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 a shortage of available qualified clinicians and by extension, a shortage of nursing educators. Consequently, nursing educators’ responsibilities continue to grow even while working at maintaining course schedules, clinical activities and supervision of learners. Nursing simulation has grown rapidly, often staffed with traditional faculty with full course loads. Considered advanced at the time, the patient simulators of the early 2000s were relatively simple when compared to current models; manufacturers of the early simulators were selling “systems” with everything included to implement simulation activities. Today’s manikin-based simulators are far more complex, although in some ways easier to operate, but require more infrastructure to support operation. Simulation facility design has also changed over the last two decades, with greater requirements due to diversity of simulation activities and technologies. Simulation technologies are often integrated with audiovisual systems, have dedicated wireless and Ethernet networks, headwall integration, powerful servers and institution compliant computers. As Electronic Health Records and medication dispense technologies are integrated into simulation activities, new challenges emerge. The many different technologies used in simulation are not coming from one vendor, but many. Typically, venders do not cooperate with each other 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.
Mr. Atkinson teaching simulation specialists. Image Credit: S. Scott Atkinson of University of Akron Simulation Specialists Associates Degree Program.


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

The NCSBN Guidelines:

  • There is a commitment on the part of the school for the simulation program.
  • Program has appropriate facilities for conducting simulation.
  • Program has the educational and technological resources and equipment to meet the intended objectives.
  • Lead faculty and sim lab personnel are qualified to conduct simulation.
  • Faculty are prepared to lead simulations.
  • Program has understanding of policies and processes that are part of the simulation experience.

Implementation of these guidelines are voluntary, flexible and open to interpretation. How is “commitment to simulation programs” measured? How does anyone know if their facilities are appropriate for conducting simulation? Such questions are not intended to imply that simulation specialists do not have appropriate answers, but how each simulation program interprets these guidelines will be different and a lack of standardization 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 have been applied, to a certain degree. The map discloses that application of the Guidelines is far from universal. Much of North America undergraduate nursing programs have not yet formalized the percentage of clinical hours that can be completed through simulation. Some states permit up to the recommended 50%, while others range from 15%, 25% and 30%.

22 States have applied the guidelines at various rates, but so much of North America remains unreported or undefined. If all 50 US States were to use simulation for 50% of student clinical hours, the demand on nursing program educators and the demand for more simulation staff would be enormous. Implementing simulation is not a time saving endeavor, nor is it more convenient. The technology is complex, expensive and although popular with students and many educators, the research, at best, supports that simulation is as good as traditional clinical experiences.

Each state has evaluated its ability to incorporate simulation into the development of competent nurses, and surprisingly, 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, INACSL added its newest standard: Operations. Subject-matter experts were recruited and tasked with writing the new standard. Prompted initially by SimGHOSTS’ leadership, representatives from other simulation groups were invited to share the authorship. Early in the process, the “standard” appeared more like a job description. However, it did not take long for the team to separate operations from the roles that performed the tasks. The new Operations Standard provides a better framework for understanding the scope of the field, while giving a foundation for defining existing, new and emerging roles.

SSH is trying to improve simulation program outcomes through simulation program accreditation. The 2016 SSH Accreditation Standards provide a framework for establishing what a simulation program should be. For simulation programs who are not ready for formal accreditation, the Accreditation Standards can still help simulation programs to develop and mature.

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

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

SimGHOSTS, an organization dedicated to promoting and supporting the role of the Healthcare Simulation Technology Specialist, has annual meetings around the world. It was the rise of SimGHOSTS, now an affiliate of SSH, that the Society for Simulation in Healthcare, the world’s largest healthcare simulation education organization, began developing professional 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 Operations
Center for Clinical Simulation & Learning, Advanced Tech Lab, Tarleton State University. Image Credit: H. Michael Young

Formal Education

Universities, colleges and trade schools have explored the development of certificates and degrees for Operations Specialists, 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 teaches simulation courses at the University of Akron. Mr. Atkinson prefers “simulation specialists” as a title but recognizes the diversity and value of the various operational roles. At least three other colleges offer or will offer associate degrees for this role. Discussion of establishing a bachelor’s degree for simulation operations has been ongoing for about five years at several universities, but concern arose that the high-cost of tuition placed undue financial burden on students, and that current salaries would not justify the investment. The CHSOS, like the CHSE does require a bachelor’s degree, or equivalent. And over the last few years, SSH continues to see CHSOS numbers rise.

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

Final Thoughts

Some simulation specialists believe that the model needed is the concierge model. The simulation program and its staff then become service providers for traditional course faculty and their students. Faculty still oversee the progress of their students, but simulation specialists (simulation educators, operations specialists, mentors, etc.) develop and deliver simulation activities on behalf of faculty. This approach is becoming more accepted and appreciated, while some programs insist that faculty supervise all simulation activity. With responsibility for student performance still falling on course faculty, the concierge model still requires a cooperative relationship between simulation staff and program faculty, and the 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 simulation education, technology and operations consultant for Level 3 Healthcare. As a member of SSH and INACSL, Mr. Young is at the forefront in promoting the role of the Operations Specialist. A member of the SSH Certification Council, Young chairs the CHSOS Sub-Committee and holds the Certified Healthcare Simulation Educator certification. In 2017, Young was invited, along with other subject-matter experts, to contribute to the authorship of the INACSL Standards of Best Practice: Simulationsm: Operations. In 2016, Mr. Young, with lead editor and author Laura T. Gantt co-edited and authored Healthcare Simulation: A Guide for Operations Specialists. Young is a regular author for the company blog, social media and is a presenter and contributor for webinars on subjects related to simulation operations and technology.


  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.