Equity, Diversity, and Inclusion in Simulation – A Reflexive Tool for Simulation Delivery Teams

By Eve Purdy (@purdy_eve), Victoria Brazil (@SocraticEM) and Ben Symon (@symon_ben)

You are a simulation facilitator working in a tertiary care emergency department. Over the past few months you have been working with ED teams to get to patients to the CT scanner “fast and safe”. Today you delivered a simulation case related to a Category A head injury. Ryan, a 24-year-old man was assaulted. He suffered an isolated head injury and was GCS 8 on scene and was intubated by paramedics. On arrival in the ED the team worked quickly to assess him and identify life threatening injuries. They made it to the CT scanner in 10 minutes. During the debrief, the team discusses trade-offs between safety and speed. There were plenty of actionable ideas about how we might improve. At one point a senior member of faculty, who dropped in on the simulation session, told a story about an overweight patient getting stuck in the CT scanner. The comment makes you a bit uncomfortable but the group laughed and so you just move quickly past it to get back to some of the core content. After the session, you and the simulation delivery team (SDT) meet to talk about what went well and what could have gone better.

The international simulation community is currently reckoning with how to best incorporate and approach equity, diversity, and inclusion (EDI) in simulation. (1-6) There seems to be two main discourses:

  • Ensuring that there is meaningful, non-tokenistic, representation of various groups in existing simulation content. For example, one recent study showed that of nine cases presented in an advance life-support course zero were female patients. (1,4) This type of oversight promotes systematic bias – in this case it may prime learners to consider more “serious” heart problems in men and less so in women. Similar issues related to other types of diversity (race, culture, socioeconomic status etc.) in the creation of cases.
  • Deliberately addressing objectives related to EDI in the design, delivery, and debriefing of simulation is an area of potential growth. (3,5,6) While a worthy goal that may allow simulation teams to explore important concepts related to topics such as bias, communication, microaggressions etc. there are also real risks such as stereotyping and identity threats.

Our research group’s recent work shows that simulation is a moment of cultural compression – a time when the values and beliefs are transmitted with particular efficiency. This reality underscores the importance for simulation teams to 1) understand if/how we might be doing unintentional harm and 2) identify ways to foster positive growth as it relates to EDI. (7) Despite the clear need, there is limited guidance available from the simulation community about how best to deliberately address and embed EDI topics for groups interested in taking this next step with their teams.

There are many possible next steps, a crucial one is vigilant self-awareness.

Being anti-racist, diverse, inclusive, and equitable in approach must be a priority for educators, facilitators, and clinicians. (8) This requires continuous self-education, reflection, and interrogation of practices and assumptions. We must develop routines that commit us to deliberate choices that we then carry out with intention. There is not a quick solution or easy intervention. It requires ongoing negotiation with where we are and who we want to be.

Towards that goal, our simulation service has decided to incorporate and study a tool to enhance the reflexivity of the SDT as it relates to our design, delivery, and debriefing of simulations through an EDI lens.

We are confident that SDT reflexivity is an important step in advancing the ability of our group to support high performing teams as they work with diverse colleagues and care for diverse patients. Over the next six months we will engage in a collaborative autoethnography to explore how this tool impacts our team and our approach to design, delivery, and debriefing of simulation. We are choosing to share this tool ahead of that research because we feel strongly that these conversations frankly cannot wait. We encourage you to adapt it for your own teams and are interested in any experience or suggestions you have along the way.

Back to the case…

Your SDT has just started to use a conversation guide to debrief simulations. After discussing a couple of quick technical glitches, the group launches into a discussion using the tool. A few important issues are raised.

PromptIssues Raised
EDI in this simOne of the simulation service members points out that during the “CT Fast and Safe” simulation curriculum there hasn’t been a female patient. The team discusses that many – but not all –  severe isolated head injuries are in young men. They voice that this may have driven the design decisions but collectively see that this is not representative of all head injury patients and discuss the potential impact on participants.
Missed opportunitiesYou share that you missed an opportunity in the debrief. You were uncomfortable with the story raised by your more senior colleague about the obese patient getting stuck in the CT scanner. You know that overweight patients are subject to bias from healthcare professionals but you did not address this overtly problematic statement in the moment. You discuss with the team the factors that prevented you from doing so. You know that in the moment it could have been a very powerful time to explore an important issue. One of your co-debriefers suggests that you rehearse the words you wish you had chosen. Together you engage in a quick 1-minute role-play to try out a better approach.
HarmsThere were no clear harms associated with the design of the case itself however, the team does talk about the harms associated with comments made by the senior ED staff and more importantly the failure of the debriefers to address these in the moment. The team recognizes that this is a critical time when stories can strongly transmit values and culture. You also recognize that there may have been participants who felt directly targeted by the statements.
BiasesYou look at your SDT and see a rather fit group. The team talks about their own biases associated with obesity in the delivery of healthcare and in the delivery of education. Many agree these perspectives may have contributed to not addressing the comment directly.
Action itemsInterrogation of the CT Fast and Safe cases for gender and race diversity and adaptation of cases as needed –simulation service member to completeCoffee with the senior colleague who made the comment to discuss the impact it had on you and potentially on participants – you, as the team lead, decide to take this one onFinding one article/video/blog about weight bias in healthcare for the SDT to read and to share (in context) with participants along with the regular reading that goes out after the simulation session – simulation fellow to complete

Though the simulation session started with “Getting to CT Fast and Safe”, this tool has unearthed many other important aspects of learning that are happening whether we want them to or not, and whether we choose to see them or not. It forces the simulation team to critically examine their own perspectives and understand how what they do actively transmits values and beliefs. Hopefully, over time, it will spark the reflection and prompt the actions that move us closer towards our ideals of delivering simulation…and healthcare… that is equitable, diverse, and inclusive.


  1. Silverman, L. S., & Fabi, R. (2021). Deadly bias: a call for gender diversity in cardiac life support simulation training.
  2. Palaganas, J. C., Charnetski, M., Dowell, S., Chan, A. K. M., & Leighton, K. (2021). Cultural considerations in debriefing: a systematic review of the literature. BMJ Simulation and Technology Enhanced Learning, bmjstel-2020.
  3. Foronda, C. L., Baptiste, D. L., Pfaff, T., Velez, R., Reinholdt, M., Sanchez, M., & Hudson, K. W. (2018). Cultural competency and cultural humility in simulation-based education: An integrative review. Clinical Simulation in Nursing15, 42-60.
  4. Foronda, C., Prather, S. L., Baptiste, D., Townsend-Chambers, C., Mays, L., & Graham, C. (2020). Underrepresentation of racial diversity in simulation: An international study. Nursing education perspectives41(3), 152-156.
  5. Markey, K., Doody, O., Kingston, L., Moloney, M., & Murphy, L. (2021). Cultural competence development: The importance of incorporating culturally responsive simulation in nurse education. Nurse Education in Practice52, 103021.
  6. Buchanan, D. T., & O’Connor, M. R. (2020). Integrating Diversity, Equity, and Inclusion into a Simulation Program. Clinical Simulation in Nursing49, 58-65.
  7. Purdy, E., Alexander, C., Caughley, M., Bassett, S., & Brazil, V. (2019). Identifying and transmitting the culture of emergency medicine through simulation. AEM education and training3(2), 118-128.
  8. Kendi, I. X. (2019). How to be an antiracist. One world.

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