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Table 2 Impacts of EDI tool on SDT culture, skills, and practices

From: Exploring equity, diversity, and inclusion in a simulation program using the SIM-EDI tool: the impact of a reflexive tool for simulation educators

Impact

Explanation

Example

Team reflexivity

The tool effectively prompted the team to examine their own feelings, reactions, motives, sources of power, and make-up and how those may have impacted the simulation design, delivery, or debriefing

“I wasn’t doing the debriefing for that case but we ended up having a bit of a discussion [in the SDT debrief] about why we didn’t go there [into a conversation about gender in the workplace]. It ended up being valuable for our group because it allowed some introspection for us as debriefers first to think about why or why not, we would go there. And maybe I would have been too quick to go there because it’s something that I’m interested in and I think is quite important. But that might not be the same for everybody. So just starting that conversation within ourselves.”—Participant 4, follow up interview

“I think it gets people thinking because I don’t think we generally take time to stop and think about it.. you know underlyingly thinking about equity, diversity inclusion, I think it makes you stop and actually think, "Am I doing that? And am I doing it well? Or am I at least making some sort of effort towards changing?”—Participant 2, follow up interview

“I am unsure if this [a faculty member asking the SP if he wanted to change his assigned name] was odd, insensitive or actually quite thoughtful. It was awkwardly brushed over and he declined to change. I am not sure how he felt about it, but the conversation made me uncomfortable. Perhaps I should have enquired more.”—anonymous self-reflection

Normalization of conversations related to EDI among the SDT

The team identified that regular conversations about topics related to EDI became normalized within the simulation team organizational culture

“It, it’s not really a faux pas at all anymore. It’s just, it’s just part of the conversation now. Which, which it wasn’t before…After any simulation that we do, you could say, "Oh shall we have a chat about EDI?", and everyone would just fall into place and be like, "Yeah, no worries. Let’s talk about it.". Whereas before, that would have been an odd conversation to have.”—Participant 6, follow-up interview

Building confidence to engage in EDI conversations with sim participants

Many on the team felt more confident in engaging in debriefing conversations related to EDI topics and reflected on how general simulation debriefing skills translate well into conversations related to EDI. However, many still feel less comfortable than in conversations related to standard teamwork and medical concepts

“I guess I just feel much more confident about naming a dynamic if it was there… If I thought there was some discomfort and some tension, I would be confident to name that as part of my debriefing repertoire, whatever was the source of that, including EDI. I would like to think I would do that in the same spirit as most things, which is, “Tell us how you’re thinking, tell us if we’ve got this wrong somehow?”, not with the idea of telling people how they should manage it.”—Participant 7, follow-up interview

“I suppose the summary [of the impact] would be it’s just engaging in conversations I would most likely previously have avoided.”—Participant 6, follow-up interview

“That kind of degree of trepidation, at least for me, it has not kind of fully not at all resolved in this seven month period, like at the beginning all of the interviews and I think discussions we were having a group there’s a lot of fear around that specifically. And I think we maybe have a bit more insight into that fear now and can couch it but definitely has not been resolved”—Participant 1, follow-up interview

Highlighting complexity

Conversation prompted by the tool started to unravel the complexities of EDI in simulation. The team began to wrestle with, but rarely reconciled, the trade-offs and impacts of decisions related to design, delivery, and debriefing

“Where’s the line between what is a case that you have to do that [get input from a relevant group] for and a case that you don’t? It probably changes for everybody. So, if I designed a paediatrics simulation with parents who play an important role in that simulation, but I’m not a parent—do I have to reach out to a parent to inform that perspective and design of the case?…It probably depends on what the learning objectives are, and how dependent that is on the scenario. So…it starts to get a little bit complicated when you when you think of it all. You can kind of understand why people’s reaction is oh, well, we actually just won’t do that. Because it sounds hard.”—Participant 4, follow-up interview

Value signposting

The implementation of the tool effectively signaled to the SDT that EDI is an important value of the simulation service

“There is a certain sort of sense of almost like duty that this something we’re supposed to do. So whereas before you could be completely oblivious to it [EDI]…now, not addressing it, I think would feel like a failure. So there’s increasing confidence by doing it but it’s almost now an expectation.”—Participant 6 follow-up interview

“I guess it is a valuable cultural tool in terms of signalling the importance of EDI issues in a team. If all the leadership in medical education, wherever I was, were on board, I think that would just say something really powerful about the value that’s placed on EDI.”—Participant 8, follow-up interview

Team familiarity

The tool was a vehicle for the SDT to engage in meaningful conversations with each other which led to deeper understanding of colleagues

“The opportunity to have actual in depth, real conversations with my colleagues that are not just superficial is powerful. I have learned things about my colleagues that I didn’t know, that has actually been good, but also sometimes a little bit confronting. I think they have actually allowed us to grow more as a team and become a little bit closer and more understanding of where everybody’s at.”—Participant 4, follow-up interview

Marginal changes

There were no large-scale changes or new programs introduced. SDT members described some small changes such as patient names and demographics, more frequently engaging in an “Acknowledgement of Country”, and many subtle choices related to debriefing topics. These changes were marginal and hard to measure. These changes were at times challenging for the SDT team to appreciate

“We made an effort to be aware of the diversity and inclusion more prominently, during our simulations from giving an acknowledgement of country…and then also, just being aware in terms of points we might be noticing from different positions in the team, or interactions between a family or between a patient and the team. I think we tried to be more aware of those issues in our debriefing topics that we chose to discuss.”—Participant 8, follow-up interview

Translation into Clinical Practice

SDT members agreed that simulation is a place where signalling and role-modeling around EDI within the organization is occurring. Some members of the SDT in clinical roles felt that the tool enhanced their understanding and approach to EDI, not only in simulation but also within the clinical workspace

“I think that the language that makes up how I think what we will be doing is essentially role modeling how we would expect people to broach the topic, and how we might tactfully and safely in a psychologically safe way. Raise the potential that people may have experienced some degree of bias or stereotyping in a simulation will serve as an excellent role model for people who need, or who ought to raise similar concerns in a clinical environment.”—Participant 1, initial interview

“I think what it has changed for me a lot is the way that I approach diverse patient groups on the floor. And it has allowed me to have a lot more open questioning, and then also a lot more understanding for my teams on the floor.”—Participant 5, follow-up interview