Table 3 Fears related to navigating EDI in simulation
Fear | Explanation | Evidence |
|---|---|---|
Tokenism | The team was concerned about worried about empty symbolic nods to EDI that did not have meaningful impact | “I don’t really think there’s been very much design change. I suspect, there’s probably some roads that we could improve on with design, but also, I think it’s potentially one of the most difficult and or dangerous things to try and change because there’s certainly a risk of being tokenistic.”—Participant 6, Follow-up interview |
Stereotyping | The team was concerned about the risks of stereotyping patients in design and delivery of simulation. They reflected on the powerful signalling that simulation sends and were concerned about the problems associated with negatively or inaccurately portraying a group. Most participants had problematic experiences they could draw on that they feared recreating. The team reflected however, that we do rely on some form of stereotyping in the portrayal of all our patients and that navigating appropriate and inappropriate representation is a complicated issue | “[I worry about] stereotyping and also then having conversations that about people without people. And also getting into generalizations when specifics matter about populations or groups and just saying things like, ‘they always don’t want to make eye contact and other such shit things that we’ve heard about groups’… I do think most people are trying to do something good. But that isn’t good enough.”—Participant 7, Follow-up interview “[recalling a scenario during training] then the case started and the mannequin’s voice was basically the simulation tech in a Jamaican accent and this person had been found down outside of this supervised consumption site and was in torsades, because their methadone interacted in prolonging their QTc. So they basically played into every damaging, problematic stereotype that one could imagine with the black mannequin being the first time that any of us had seen it. Everybody in the room felt extremely uncomfortable”–Participant 4, Follow-up interview “We would never in a million years, have someone play a black person who wasn’t black. And yet it occurs to me that we have simulated patients playing dementia patients every month. And it seems that old people, for some reason it’s fine to appropriate their experience… I don’t know what the answer is.”—Participant 7, Follow-up interview |
Being Offensive | Participants feared causing offense to populations as well as participants in both simulation design, delivery, and debriefing. This fear of being offensive likely underpins why some topics felt easier to broach while others more challenging | “I think that’s what, for me, can be a little uncomfortable when you walk into territory where you have the potential to cause offence to people, because you don’t, you know, you don’t want people to walk away from the simulation, either a) offended by what was said, or what was discussed, or how a case was portrayed, or b) Walk away with a negative experience.”—Participant 10, Follow-up interview “I think people find themselves addressing issues related to diversity, equity & inclusion, that they feel on safe ground with, whether that be because they have a personal experience or a personal lens, or something that gives them some credibility, I think is probably a big worry for people. I think if I had to boil it down to one, worry, that would be it, would be credibility.”—Participant 4, Follow-up Interview |
Maintaining Psychological Safety | Participants recognized that psychological safety might be threatened by challenging conversations and that having such conversations could be harmful with a group that does not feel safe. At the same time, they recognized that if psychological safety has been appropriately fostered, simulation could be the perfect place to have difficult discussions. Participants realized that different debriefers will have varying skill and comfort level in navigating this delicate balance | “You know, I guess you get a bit uncomfortable, because they’re, you know, they are potentially some high stakes conversations. But I think for me, it’s just about being very explicit that we can we come at this from a place of, of learning and practice improvement?” —Participant 10, Follow-up interview “And then the thing is that with any kind of scenario, it all depends on who’s going to be the participants and who’s going to be debriefing, as well. Because if you’ve got someone that may not necessarily have the debriefing skills to bring it up in a sensitive way, there is a lot of potential to do harm as well.”—Participant 5, Follow-up interview “It sounds like we’re a little bit fearful that that might threaten psychological safety but at the same token, wouldn’t it be great to be able to discuss and reflect on those feelings of discomfort in a place that I think we’ve tried very hard to make really safe”—Participant 9, Follow-up interview |
Signal-to-noise mismatches | Participants worried that some attempts to increase diversity and representation may detract from the “medical learning” or objectives for the case as learners inappropriately focus on those cues. They discussed this problem s diagnostic of a broader issue within education but also found that navigating the real considerations it presents a challenge | “There’s this sense that if you mix things up a little bit like make the patient demographics or the situation, more culturally or ethnically variable, that sometimes that would seem to be a bit like noise for the participants, like they would start focusing on why that is and looking for another message or agenda.”—Participant 10, Follow-up interview |
Sim as the appropriate method | Participants, while acknowledging that EDI was relevant to simulation, worried that it may not always be the right forum to specifically approach learning objectives specifically related to EDI. Matching learning objectives with appropriate modality was highlighted as an ongoing concern for educators | “We risk not approaching or talking about these things but it could be that the way that we actually do it needs to be different…simulation may not actually be the right modality. To do that, it could be that some case based conversations are actually a more powerful way.”—Participant 4, Follow-up interview |
Social Implications | Some participants feared that attempts to advance EDI in simulation may be negatively perceived by those outside of education circles | “I think one fear that I had was that… I don’t know if you’ve ever had, how much you have encountered this in your career, but a lot of the time people within the education circle are very positive, very happy. They describe how things can be done very well and then a lot of your ED colleagues are probably FACEMs who have been around for 20 or 30 years who most of them are white, grumpy old men who just roll their eyes and have absolutely no interest in being involved in any of this.”—Participant 6, Follow-up interview |
Not doing enough | While participants all sorts of fears about acting, they also had fears about doing too little. There was a recognition among the group that not addressing EDI in simulation is also a harmful path | “I think we can’t do nothing, I think we need to do something and it’s a really important topic. I think it’d be an ongoing challenge but I think starting out on the journey to explore that is essential and I think it’s an option not to also be the classic archaic medical profession”—Participant 6, Initial interview “I like to think that my own awareness translates into better design, delivery and debriefing. But I am worried that that’s also not quite enough. But don’t know exactly how to get to that next step…I also debate in my mind about whether that’s necessary. I kind of think actually running a simulation program, that is aware of issues related to equity, diversity and inclusion, and is mindful of them and is at times including that a little bit in design and delivery and, you know, at times bringing that in debriefing is actually okay, if that’s not the front and centre objective of what you’re doing. So, I go back and forth in my mind about whether we need to be doing a lot more than we currently are or whether what we’re doing isn’t enough? I don’t really have the answers to that.”—Participant 4, Follow-up interview |