Teaching Equity, Diversity, and Inclusion Through Simulation: A New Science

Abstract

In the first issue of its kind, Clinical Simulation in Nursing placed a call for manuscripts related to equity, diversity, and inclusion (EDI) in health care simulation. While the practice of simulation has been burgeoning, relatively little has been documented regarding its use in teaching challenging concepts such as EDI.As identified in the European strategic direction for Nursing and Midwifery (World Health Organization 2021World Health OrganizationBuilding better together. Roadmap to guide implementation of the Global Strategic Directions for Nursing and Midwifery in the WHO European Region. WHO Regional Office for Europe, Copenhagen2021Google Scholar), our professions comprise half of the global health care workforce, account for 90% of contact between patients and health professionals and hold a pivotal role in reducing health disparities and inequities between population groups. Nurses continue to influence policy, practice and care outcomes and are increasingly prioritizing research that explicitly addresses health inequities and social determinants of health (National Institute of Nursing Research 2022National Institute of Nursing ResearchNational Institute of Nursing Research 2022-2026 Strategic Plan Fact Sheet.2022https://www.ninr.nih.gov/sites/files/docs/NINR_One-Pager12_508c.pdfDate accessed: September 8, 2022Google Scholar). As a profession, we have also become increasingly cognizant of the social and structural determinants of education and the disparities these create among learners (Conference Participants Josiah Macy Jr. Foundation Conference on 2022Conference Participants Josiah Macy Jr. Foundation Conference onCOVID-19 and the impact on medical and nursing education.Academic Medicine. 2022; 97: S3-S11https://doi.org/10.1097/ACM.0000000000004506Crossref PubMed Scopus (1) Google Scholar; Murray, 2021Murray Teaching the social and structural determinants of health; considerations for faculty.Journal of Nursing Education. 2021; 60: 63-64https://doi.org/10.3928/01484834-20210120-01Crossref PubMed Scopus (3) Google Scholar). Educators are being prompted and perhaps challenged to evaluate existing structures and systems that impede health as well as student progression. So, what does this mean for us as health care simulation educators?First, we must recognize that research in simulation pedagogy, which employs an EDI framework, is often scant or at best, early stage. Because diversity is present in so many forms, one strategy may be to teach general concepts of cultural humility or to prioritize teaching efforts towards specific populations based on current health trends. Another strategy may be to adopt a values-based learning approach by embedding the concepts of care, compassion, courage, and commitment which as articulated in several national frameworks represent the core values underpinning nursing practice (Markey and Okantey, 2019Markey K. Okantey C. Nurturing cultural competence in nurse education through a values-based learning approach.Nurse Education in Practice. 2019; 38: 153-156https://doi.org/10.1016/j.nepr.2019.06.011Crossref PubMed Scopus (25) Google Scholar). Therein lays a unique opportunity for educators to create, build, and evaluate simulation scenarios that reflect population needs and fill existing gaps.Although a body of evidence in simulation may not yet exist, we can use the literature and draw upon evidenced based simulation practices to inform culturally diverse simulation design and implementation. First, we must acknowledge that those who identify as members of historically marginalized and underrepresented groups face unique and specific challenges in their health care experiences. We therefore support recent calls for meaningful inclusive partnerships with relevant communities so as to capture the uniqueness of these experiences and develop authentic learning experiences (Ní Chianáin et al., 2021Ní Chianáin L. Fallis R. Johnston J. McNaughton N. Gormley G. Nothing about me without me: A scoping review of how illness experiences inform simulated participants’ encounters in health profession education.BMJ Simulation and Technology Enhanced Learning. 2021; 7: 611-616https://doi.org/10.1136/bmjstel-2021-000886Crossref PubMed Scopus (2) Google Scholar).Second, as educators, we need to better create safe and inclusive learning environments. While it may sound simple, this feat requires establishing an environment that symbolizes value for diversity. From diverse signage to variations in skin tones of manikins and diverse standardized patients, the simulation center and virtual capabilities should reflect the diversity in our world. Similarly, diversity amongst faculty and students should be acknowledged, celebrated and indeed consciously expanded. Differences in opinion and individual perspective should be encouraged and welcomed. As simulation educators, we must also consider our own values and unique cultural lens and have sufficient skills to facilitate authentic, sometimes uncomfortable conversations while taking cognizance that scenarios may in fact reflect the lived reality of some participating students (Fioravanti et al., 2018Fioravanti M.A. Puskar K. Knapp E. Kane I. Terhorst L. Mitchell A.M. Lindsay D. Creative learning through the use of simulation to teach nursing students screening, brief Intervention, and referral to treatment for alcohol and other drug use in a culturally competent manner.Journal of Transcultural Nursing. 2018; 29: 387-394https://doi.org/10.1177/1043659617727832Crossref PubMed Scopus (17) Google Scholar). Further, strategies such as Prebriefing for Cultural Humility (Foronda et al., 2022Foronda C.L. McDermott D.S. Crenshaw N. Prebriefing for Cultural Humility.Clinical Simulation in Nursing. 2022; (Online publication ahead of print)https://doi.org/10.1016/j.ecns.2022.02.008Abstract Full Text Full Text PDF Scopus (1) Google Scholar) and Debriefing for Cultural Humility (Foronda, 2021Foronda C.L. Debriefing for cultural humility.Nurse Educator. 2021; 46: 268-270https://doi.org/10.1097/NNE.0000000000000957Crossref PubMed Scopus (4) Google Scholar) may be used in simulation. For those in academia, a paradigm shift is needed for faculty to use competency-based education yet exude flexibility.Third, we will look to advance science and influence policy in the area of EDI in simulation. Currently, the Healthcare Simulation Standards of Best Practice (INACSL Standards Committee, 2021INACSL Standards Committee Healthcare Simulation Standards of Best PracticeTM.Clinical Simulation in Nursing. 2021; https://doi.org/10.1016/j.ecns.2021.08.018Abstract Full Text Full Text PDF Scopus (6) Google Scholar) do not guide us specifically on the best practices to promote EDI. Some would argue that there is not enough research to support development of such a standard at this time. Until there is a robust body of evidence, this gap will remain. Therefore, it is critical that high quality, comprehensive EDI simulation research is conducted to evaluate learner outcomes so that best practices may be assembled and shared.It is our hope that this special issue brings awareness to the need for EDI in simulation. It is exciting to view the creative approaches that other simulation educators have used in this issue to promote health for historically marginalized and underrepresented individuals and groups. Although the science of EDI in health care simulation is new, let us be inspired to spearhead measures to impact learners as well as the patient populations for whom we care. In the first issue of its kind, Clinical Simulation in Nursing placed a call for manuscripts related to equity, diversity, and inclusion (EDI) in health care simulation. While the practice of simulation has been burgeoning, relatively little has been documented regarding its use in teaching challenging concepts such as EDI. As identified in the European strategic direction for Nursing and Midwifery (World Health Organization 2021World Health OrganizationBuilding better together. Roadmap to guide implementation of the Global Strategic Directions for Nursing and Midwifery in the WHO European Region. WHO Regional Office for Europe, Copenhagen2021Google Scholar), our professions comprise half of the global health care workforce, account for 90% of contact between patients and health professionals and hold a pivotal role in reducing health disparities and inequities between population groups. Nurses continue to influence policy, practice and care outcomes and are increasingly prioritizing research that explicitly addresses health inequities and social determinants of health (National Institute of Nursing Research 2022National Institute of Nursing ResearchNational Institute of Nursing Research 2022-2026 Strategic Plan Fact Sheet.2022https://www.ninr.nih.gov/sites/files/docs/NINR_One-Pager12_508c.pdfDate accessed: September 8, 2022Google Scholar). As a profession, we have also become increasingly cognizant of the social and structural determinants of education and the disparities these create among learners (Conference Participants Josiah Macy Jr. Foundation Conference on 2022Conference Participants Josiah Macy Jr. Foundation Conference onCOVID-19 and the impact on medical and nursing education.Academic Medicine. 2022; 97: S3-S11https://doi.org/10.1097/ACM.0000000000004506Crossref PubMed Scopus (1) Google Scholar; Murray, 2021Murray Teaching the social and structural determinants of health; considerations for faculty.Journal of Nursing Education. 2021; 60: 63-64https://doi.org/10.3928/01484834-20210120-01Crossref PubMed Scopus (3) Google Scholar). Educators are being prompted and perhaps challenged to evaluate existing structures and systems that impede health as well as student progression. So, what does this mean for us as health care simulation educators? First, we must recognize that research in simulation pedagogy, which employs an EDI framework, is often scant or at best, early stage. Because diversity is present in so many forms, one strategy may be to teach general concepts of cultural humility or to prioritize teaching efforts towards specific populations based on current health trends. Another strategy may be to adopt a values-based learning approach by embedding the concepts of care, compassion, courage, and commitment which as articulated in several national frameworks represent the core values underpinning nursing practice (Markey and Okantey, 2019Markey K. Okantey C. Nurturing cultural competence in nurse education through a values-based learning approach.Nurse Education in Practice. 2019; 38: 153-156https://doi.org/10.1016/j.nepr.2019.06.011Crossref PubMed Scopus (25) Google Scholar). Therein lays a unique opportunity for educators to create, build, and evaluate simulation scenarios that reflect population needs and fill existing gaps. Although a body of evidence in simulation may not yet exist, we can use the literature and draw upon evidenced based simulation practices to inform culturally diverse simulation design and implementation. First, we must acknowledge that those who identify as members of historically marginalized and underrepresented groups face unique and specific challenges in their health care experiences. We therefore support recent calls for meaningful inclusive partnerships with relevant communities so as to capture the uniqueness of these experiences and develop authentic learning experiences (Ní Chianáin et al., 2021Ní Chianáin L. Fallis R. Johnston J. McNaughton N. Gormley G. Nothing about me without me: A scoping review of how illness experiences inform simulated participants’ encounters in health profession education.BMJ Simulation and Technology Enhanced Learning. 2021; 7: 611-616https://doi.org/10.1136/bmjstel-2021-000886Crossref PubMed Scopus (2) Google Scholar). Second, as educators, we need to better create safe and inclusive learning environments. While it may sound simple, this feat requires establishing an environment that symbolizes value for diversity. From diverse signage to variations in skin tones of manikins and diverse standardized patients, the simulation center and virtual capabilities should reflect the diversity in our world. Similarly, diversity amongst faculty and students should be acknowledged, celebrated and indeed consciously expanded. Differences in opinion and individual perspective should be encouraged and welcomed. As simulation educators, we must also consider our own values and unique cultural lens and have sufficient skills to facilitate authentic, sometimes uncomfortable conversations while taking cognizance that scenarios may in fact reflect the lived reality of some participating students (Fioravanti et al., 2018Fioravanti M.A. Puskar K. Knapp E. Kane I. Terhorst L. Mitchell A.M. Lindsay D. Creative learning through the use of simulation to teach nursing students screening, brief Intervention, and referral to treatment for alcohol and other drug use in a culturally competent manner.Journal of Transcultural Nursing. 2018; 29: 387-394https://doi.org/10.1177/1043659617727832Crossref PubMed Scopus (17) Google Scholar). Further, strategies such as Prebriefing for Cultural Humility (Foronda et al., 2022Foronda C.L. McDermott D.S. Crenshaw N. Prebriefing for Cultural Humility.Clinical Simulation in Nursing. 2022; (Online publication ahead of print)https://doi.org/10.1016/j.ecns.2022.02.008Abstract Full Text Full Text PDF Scopus (1) Google Scholar) and Debriefing for Cultural Humility (Foronda, 2021Foronda C.L. Debriefing for cultural humility.Nurse Educator. 2021; 46: 268-270https://doi.org/10.1097/NNE.0000000000000957Crossref PubMed Scopus (4) Google Scholar) may be used in simulation. For those in academia, a paradigm shift is needed for faculty to use competency-based education yet exude flexibility. Third, we will look to advance science and influence policy in the area of EDI in simulation. Currently, the Healthcare Simulation Standards of Best Practice (INACSL Standards Committee, 2021INACSL Standards Committee Healthcare Simulation Standards of Best PracticeTM.Clinical Simulation in Nursing. 2021; https://doi.org/10.1016/j.ecns.2021.08.018Abstract Full Text Full Text PDF Scopus (6) Google Scholar) do not guide us specifically on the best practices to promote EDI. Some would argue that there is not enough research to support development of such a standard at this time. Until there is a robust body of evidence, this gap will remain. Therefore, it is critical that high quality, comprehensive EDI simulation research is conducted to evaluate learner outcomes so that best practices may be assembled and shared. It is our hope that this special issue brings awareness to the need for EDI in simulation. It is exciting to view the creative approaches that other simulation educators have used in this issue to promote health for historically marginalized and underrepresented individuals and groups. Although the science of EDI in health care simulation is new, let us be inspired to spearhead measures to impact learners as well as the patient populations for whom we care.