Author response to published editorials on ASPiH standards for simulation-based education

We would like to thank the International Nursing Association for Clinical Simulation and Learning (INACSL), The Gathering of Healthcare Simulation Technology Specialists (SimGHOSTS) and the Association of Standardised Patient Educators (ASPE) for their supportive and helpful reflections on our standard-setting article.

Simulation-based education (SBE) is widely acknowledged as a key educational modality that has led to a paradigm shift in healthcare education. Despite its popularity and increasing application, it is still too often used only as a one-off interaction with learners. The use and evaluation of simulation as part of an overarching approach to patient safety has been insufficiently explored. There are few studies linking SBE to clinical outcomes.¹ There remains poor capture of data of operational or cost-effectiveness of SBE and we continue to be unclear as to how best to deliver SBE as not all training programmes produce benefit.^{1 2}

Underlying many of the issues highlighted is a lack of standardisation in the approach to SBE with failure to adopt best practice in design and delivery of SBE programmes.¹ It is this challenge that the Association for Simulated Practice³ in Healthcare (ASPiH) took up in 2015, which resulted in the publication of the ASPiH standards in the current issue of the journal.⁴ The ASPiH standards have demonstrated a good fit⁴ with existing practices and priorities of standard setting bodies within education and SBE in the UK and across the world. Thus, demonstrating the generalisability of these simulation standards across educational environments and geographical boundaries.

We welcome the interest that INACSL (Dreifuerst and Mariani),⁵ SimGHOSTS (Crawford)⁶ and ASPE (Bohnert and Lewis)⁷ have shown in the recent publication of our standards. INACSL⁵ and SimGHOSTS⁶ highlight the need for an international consensus on the development of future standards and we welcome this in the spirit of advancing the cause of SBE. We must ensure that this does not stifle innovation and prevent development of other standards by organisations across the world to suit the needs of their community.

Fundamental to the adoption and sustaining of new innovations is the establishment of the relevance to the user community that it is intended for.⁸ Simulation communities must have the freedom to adopt and adapt standards as they see fit. Crawford⁶ states that the ASPiH standards should not be used outside the UK, while Bohnert and Lewis⁷ highlight ASPiH’s use of the implementation science framework. They state that ‘ASPiH’s thorough collection of responses to its standards is a benchmark for other organizations to follow.’⁷ We would therefore argue that ASPiH SBE standards can be used by any simulation provider around the globe, if it suits that community and has buy-in.

Dreifuerst and Mariani⁵ have suggested that ‘embedding debriefing into another standard may minimize its importance.’ We believe that debriefing is integral to the delivery of SBE and should not be seen as a stand-alone standard. Therefore, we have embedded debriefing in the faculty, programme, assessment and in situ simulation guidance sections which underpin the ASPiH standards. Feedback received during the consultation process (consultation report)³ endorsed this view.

A systematic implementation process is necessary for a national attempt to spread evidence-based programmes.⁵ We see the embedding and sustaining of the standards in the community as the next challenge for ASPiH. Crawford⁶ has highlighted the role of accreditation in quality assurance of SBE. We believe that accreditation has an important role to play. Accreditation is defined as a seal of approval from an independent accrediting body certifying that an organisation or individual has met specific standards.⁹ While standards can help individuals and organisations raise the quality of SBE and improve the training, accreditation models could help quality assure entire communities to perform better.¹⁰ Accreditation research in healthcare suggests that engaging with accreditation results in organisations investing more resources to improve the quality of the faculty and that of the programmes the organisation provides. Accreditation is voluntary and can be more effective in promoting good practices than mandatory regulatory mechanisms, and in most hospitals, accreditation processes appear to be the primary driver of safety efforts.¹⁰

ASPiH is a not-for-profit membership organisation with members from across the simulation community, our mission is to promote and support SBE in pursuit of best practice for our patients and learners. Crawford⁶ has highlighted the issue of accreditation being a money-making vehicle for simulation organisations. ASPiH believes that this should not be the case and has embedded accreditation as a membership benefit,³ incorporating costs into the membership fee structure to encourage more simulation providers to quality assure their practice.

We are heartened by the response from Bohnert and Lewis⁷ who suggest that the methods of the implementation science framework used by ASPiH to develop their standards are rigorous and ‘may be instructive to societies and networks in the development of professional standards’ and that ASPiH’s transparency through ‘the housing of its surveys, participants, pilot sites, and earlier drafts on the association’s website’ would allow future educators to ‘generalize ASPiH’s approach to developing standards to other content, practices, and associations.’⁷

We believe that as more simulation providers use the ASPiH standards to measure their practice, we will improve the quality of SBE that is provided, have a greater impact on patient care and prove that SBE is truly the new paradigm shift in education.