635CHAPTER 54
How to Assess Our Own Expertise: Certification and Accreditation
DEFINITIONS
For purposes of this chapter, the authors present the following definitions of terms:
1. Certificate of attendance—Certificates of attendance or participation are provided to participants who have attended or participated in classes, courses, or other educational or training programs. The certificate awarded at the completion of the program signifies that the participant was present and, in some cases, that the participant actively participated in the program. Demonstration of accomplishment of the intended learning outcomes by participants is not a requirement for receiving the certificate. Therefore, possession of a certificate of attendance or participation does not indicate that the intended learning outcomes have been accomplished by the participant. Examples include certificates of attendance provided at many conferences (Institute for Credentialing Excellence [ICE], 2010).
2. Certification—Professional or personnel certification is a voluntary process by which individuals (participants) are evaluated against predetermined standards for knowledge, skills, or competencies. Participants who demonstrate that they meet these competency standards, by successfully completing the assessment process, are granted a time-limited credential. To retain the credential, individuals must demonstrate continued competence. The credential awarded by the certification program provider denotes that the participant possesses particular knowledge, skills, or competencies. The assessment is independent of any specific class, course, or other education or training program (ICE, 2010).
CHSE—certified health care simulation educator
CHSE-A—certified health care simulation educator—advanced
CHSOS—certified health care simulation operations specialist
3. Accreditation—The process by which a credentialing or educational program is evaluated against standards defined by a third party. When in compliance with these standards, the program is awarded recognition. Accreditation is valuable because it enables organizations to demonstrate to the profession it represents and to the general public it serves, that their program has met the stringent standards set by the credentialing community. Accreditation also enhances a program’s credibility and legitimacy by providing impartial, third-party oversight of a conformity assessment system (ICE, 2010).
636BACKGROUND
History
Since the time of Florence Nightingale, nursing has based its practice on scientific principles that guide decisions based on research findings. The branch of knowledge we know as the art of nursing has arranged these truths or facts as best practices for clinical application, education, and future research endeavors. The use of simulation has entered the mainstream in health care education and practice. As simulation research evolves, the science of simulation contributes substantively to healthcare education and evidence-based practice.
Certification standardizes beliefs and practices that constitute high-quality simulation experiences. The process of certification has evolved through intentional deliberations that resulted in policy decisions. Certification in simulation is the logical next step, following recognition of simulation as a viable means of health care instruction, the increase in simulation centers, and the development of the simulation standards by the International Association for Clinical Simulation and Learning (INACSL).
The positive consequences of certification on simulation curriculum design and outcomes has been demonstrated in the literature. More than 160 studies, reports, and articles suggest that certified teachers in classrooms profoundly impact student learning. Similar results have been documented in the simulation literature. The connection between professional certification and the organization of instruction is evident in improved participant learning (National Board for Professional Teaching Standards, 2017). The notion of health care simulation certification has developed only recently. “Certification” may take many forms. There are intensive weeklong seminars that provide training to novice and experienced simulation educators and culminate with certificates of completion awarded to attendees. Basic core competencies in simulation learning methods, scenario building, and integration into health care curricula, specifically in nursing, are some of the topics presented (Monash University, 2012; National League for Nursing [NLN], n.d.). Postgraduate coursework in simulation is also available, along with academic degrees focused on simulation-based education. Although knowledgeable and experienced simulation experts offer these seminars, there is no central certifying agency for these academic-based courses, which would provide a reliable, best practice simulation program for individuals or institutions.
Historically, the National League for Nursing Accrediting Commission (NLNAC) and the Commission on Collegiate Nursing Education (CCNE) provide accreditation for nursing education programs by performing a systematic review of practices, outcomes, and operations that demonstrate adherence to standards associated with the nursing services provided. The Society for Simulation in Healthcare (SSH) began accrediting health care simulation programs in four key areas: assessment, research, teaching and education, and systems integration (SSH, 2012), but this accreditation is focused on simulation programs, not academic programs. The creation of the simulation standards by the INACSL as well as the certification and accreditation programs by SSH have initiated the process of requiring scientifically sound and consistent simulation practice founded on research-based principles.
From Societal Values to Professional Certification
Certification and accreditation offer assurances to the public that an individual or institution provides accurate and reliable simulation instruction and evaluation. Achieving certification suggests that the individual is able to perform at a predetermined level of expertise, in order to provide simulation experiences or services in a consistent and accurate manner within the scope of simulation knowledge and competencies. As stated earlier, certification in simulation can be earned by meeting the eligibility requirements for the certification test, applying for certification, and ultimately taking and passing the international certification examination.
637Certification, Fellowships, and Certificates of Attendance
The determination to obtain new knowledge may be daunting. Understanding the myriad options available to novice simulation users is important. Clarifying the differences among certification, fellowship, and certificate of attendance especially aids understanding.
As presented in this chapter’s definition of terms: certification evaluates against predetermined standards for knowledge, skills, or competencies. The method of evaluation can be examinations (knowledge), demonstration (skills), or a mixture of testing and demonstration (competencies). It is also a common practice to maintain certification, requiring the individual to continually demonstrate competence by attending education sessions specific to the field of certification. Some examples of health care certifications are critical care registered nurse (CCRN) and certified emergency nurse (CEN) credentials. One of the first health care simulation certifications offered was the SSH’s certification program. It offers certification as a health care simulation educator (CHSE), an advanced credential, the CHSE-A, and certification in health care simulation operations (CHSOS).
The SSH’s development of a simulation certification process began with an analysis of practice, developing an examination blueprint and piloting the examination. The CHSE blueprint was completed in 2011 and includes five domains: professional values and capabilities; knowledge of simulation principles, practice, and methodology; educating and assessing learners using simulation; managing overall simulation resources and environments; and engaging in scholarly activities. The CHSOS certification launched in 2014 and also includes five domains: concepts in health care and simulation; simulation modalities and technologies; health care simulation program practices, processes, and procedures; professional role development; and instructional design and theory. Although the CHSE and CHSOS credential are examination based, the CHSE-A credential requires a portfolio assessment. Candidates must be currently certified as a CHSE and meet other requirements before submitting a portfolio that includes video examples (Spain, Decker, & Kutzin, 2014).
Professional or personnel certification is a voluntary process. Participants who demonstrate that they meet these standards by successfully completing the assessment process are granted a time-limited credential. To retain the credential, the participant must maintain continued competence. The assessments are not designed to evaluate mastery of the intended learning outcomes of a specific class, course, or training program. The CHSE, CHSE-A, and CHSOS are the certification programs for simulation professionals. Table 54.1 shows an overview of several simulation programs.
Whereas certification leads to a recognized third-party credential that individuals can use to demonstrate meeting a minimum standard, certificates of attendance denote attendance and participation in education programs. These programs consist of lectures, group work, hands-on experiences, or a combination of these activities. Program length varies from a few hours to a week or more. Examples of simulation certificate programs are the Center for Medical Simulation’s Institute for Medical Simulation, Drexel University’s Certificate in Simulation, Institute for Simulation Educators (NLN), and Southern Indiana’s Clinical Simulation Certificate Program.
There are also fellowships in simulation through which a group of people with interest in simulation come together to obtain understanding and skills within the field of health care simulation. Fellowships vary in length and purpose. Some allow an individual to acquire new knowledge and skills. Others focus on improving the participant’s ability to create, operate, and facilitate simulations. Others focus on disseminating simulation information to stakeholders. Examples of these fellowships include the INACSL–Canadian Aviation Electronics (CAE) Healthcare Simulation Fellowship, which extends more than 6 months (INACSL, 2016), and the U.S. Veterans Health Administration’s Interprofessional Fellowship in Advanced Clinical Simulation, which runs over 2 years. The purpose of the latter is to develop leaders with vision, knowledge, and commitment to advance, implement, teach, and evaluate simulation-based training strategies for the improvement of health care for veterans and the United States (Veterans Health Administration, 2016).
The INACSL–CAE fellowship is a three-part program consisting of webinars, face-to-face workshops, and mentoring. Each cohort consists of no more than 30 participants and three facilitators. Facilitators are simulation experts with 5 or more years of experience creating and delivering effective simulation education globally. The fellowship is designed for new simulation educators, existing simulation educators who need additional support, and directors overseeing a simulation center (INACSL, 2016).
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642Academic programs focused on simulation are becoming more popular. Many degree-granting institutions offer programs focused on a particular area of simulation, such as Leadership in Simulation Instruction and Management (Robert Morris University) or Modeling and Simulation of Behavioral Cybersecurity Certificate (University of Central Florida). Others are more general in nature; examples are the Simulation Education Graduate Certificate (Bryan College of Health Sciences), the Master’s of Science in Healthcare Simulation (University of San Francisco), or the Master’s in Medical and Healthcare Simulation (MSMS) at Drexel University College of Medicine.
Topping and colleagues (2015) said it best, “Nurse educators require a far broader range of competencies than those just associated with designing, running and debriefing. They need to draw on extensive knowledge, behaviors, skills and demonstrate comportment acquired from both nursing and education” (p. 1112). Choosing an educational program, whether it is a week-long certificate course, academic program, fellowship, or other continuing-education program, is the first step in demonstrating competence in simulation. Achieving a recognized credential, such as the certified health care simulation educator (CHSE), certified healthcare simulation educator—advanced (CHSE-A), or certified healthcare simulation operations specialist (CHSOS) is becoming the standard for many simulation professionals.
Certified Health Care Simulation Educator
A CHSE has mastered the content of the health care discipline in which he or she is enrolled. Mastery includes comprehension of the subject matter as well as how to apply the content in a simulated experience. Mastery of how to use instructional simulation to achieve participant objectives requires the CHSE to employ a variety of facilitation methods and strategies for this purpose.
Values and principles of simulation professionals that make certification a realistic career goal reflect a commitment to a diverse body of learners and a working knowledge of how learners master the discipline-specific content and apply that content in a simulation scenario. When developing instructional methods for a simulation experience, the CHSE takes into account the cultural and individual variations among participants, their development of self-confidence, and self-efficacy, and what motivates participants to achieve objectives. Respect for others, cultural competence, and confidentiality and privacy are ethical practices to be considered as well.
A significant contribution that a CHSE makes to a successful simulation experience is keeping participants focused, engaged, and motivated to achieve objectives. This is accomplished in many ways, two of which are instructional organization and maintaining a structured and safe learning environment. Through formative assessment, the CHSE assesses the participant’s progress and can clearly communicate the participant’s performance to others.
The CHSE is proficient in critical and creative thinking. By designing simulation scenarios, creative talents are demonstrated. The CHSE studies the literature and critically appraises research findings, staying abreast of international trends in simulation, its learning theories, and instructional methodologies. The CHSE is a thoughtful professional who examines his or her own best practices for the purposes of integrating new study findings, an expanded knowledge base, and an increased skill set into his or her own simulation practice.
The CHSE is a member of an active and stimulating community of professionals. Collaborative discourse and dissemination of research findings form the basis of a cooperative alliance among fellow CHSEs in an effort to improve participant performance during simulation. Simulation policies, curricular threads, staff development strategies, and allocation of resources are some of the topics that bring CHSEs together in collaboration.
The public can expect the process of certification for CHSEs to accomplish what certification of teachers has done: improve participant outcomes, enhance professional development, 643and develop effective instructional methods for future practitioners in a variety of health care disciplines.
KEY ASPECTS OF SIMULATION: THE PROCESS OF CERTIFICATION
The process of certification sets rigorous and high standards for planning, implementing, and evaluating simulation experiences. Knowledge of the key aspects of simulation is essential for the certification of health care simulation professionals. Achievement of certification status can be demonstrated by following best practices in simulation, such as establishing realistic participant objectives, ensuring standardized exposure of participants to simulation scenarios, accurate measurement of participant outcomes, competent debriefing strategies, facilitating research, using adequate staffing and resources, and managing simulation centers effectively. Examples of how the CHSE might exhibit best practices in key aspects of simulation are described in this section.
Establishing Participant Objectives
Fundamental to an effective simulation experience is the establishment of participant objectives that serve as a guide to the development and execution of the simulation. CHSE is familiar with driving forces influencing the need for instructional and evaluative simulation experiences. Patient safety may be the front-runner in this regard, as are health care curriculum outcomes and desired patient care outcomes. With these societal needs as a framework, and the purpose of the simulation identified as instructional or evaluative, participant objectives are created with consideration for the participant’s knowledge level and clinical background. Because participant objectives are realistic and measurable, elements of the simulation scenario are predetermined accordingly.
High performance standards and rigor with respect to objectives are applied in the construction of participant objectives. Before the simulation experience, the CHSE provides unambiguous objectives to participants with respect to realistic time frames in which to meet the objectives. Objectives inform the participant of previously learned and newly acquired knowledge, skills, and attitudes required to complete the simulation experience.
For example, consider this part of a participant objective: “The participant will identify adventitious breath sounds.” This statement requires the participant to auscultate the thorax and identify an abnormal ausculatory breath sound, such as crackles or rhonchi. Demonstration of this assessment skill by the participant presupposes adequate instruction and practice on the physical examination of lung sounds. Rigor is evident as the CHSE develops the simulation scenario with this skill in mind and observes the participant to verify that the thorax was indeed auscultated correctly, with proper stethoscope use and placement on the chest.
Standardized Exposure to the Simulation Experience
The CHSE strives to preserve the integrity of the simulation scenario by maintaining confidentiality. Simulation coordinators and participants are responsible for safeguarding the content of simulation experiences. Disclosure of any part of an instructional scenario detracts from the learning process, may compromise participant objectives, and deprives the participant of the full effect of the simulation for professional growth and development. If the scenario’s purpose is summative evaluation, disclosure nullifies its validity.
Simulation educators have devised effective means of ensuring standardized exposure to evaluative simulation experiences. This can be accomplished with smaller groups of participants by simultaneously running the evaluation simulation for all participants. Of course, several simulation facilitators and labs are required when testing all participants at the same time. In contrast, 644larger numbers of participants may be required to sign confidentiality agreement forms. This method of providing confidentiality and standardized exposure to the simulation is more common and relies on an established and accepted honor system.
Measuring Participant Outcomes
Participant objectives drive the outcomes of a given simulation experience. Measurement of participant outcomes should follow a standardized procedure and format. The CHSE plans instruments, processes, and methods of measurement in advance. The effectiveness of the simulation experience is determined by evaluating participant outcomes.
Jeffries and Rogers (2007) describe participant outcomes as skill performance, acquisition of knowledge, development of critical thinking, and participant satisfaction and self-confidence. The CHSE ensures the valid and reliable measurement of these outcomes by using previously identified instruments that fit the summative assessment framework.
For example, participant self-confidence can be measured effectively by self-report. Questionnaires, journaling, and diary entries are valid methods used to assess self-confidence. Participant behaviors, such as psychomotor skills or communication techniques, have been assessed accurately using checklists, anecdotal notes, and direct observation. Attitudinal scales are instruments using a Likert-scale format and are useful for determining participant self-efficacy and participant satisfaction with an instructional strategy at a particular moment in time (Jeffries & Rogers, 2007). The CHSE remains accountable for the evaluation of participant outcomes by using accurate and dependable measurements.
Debriefing
Participant reflection enhances clinical judgment as part of the learning experience and is facilitated during the debriefing exercises that follow an instructional simulation. The CHSE is adept at identifying circumstances that encourage reflection, and therefore, intentionally incorporates reflection into the simulation’s debriefing session in order to further participant outcomes.
The CHSE is competent in providing a safe environment for the debriefing process in which trust, confidentiality, and open dialogue are encouraged and protected. Practice with this competency is required for mastery. Providing a safe learning environment requires a command of complex instructional variables and their interactions. Fundamental to the success of the debriefing process is experience with instructional variables, such as group dynamics, seating configuration, and establishing an atmosphere of acceptance. Too many participants or insufficient time for debriefing can invalidate the outcomes of the simulation experience. Many advocates of simulation affirm that a satisfactory debriefing session is required for an effective simulation experience.
Conducting Research
Best practices in simulation are established through scientific inquiry. In addition to using evidence-based research findings, the CHSE facilitates, performs, and evaluates simulation research. Because certification confers status related to high-performance standards on the individual knowledgeable in simulation, the CHSE uses research findings that reflect best practices by incorporating rigorous standards into the planning, implementation, and evaluation of simulation experiences.
Facilitating research is accomplished by the CHSE in a variety of ways. The CHSE occupies a strategic position for the development of research questions expanding knowledge related to simulation experiences. Decker (2007) lists examples, such as, “What conditions promote reflection during a simulated learning experience?” or “Does the integration of reflection into a simulated learning experience affect learning outcomes?” (p. 82). The CHSE facilitates research efforts by grant writing, collecting data, participating in interrater reliability studies, and analyzing simulation study findings.
645The CHSE carries out simulation research on a continuum. Discrete instructional strategies or evaluation techniques used during simulation have been investigated by CHSEs. Alternatively, the CHSE has been involved in comprehensive, complex, high-stakes, multisite scientific inquiries. In addition, the incorporation of technical staff into the simulation experience has been examined by CHSEs.
Evaluation research in simulation is a current focus in the literature. Valid and reliable instruments are needed to assess the effectiveness of simulation experiences. Once these instruments are developed, replication studies are required to establish validity and reliability. The CHSE is integral in testing the psychometrics of evaluation instruments. Regardless of the context or type of research, the CHSE is a leader in establishing simulation standards of best practice.
Managing Staff
The CHSE is an effective manager of personnel and resources necessary to carry out effective simulation experiences. The CHSE oversees support staff, often student workers, who stock the simulation lab and perform setup and cleanup activities. Additional support staff responsibilities managed by the CHSE include record keeping, ordering supplies, operating audiovisual and computer equipment, and peer tutoring of psychomotor skills. Graduate student staff are a good resource for participants who are new to the simulation experience. Student staff at the doctoral level are able to assist with research activities, such as data collection and analysis or evaluating study findings.
Professional staff assisting the CHSE may perform skills instruction or evaluate skills performance by participants. The CHSE may be responsible for professional and nonprofessional staff assisting in simulation activities for prelicensure students in addition to graduate students. Students enrolled in more than one health care discipline may be simulation lab consumers, and therefore under the supervision of the CHSEs.
Simulation Centers
Certified individuals may be the manager of a simulation center, a large simulation environment devoted entirely to simulated experiences. In this case, the certified individual must have a working knowledge of the planning, construction, and use of a complex physical structure or building serving several disciplines and curriculum levels. In a collaborative relationship, the CHSE may employ a newly evolving simulation professional—the simulation center architect. The value of this type of architect in the planning phase of a simulation center is significant.
The CHSE uses his or her knowledge of simulation experiences, required level of fidelity, health care courses, discipline-specific curricula, budgetary constraints, and dedicated physical space to assist in the planning and construction of the simulation center. The number of simulation labs with and without control rooms, classrooms, smaller debriefing rooms or conference rooms, skills testing areas, observation rooms, break rooms and areas for staff, and space for technologic infrastructure are all considered by the CHSE in setting up a simulation center. This is usually a collaborative effort with departmental or community partners as stakeholders. However, the CHSE takes the leadership role in the creation of the simulation center.
Certified Health Care Simulation Operations Specialist
A recent role in simulation has its origin in technology. The CHSOS is a specialized professional staff member who assists the CHSE with the technical operations of simulation scenarios. Some simulation educators are also simulation technicians, just as some simulation coordinators also function in this role. The CHSOS is acquainted with simulation content for courses, curricula, and health care programs, and is proficient in managing the environment needed to achieve participant outcomes. Although the CHSE and CHSOS are not mutually exclusive in larger simulation facilities, staff tend to become more highly specialized, thus leading them to choose one role or 646the other. However, in many simulation facilities staff function in multiple roles leading to many individuals obtaining both the CHSE and CHSOS credential to demonstrate their competence in both aspects of simulation.
Additional Considerations
The process of certification in simulation is rigorous and is designed to ensure that individuals achieving certification have met basic requirements as set forth by the certifying body. Although every key aspect of simulation cannot be accounted for in the certification process, many of the core knowledge areas are assessed, from the idea for a simulation scenario, to creating a simulation experience, to the evaluation of the effectiveness of a simulation, to the creation of multidisciplinary simulation centers. Experience and knowledge of simulation instructional and evaluation techniques are necessary to achieve the rigor characteristic of the status of certification. High standards of practice are required and are easily identified as the signature feature of the CHSE.
ACCREDITATION
General accreditation of simulation programs is conducted by the SSH. Both provisional accreditation and full accreditation are offered by SSH for simulation programs around the world. Provisional accreditation allows programs with established structure and processes but no outcomes to apply for this status. Full accreditation allows programs to be recognized for meeting the standards in a core set of criteria along with an additional specialty area, which includes assessment, research, teaching/education, or systems integration. To obtain full accreditation, simulation facilities must submit documentation and then also undergo a site visit to ensure they have met the standards (SSH, 2012). If successful, the simulation program is accredited for a term of 5 years, after which reaccreditation is required.
In addition to SSH, other organizations accredit simulation programs: the American College of Surgery (ACS), the American Society of Anesthesiologists (ASA), and the Veterans Health Administration (VHA) through its SimLEARN National Simulation Center initiative. The differences among these discipline-or agency-specific accreditations and the more general SSH accreditation is that the SSH accreditation program recognizes simulation expertise and is open to any agency conducting simulation-based training.
SIMULATION STANDARDS
INACSL set out to establish best practice standards for simulation early on in the evolution of healthcare simulation development. The INACSL is the only health care organization to date to create standards for simulation. It asserts that best practices in health care disciplines and curricula are reflected in standards of practice. According to INACSL, simulation standards are shared principles, beliefs, and values that provide the framework for decisions, policies, and procedures in academic or practice settings. INACSL standards are discussed in detail in Chapter 1.
The CHSE should have a working knowledge of these standards and how to apply them in educational and clinical environments. These standards for simulation experiences were designed not only for the purpose of establishing consensus among simulation experts with regard to the content of the standards, but also for meeting the needs of the health care providers using simulation. The standards can be applied to instruction, curriculum design, and participant evaluation in health care disciplines and curricula. In addition, the standards can be used as a framework for research development and testing. Regardless of the context within which these standards are used, they were developed to represent a best practice perspective, and hence are at the heart of all health care simulation certification efforts.
647The CHSE follows Standard I: Standardized Terminology by being conversant in the terminology of simulation. Likewise, the CHSE enforces the second standard that addresses professional integrity. However, one of the best practice principles of this standard requires the CHSE to safeguard the emotional and psychologic safety of participants interacting within the simulation setting.
The importance of Standard III: Participant Objectives and its interaction with the fourth standard describing facilitation methods holds the key to the effectiveness of the simulation experience with regard to participant outcomes. The CHSE has mastered a repertoire of methods for facilitating the achievement of participant objectives.
The CHSE is aware that time to think and problem solve on the part of the participant is necessary in a safe learning environment, and highlights the fifth standard addressing attributes and qualities of the simulation facilitator. Role modeling of ethical and professional actions is a quality of effective simulation facilitators.
Some simulation experts believe that debriefing is the most important part of a simulation exercise. Debriefing is the topic of the sixth simulation standard. The CHSE is aware that during debriefing activities, the participant learns to apply critical thinking methods. The CHSE must be skillful in directing the tone and direction of debriefing activities in order to maintain confidentiality, a safe learning environment, and the integrity of the simulation scenario.
A challenge to the CHSE is adherence to the seventh standard, which deals with evaluation of outcomes. Because formative and summative evaluation occur in simulation experiences, the CHSE must be purposeful and focused in eliciting expected outcomes, especially during high-stakes evaluations. A high-stakes evaluation determines outcomes of a simulation activity that have significant consequences, such as a major grading decision or ranking of the participant.
Contemporary evidence-based health care is a team effort, which drove the development of Standard VIII. Institute of Medicine recommendations, such as collaboration, professional communication, and related interprofessional health care provider skill sets, form the foundation for mastering this standard’s competencies. The nature of simulation-based experiences are effective approaches in meeting the outcomes of interprofessional education.
Design features are particular to the objectives of the simulation, as Standard IX states, thus maintaining the worth and value of the simulation-based experiences. A simulation developed with an instructional design has a purpose necessarily distinct from a simulation designed for testing and evaluation. Likewise, one can expect that instructional designs for different levels of learners should be different.
The CHSE who demonstrates expertise with these standards has invested time, effort, and commitment to the performance of best practices in simulation. Because the process of certification communicates to the public that the simulation educator has achieved a status defined by established standards of practice, adherence to these simulation standards is incorporated into the day-to-day work behaviors of the CHSE. Likewise, the accredited simulation center represents a cluster of best practice criteria fostering high-quality simulation-based experiences and staff. Consumers of health care education and its related disciplines should expect the highest level of performance when engaged in simulation-based experiences in accredited simulation centers hosted by CHSEs.
REFERENCES
Boise State Simulation. (n.d.). Healthcare simulation certificate. Retrieved from https://graduatecollege.boisestate.edu/programs2/healthcare-simulation
Bryan College of Health Sciences. (2017). Simulation education certificate. Retrieved from https://www.bryanhealthcollege.edu/bcohs/academic-programs/certificate-programs/simulation-certificate
Center for Medical Simulation. (2017). Simulation Fellowship and International Scholars Program. Retrieved from https://harvardmedsim.org/simulation-fellowship-and-international-scholars-program
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