More than a Job: The Ongoing Professionalization of Healthcare Simulation
Professionalization is often seen as a noble goal for emerging knowledge occupations. The professionalization process is generally a long one, with no one clear path forward. Some occupations journey this road for many years, navigating detours along the way. Healthcare simulation is a technique that creates a situation or environment to allow persons to experience a representation of a real healthcare event for the purpose of practice, learning, evaluation, testing, or to gain an understanding of systems or human actions. A simulationist is a person who is involved in the design, implementation, and/or delivery of healthcare simulation activities (Lioce et al., 2016). The following article takes a look at the ongoing process of defining healthcare simulation as a profession and simulationists as professionals.
A profession is “a disciplined group of individuals who adhere to ethical standards and who hold themselves out as and are accepted by the public as possessing special knowledge and skills in a widely recognized body of learning derived from research, education, and training at a high level, and who are prepared to apply this knowledge and exercise these skills in the interest of others” (Clarke, n.d.). Professions are established and maintained as a means of providing essential services to the individual and society.
Professionalization is a social process whereby occupations seek to become, publicly recognized as professions according to the degree to which they meet the alleged criteria. Professionalization can be a “bottom-up” process initiated by those in the occupation, or a “top-down” approach, mandated by employers or the government (as an employer or as a policymaker).
Oftentimes, the process is a blend of the two. For an employer, professionalization might mean requiring a specific course of academic study, degree, certification, or professional society membership as a criterion of initial and/or continuing employment. For a professional association, professionalization might mean setting up a code of conduct or creating certifications, training programs, or educational norms. (Clarke, n.d.). Professionalization can:
- Improve the nature of the workforce by setting norms.
- Establish and standardize roles, along with the associated knowledge, skills, and abilities, to readily adjust supply and demand, enhance awareness of career paths, and facilitate recruitment by employers.
- Direct the supply of labor to propel the interests of its members.
- The regulation of workers whose occupation can influence the well-being, safety, or property of others.
- Guide the conduct of specialists in the field, particularly with regards to morally or ethically ambiguous activities.
- Upgrade public trust and confidence.
- Elevate the status of occupation.
Defining characteristics of a profession include: a body of specialized knowledge and skills, identified standards of best practice, recognized professional organizations, institutional preparation including certification and/or licensure, autonomy and accountability, and ethical constraints, often delineated in a code of ethics. Now, let’s take a closer look at where healthcare simulation stands based on a few of these metrics:
Body of Specialized Knowledge and Skills
According to a classical definition ‘Professions profess’. They profess to know better than others the nature of certain matters, and to avow better than their clients what ails them or their affairs’. Knowledge, ethics, and governance are the central elements of professions. Knowledge is the core of professionalism, but how that knowledge is created, exercised, evaluated, and reconstructed is critical (Clarke, n.d.).
Professionalization describes the education, training, and other activities that transform a worker into a professional and the social processes by which an occupation becomes a profession (Phillips & Dalgarno, 2017). The profession is based on one or more supporting disciplines from which independent applied knowledge and skills can be built. Being a healthcare provider does not equate to being a healthcare simulationist. Whereas a background in one of the practice disciplines is helpful, specialized knowledge and skills are required to successfully deliver healthcare simulation-based education. In the early development of simulation-based education, much of the training was provided by the manufacturers of the equipment.
As the practice of healthcare simulation has evolved over the past decade, more attention has been paid to the pedagogy underlying the practice. The increased focus on pedagogy, training, and professional development of the simulationist has expanded far beyond the technical aspects of clinical simulation (Hallmark et al., 2021).
Standards of Best Practice
Best practices are the working standards or ethical guidelines that provide the best course(s) of action in a given situation and serve as a roadmap for a profession on how to do business. These standards also provide the best way to deal with problems and issues that arise. A profession has agreed-upon performance standards for admission to the profession and for continuance within it. The initial seven standards for healthcare simulation were published in 2011, to guide the design, conduction, and evaluation of simulation activities.
The adoption of best practices helped advance the science of simulation as a teaching methodology. These standards underwent revision and rebranding this year and are now known as the Healthcare Simulation Standards of Best Practice ™. The standards provide a detailed process for evaluating and improving simulation operating procedures and delivery methods. Adoption of the 10 standards demonstrates a commitment to the quality and implementation of rigorous evidence-based practices in healthcare education to improve patient care (INACSL Standards Committee, 2021).
A professional association usually seeks to further a particular profession, the interests of individuals and organizations engaged in that profession, and the public interest. The mission of these professional societies is primarily educational and informational. Through their work, they help to define and set standards for their professional fields and to promote high standards of quality through awards and other forms of recognition. (Phillips & Dalgarno, 2017). There are many national and international associations supporting healthcare simulation.
The Society for Simulation in Healthcare (SSH) was established in the United States in 2004. Members include physicians, nurses, allied health and paramedical personnel, researchers, educators, and developers from around the globe. The primary goal of the organization is to improve the safety of patient care by seeking improvement in performance and reduction in errors through the use of simulation (SSH, 2020). With over 1,800 members worldwide, the International Nursing Association of Clinical and Simulation Learning (INACSL) is an association dedicated to advancing the science of healthcare simulation. The organization’s mission is to be the global leader in the art and science of healthcare simulation through excellence in nursing education, practice, and research (INACSL, 2021).
The Society for Simulation in Europe, known as SESAM, was formed over 20 years ago in Copenhagen to encourage and support the use of healthcare simulation for the purpose of training and research (SESAM, 2021). A few other professional healthcare simulation organizations include the Association for Simulated Practice in Healthcare (ASPiH), the Association of Standardized Patient Educators (ASPE), and SimGHOSTS (The Gathering of Healthcare Simulation Technology Specialists), which is geared toward operations.
Certification and Licensure
Within a profession, individual practitioners are characterized by a strong service motivation and lifetime commitment to competence, as evidenced by the attainment of a specialized certificate, certification, or license in the discipline. Certificates and certifications are especially helpful to employers who may otherwise find evaluating the skills and knowledge of job applicants difficult. Certificates are generally associated with training or education courses and verify through examination that particular content was learned in courses or curricula. They are generally “good for life” and cannot be revoked, although a certificate’s relevance to an employer will diminish over time, especially in a fast-moving field like healthcare simulation.
They serve as an indication of knowledge at a particular point in time. Certification is a formal procedure by an authorized body and is based on a study of the factors that predict success in a job. Certification relies on examinations that meet testing standards. Certifications are time-limited and require periodic recertification, and there are procedures in place to remove certification for ethical breaches or knowledge deficiencies.
Post-bachelor’s certificates in healthcare simulation are available on several college campuses in the United States and certification as a healthcare simulation educator (CHSE) or an operations specialist (CHSOS) is available through SSH. To date, 2,584 individuals from 38 countries have achieved recognition as certified healthcare simulation educators (CHSE) and 88 simulationists from across the globe, have been awarded advanced certification as an educator (CHSE-A). Five hundred and seventy-three operation specialists from 19 countries hold basic certification (CHSOS). Advanced certification in operations began in March of this year, and so far, 25 CHSOS-A certifications have been conferred (SSH, 2021).
Licensure involves a government restriction on practice without a license, generally involving public safety or trust. This may establish standards for legal liability in the case of negligent practice. While many of those working as simulationists are licensed in one or more healthcare disciplines, licensure in healthcare simulation is not a requirement, at this time.
The definition of a profession that a code of ethics governs the activities of each profession is inherent. Such codes require behavior and practice beyond the personal moral obligations of an individual. They define and demand high standards of behavior in respect to the services provided to the public and in dealing with professional colleagues. Often these codes are enforced by the profession and are acknowledged and accepted by the community (Harris, 2021).
Three years ago, the professionalization of healthcare simulation took a big step forward with the publication of the “Healthcare Simulationist Code of Ethics”. An international group of simulation experts established a set of values to support the quality and ethical practice of healthcare simulation. Since being released at the end of 2018, the “Healthcare Simulationist Code of Ethics” has been translated from English to 17 other languages. To date, nearly 100 organizations/institutions have formally adopted the code (Park & Murphy, 2018; SSH, 2020).
Society is becoming increasingly professionalized. The proliferation of information and technology is yielding more and more careers that require specialized knowledge and training. Healthcare simulation is still a relatively young occupation and technological advances are causing a rapid expansion of the field. Obtaining the status of a full profession will require significant effort from those involved in the practice of healthcare simulation, to work together to achieve recognition and gain control over the defining characteristics of a profession.
Professionalization can be both a magnet, attracting people to the field and a funnel, restricting others from entering the field. Something to consider, while professionalization of healthcare simulation provides a useful degree of quality control for those who work in the field, professionalization also imposes barriers to those who wish to enter the field at a time when demand for simulationists exceeds supply.
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Jeanne Carey is the Director of Simulation at Baylor University Louise Herrington School of Nursing in Dallas, Texas. She holds advanced certification as a simulation educator and has 10 years of experience in all aspects of simulation, including the development and implementation of new simulation-based learning activities, training of simulation facilitators, and recruitment and management of standardized patients. Carey and the LHSON Simulation Team created the Two-Heads-Are-Better-Than-One (2HeadsR>1) strategy for role assignment in simulation. She is active in several simulation organizations and currently serves as an INACSL Nurse Planner.