News and Commentary Redesigning simulation-based learning environments to promote DEI and cultural humility

Headshots of Drs. Cynthia Foronda, Ruth Everett-Thomas, and Desiree A. Díaz
From left to right: Drs. Desiree A. Díaz, Ruth Everett-Thomas, and Cynthia Foronda (2018 Macy Faculty Scholar)

The use of simulation in nursing and medical education has been a useful teaching modality for many years, but with the onset of the COVID-19 pandemic, the need for simulation intensified. As with so many aspects of health professions education, we are now at a point in the pandemic where we have the opportunity to reexamine the way in which simulation-based education is delivered and seek opportunities for improvement. In this edition of Macy Notes, and in honor of Healthcare Simulation Week 2022, guest authors Drs. Cynthia Foronda (2018 Macy Faculty Scholar), Ruth Everett-Thomas, and Desiree A. Díaz share their recommendations on how faculty, and their learners, can work to ensure more inclusive simulation-based learning environments.

The report from the 2021 Josiah Macy Jr. Foundation Conference on COVID-19 and the Impact on Medical and Nursing Education recommends that “leaders and educators in academic health systems and health professions education institutions must collaborate with their learners to enhance health professions education by redesigning learning environments to prioritize antiracism, diversity, equity, inclusion (DEI), and cultural humility….” To enact this change, we must ask ourselves, “are our current learning environments inadvertently contributing to systemic inequities?” In order to improve learning environments, we must first recognize that many educational settings are unconsciously biased. The simulation center is no exception. Research has repeatedly demonstrated that racial diversity and cultural humility is lacking in simulation. Our aim is to bring to light the initial steps to examine and redesign simulation-based learning environments.

As health professions educators, many of us become familiar with and comfortable in our common work surroundings. We have much on our minds and it rarely occurs to step back and look for signs (implicit or explicit) of DEI. One suggestion is to schedule a walk-through of the simulation center to simply observe the visible surroundings. Conduct an environmental assessment and take note of the signage and images exhibited. Is diversity represented? Are photos of one particular race or gender repeatedly displayed? Are there any signs posted that suggest the environment is supportive of students or that diversity is valued? Examine the manikins and task trainers used. Are they of multiple skin tones?  The same applies to the standardized patient pool. When we look at the standardized patients who participate in simulation, are they diverse? Do any of them have an accent? Are the simulation facilitators or faculty diverse? Although it may seem basic, the environmental assessment is important because it contributes to learners’ first impressions of the learning space.

A second step may be to solicit the opinions of the learners who partake in the simulations. For example, consider using mixed methods approaches to obtain a pulse on the current learner perceptions of the simulation-based educational environment. The use of surveys is a helpful approach as they provide a level of anonymity that may offer more freedom to express one’s true opinion. Interviews or focus groups are other methods that often lead to rich discussions, impactful stories of personal experiences, and suggestions for improvement. Obtaining data from learners will provide a voice to inform simulation design and practices.

Third, involve learners in the examination of the simulation curriculum. How are the simulations created? Are they mapped in the curricula to scaffold information? Do they represent any healthcare disparities that are currently present? When developing simulation scenarios, it is important to co-create them. Having a participatory community group that is engaged in the creation and design of scenarios is recommended. A representative of the community being portrayed adds value to scenario design and can add content expert validation. Create a grid of all of the diversity characteristics you wish to see in the simulation curriculum and plot them out. Are LGBTQ+ members represented?  Is there one simulation that focuses specifically on LGBTQ+ health, or are LGBTQ+ families normalized and threaded throughout the curriculum? Map out the various social determinants of health (SDOH) that are addressed to assure inclusivity of varying communities. Are low-literacy, low-income, or non-English speaking families represented? Consider the current health disparities in our country and assure the simulation curriculum addresses the major ones. This activity will help to identify gaps as well as areas that may be overrepresented.

When administering the simulations, consider new guiding frameworks. You may discuss ground rules for cultural humility to establish a common mindset. Explore new means of fostering psychological safety or prebriefing such as using the method of Prebriefing for Cultural Humility©. Using ground rules and this prebriefing framework helps prepare the learners for open and brave discussions related to their learning experiences. It is important to think about the prebrief and acclimate learners to the simulation-based learning setting. Further, it is necessary to have a structured debrief for optimal learning results. In particular, the use of Debriefing for Cultural Humility© encourages contextual learning. In this novel approach to debriefing, facilitators break down the simulation to help learners appreciate the diversity, context, power imbalances, attributes, and outcomes of cultural humility. Instead of focusing solely on traditional skills through simulation, this approach places emphasis on the missing curriculum surrounding SDOH, population and community health, prevention and health promotion, and health equity.     

In the case of a true system redesign, it is important to anticipate the time and resources needed for faculty development. Prior to implementing new content that may evoke visceral reactions from both learners and faculty, faculty may require support through training in implicit bias, how to prebrief and debrief, as well as best practices in simulation. Faculty will benefit from education about health disparities and social determinants of health, as well as implementing new approaches to simulation pedagogy. A strong foundation in simulation facilitation and design is critical. Faculty should be trained on how to mitigate conflict and have a de-escalation plan in advance. Faculty may benefit from mindfulness training to elicit compassion and empathy from all participants. In sensitive simulations, educators will wish to be especially attuned to the learners. Influences such as social media have led to increased polarization, hostility, and bullying, creating the need to redesign simulation training to be more inclusive and address current societal issues. We also suggest the pedagogy of simulation itself as the preferred way of training faculty.  

The most essential step in redesigning learning environments to include DEI, SDOH, and health disparities content is to start. Educators should become deliberate in their assessment of the current climate and culture, educational setting, curricular content, and vision for the future. Now is the time to identify gaps, explore new educational frameworks, and invest in time and resources to develop faculty. As our world diversifies, evolves, and changes, so too must our educational practices.

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