee who could not learn the role or functions of the simulation operator or technologist in the lab. With previous employees, I guess I had been lucky enough to hire people with aptitudes for the work. However, for those who were inclined in the direction of technology, there were simply no journal articles, books, or guides to assist a person who might be struggling with assimilating the knowledge needed for this type of position. When I failed to find the information I needed to help my new hire, I was sure that I must not be looking in the right places yet. I was dismayed.

While I might have been distraught then, I was simultaneously elated and depressed to find that the problem I identified with a lack of resources for training simulation operators and technical staff had been previously well-described. As early as 1985, a National Research Council (NRC) report entitled Human Factors Aspects of Simulation (Jones, Hennessey, & Deutsch, 1985) outlined a number of issues, including the following:

The number of personnel required to support simulators is substantial (p. 22).

Difficulties in design and use of simulators could be reduced with analyses of the human skills and knowledge required for their operation and maintenance (p. 45).

The human operator of a simulator may be able to compensate for simulator shortcomings, but this may result in negative transfer in training (p. 50).

Activities of scenario generation and simulation control need to be described to permit understanding of functional flow (p. 65).

The types of simulators discussed by these authors include those used in aviation, motor vehicles, and nuclear power, but the above list could easily be applied today to patient simulators and those that operate them. While it may be argued that healthcare simulation has existed for several decades, resources have been slow to come along, particularly in the area of healthcare simulation technology. What the NRC wrote in 1985 was true then and, as often seems to be the case, little progress has been made in resolving simulation operator and technologist training across multiple fields.

To understand why the application of work from other fields that use simulation simply does not work when it comes to healthcare simulation may be, in part, because we do not yet fully know what it means exactly to be a simulation technologist or operations specialist. The position titles for this type of work vary wildly between organizations. The work itself involves knowing how to put human patient simulators together and troubleshoot them, how to network and program them, and how to operate them. While the human-to-machine interface is similar to other fields that use simulation, there is a difference with patient simulators that involves a relationship between living humans and patient simulators with a concurrent need for an understanding of proper patient care. In addition, simulation operations specialists (SOS), as I have come to call and know them, must also know what instructors and educators know about objectives and outcomes for varying levels and types of learners. They must know a good deal about the learners themselves and their roles; these learners may, at times, come from different disciplines and must, in the simulation lab and in real life, work well together. While most aspects of patient simulation technology may be taught over time, other parts are art and require a talent for creativity and vision. A flare for the dramatic and the ability to write a script and then improvise from it are skills not usually associated with healthcare. But a simulation lab is much more than an arena for skills training. Many days, it is more like the production of a complicated play.

In 2013, the Society for Simulation in Healthcare (SSH) leadership voted to approve the name of a new certification for those working in the simulation operations arena: Certified Healthcare Simulation Operations Specialist (CHSOS). This certification was not designed for any one type of position, but is inclusive of many of the evolving roles within healthcare simulation. For the record, the planning and outline for this book predated the CHSOS and the book should not be assumed to be a preparatory book for the exam.

Also in 2013, SSH announced that Sim Ops would be the theme for the annual preconference symposium. Both the certification and the symposium are evidence that simulation operations are an important area of specialization within healthcare education, training, and assessment. There are two sides to operations in simulation programs: administration and execution. On the administrative side, operations refer to governance of simulation programs through policy, guidelines, and financials. On the execution side, operations refers to the implementation of tasks as defined by administration and subject matter experts.

For the purposes of this book, the SOS is someone who has advanced knowledge and understanding of the many facets of day-to-day operations within a healthcare simulation lab. Because educators tend to be technologically challenged, the SOS usually has a technology background, but must also be part educator, part engineer, part director, and part artist. The resources that we have at our disposal to train SOS in any of the required realms are slim to none. The titles for the chapters in this book occurred to me over the course of an average month in the clinical simulation laboratory. For example, consider Chapter 8, which is about the fit between the employer and potential SOS. The chapter was originally entitled, Just Call Me Gumby. On a routine day in the simulation lab, those who bring the action to life are truly stretched into any number of positions, some flattering and others more compromising. Sure, just call me Gumby is the likely response to a faculty or staff question that begins with Can’t you just……………………… Typically, this blank is filled in by the requestor with something like fix this? or take care of that? or help this student? or relocate that class and/or piece of equipment?

The purpose of this book is to help people who specialize in simulation operations figure out how to get started. The book begins with chapters on the current state of the simulation professional workforce and how it has evolved. From there the book moves through topics of interest to those in the simulation workforce related to the art, science, and innovation necessary for the role of the SOS.

Each of the chapter authors for this book was recruited not because they needed to share how to do a job, but because of the innovative work that they have done to develop the role of the SOS. There are a few how to simulation books already available. The focus of those has been the educator or instructor role in simulation or simulation center development and leadership. In this book, however, each author was asked to address a topic of interest, some from novice and others from expert perspectives, in which they truly are specialists of the highest degree. Each of these authors has become indispensable because they are doing groundbreaking work that perhaps no one else has even thought of, much less done. The types of simulation professionals who discuss their work in this book have become crucial to the work of healthcare educators and researchers alike.

One colleague of mine feels certain that the day is rapidly coming when those of us at the helms of simulation centers will become unnecessary and obsolete. We were the ones that got the simulators out of the boxes, got everything running, and figured out how to make it all work in the beginning. But we are not the future of healthcare simulation. Our protégés, whether they are educators, engineers, technologists, or managers, have outperformed us and taken it to another level that involves increasing amounts of technical knowledge, creativity, and innovation. They were out of the boxes before the simulators were. For those of us who helped get simulation started in healthcare, our collective job now is to help healthcare simulation progress from its current status by making sure that the next generation comes along with a bigger toolbox than we had.

REFERENCES

Jones, E. R., Hennessey, R. T., & Deutsch, S. (1985). Human factors aspects of simulation. Washington, DC: National Academy Press.

Prensky, M. (2001). Digital natives, digital immigrants: Part 1. On the Horizon, 9(5), 1–6. 10.1108/10748120110424816

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HEALTHCARE SIMULATION OPERATIONS: BRIDGING THE GAPS

H. Michael Young

Level 3 Healthcare, Mesa, AZ, USA

INTRODUCTION

Use of simulation in healthcare has become pervasive within undergraduate clinical and pre-hospital education, hospital continuing education programs, and in various medical school specialties. Often, clinical and medical faculty are responsible for the day-to-day operations of many simulation programs, typically in addition to their other responsibilities. Today, simulation operations is not just the domain of educators and program administrators, but also of various specialists, with different titles, roles, and responsibilities. A small simulation program will be fortunate to have one fulltime staff member, regardless of specialty, but larger programs will have diverse teams of specialists, especially those working in simulation operations. Nevertheless, simulation operations is still relatively new to many simulation programs that have long held the opinion that operations is the domain of administration. The technology that has emerged within the simulation program has become very sophisticated and complex thus can benefit from the utilization of expertise from a diverse group of professionals, including those inside and outside of the healthcare domain (Alinier, Pozzo, & Shields, 2008; Gantt, 2012, p. 580). The simulation community, in general, has grown and expanded because of enterprising clinical educators who took the lead as early adopters in the use of these simulation technologies known commonly as patient simulators. Simulation has long been a part of clinical education, but the advancing complexity and interoperability of today’s technology has advanced a meaningful dialogue about specialized staffing and a need for a broader system perspective (Jones, Hennessy, & Deutsch, 1985, p. 86). Early adopters comprised the initial simulation operations team, and many of these innovators still serve as the first line of support for their respective programs. Recruitment of the simulation operations specialist (SOS) draws primarily from a pool of RNs, EMTs, allied health, and IT professionals (Foster, Sheriff, & Cheney, 2008, p. 141; Society for Simulation in Healthcare [SSH], 2013, p. 10; Vollmer, Mönk, & Heinrichs, 2008, p. 628; Zigmont, Oocumma, Szyld, & Maestre, 2015, p. 551). However, educator workload has often necessitated the creation of additional operational roles. Such roles may include, but are not limited to, simulation technician, simulation specialist, simulation technology specialist, simulation operator, and others (Education Advisory Board [EAB], 2013, p. 25), as well as non-simulation specific roles. Thanks to the introduction of SSH’s Certified Healthcare Simulation Operations Specialist (CHSOS); these roles, and others, are now being organized into a new class of specialist now referred to as the SOS. As simulation technologies continue to become more sophisticated and interoperable, so too has the demand for more specialized staff who have strong backgrounds in information technology (IT), audiovisual (AV) technology, project management, and engineering. Such personnel work alongside their clinical counterparts in their simulation programs and are responsible for coordinating the preparation, maintenance, and implementation of healthcare simulation, also known as simulation operations.

Why Is Simulation Operations Emerging as a Specialty?

New professional roles are emerging as the result of the identification of gaps in the simulation program’s ability to address the demands in clinical and medical education. Such gaps include (i) the rising shortage of faculty (American Association of Colleges of Nursing [AACN], 2015), (ii) increasing demands on the time of faculty, and (iii) a growing need for specialized knowledge, skills, and attributes (or KSAs). The latter relates to the issues around multiple layers of technological systems that must work together; this requires additional expertise, or the sharing of task responsibilities with one or more SOSs in order to achieve both immediate and long-term goals of simulation operations. This chapter will first identify many of the gaps emerging out of simulation operations, in general, and suggest ways in which such gaps are bridged with the emerging roles now identified as SOSs. Gaps in simulation programs can be defined as those recurring challenges that fall outside the expertise of the simulation team members, whether faculty or staff. By distributing tasks among specialized support staff, such as the SOS, subject matter experts are free to focus on those tasks for which they are uniquely qualified.

GAP #1: TECHNOLOGICAL EXPERTISE

SOSs, in general, have made the task of setting up and operating simulators easier for busy fulltime simulation educators and program faculty, freeing them to focus on the scenario design and participant assessment rather than operational logistics. Despite the emergence of the various SOS roles, the technical demands of a simulation program may still exceed the expertise of existing staff (Vollmer et al., 2008, p. 628).

In general, when technological systems fail, who provides timely support (Dieckmann, Lippert, Glavin, & Rall, 2010, pp. 219–220)? Typically, institutional IT departments may pass this burden on to the vendor, while others would say that the IT department should help solve the problem. With technical delays comes a delay in resolution, and with the delay in resolution comes delays in scheduled activities and loss of operational efficiency. When a simulation system component fails during a scenario, an extended warranty is of little help when it requires that the simulator be repaired somewhere else in the world at a vendor support center. Unless the implementation of backup plan has been planned or resources are on hand (Dieckmann et al., 2010, p. 220), the scheduled educational event must be cancelled or rescheduled (Canales & Huang, 2015). The healthcare simulation community has relied heavily on vendor provided extended warranties for ongoing technical support. However, while critical to the simulation program’s sustainability, warranties alone are not an adequate solution. Even if the simulator does not need to be shipped elsewhere for repair, vendor phone support can be time-consuming, and neither the caller nor the support person may be able to clearly communicate cause and effect (LaCombe & Whiteside, 2015, p. 341). Hence, a simulation program likely needs an SOS who is specifically trained and experienced in IT to overcome support issues that are the result of multiple system interoperability (e.g. network and simulator) (Vollmer et al., 2008, p. 633). For additional information on these systems, the reader is referred to Chapter 9.

GAP #2: TRAINING

Just as an RN or EMT new to simulation must receive training to use specialized technologies outside their experience (e.g. simulators), so must an IT or AV specialist learn the language and concepts related to human physiology, medical terminology and concepts, especially as it relates to the scope of capability of the simulators being used. The questions then becomes, what form will this training take? Who is qualified to teach it? Training programs for simulation professionals are typically designed for clinicians/educators working in academic or hospital environments. These persons managed all aspects of simulator adoption and utilization within the last 10–15 years. However, these training curricula fail to take into account the current trend toward the possibility that an SOS trainee could be someone who does not come from a medical or clinical background; hence, the potential for bringing in technical expertise from non-healthcare sectors is reduced because such candidates are not even considered for an SOS role. There is evidence that the need for non-clinician and IT simulation training is expanding (Griffin-Sobel et al., 2010).

Funding the Right Priorities for Training

Program administrators, through adequately funded training mandates, must be called upon to develop the scope and priority of a comprehensive training initiative. Local, regional, national, and international opportunities for continuing education in healthcare simulation are abundant. However, when educators and technical staff are expected to use only personal funds to attend, training is unlikely to occur. When programs do not invest, the probability that individuals will pay their own way is unlikely. A shift in priorities related to budgetary planning is required to ensure that simulation expertise can keep pace with the rate of simulation technology adoption. Training is necessary for both simulation program staff and institutional IT leadership who need key knowledge and skills to support a developing, robust education program.

GAP #3: DIVISION OF LABOR

Educators/Clinicians: The simulation operations team is best understood in the context of the entire simulation team, not just one particular role (Griffin-Sobel et al., 2010, pp. 41–43). Some simulation programs have the benefit of clinical educators who were early adopters and then became the primary simulation technology experts out of necessity. However, as simulation has become more technologically sophisticated and complex, expectations have changed. Support of one or two simulators utilized in a skills lab has, in many programs, progressed to over a dozen or more advanced simulators in dedicated simulation labs, with one or more control rooms and an integrated audiovisual system. Simulation technology systems include components manufactured and configured by many different vendors, each with their own proprietary system requirements and features. As a result, clinical simulation specialists, whether they are operations specialists or faculty, are learning that it is not easy to decipher whom to call when a particular part of the system fails to operate correctly (See LaCombe & Whiteside, 2015, pp. 340–342 for tips). For example, some simulators communicate with the control computer wirelessly, but do not utilize the local network. Other simulators depend on the local network (wired or wireless). One type of system depends on proprietary methods of connection, and other simulators rely on ubiquitous technologies supported by institutional IT departments. Many simulation professionals will likely not know the difference without years of practical experience. The emergence of the SOS role allows for greater diversity within the operations team, and thus frees the clinical educator to focus on issues related to their role as subject matter experts. However, reliance on other subject matter experts in the field of technology is a growing, acceptable—and in many circumstances—necessary approach to bridge gaps in knowledge and attributes of the overall simulation operations