As our global population becomes increasingly more diverse, so too does the patient population. And, this should affect how healthcare professionals train for their roles.

There has been a significant focus on promoting diversity, equity, and inclusion in healthcare education with the intention of acknowledging health disparities and improving the quality of care and health outcomes for groups outside of dominant power structures.

The problem is known – disparities exist across dimensions of race, ethnicity, gender, age, education level, and geographic location. The solutions can seem far less certain.

There are societal, structural, and personal biases that negatively impact health disparities globally. Where we seek to focus is on the training of healthcare professionals and how stronger training methods can develop more culturally-competent and cognizant providers.

There are many benefits of using simulation to train healthcare providers and providers-in-training, including, making knowledge come alive, increasing clinical understanding, boosting confidence to treat acute cases, and many more.

In this article, we discuss how simulation can help to reduce implicit bias and mitigate risk to patients of diverse backgrounds. This article includes example scenario cases and helpful tools to make or propose an educational shift in your organization with the goal of guiding more culturally-diverse learning experiences and influence safer, more equitable healthcare.

While the term "disparities" is often used to describe differences between racial and ethnic groups, there are many other dimensions of disparity – particularly in healthcare. These dimensions, or health determinants, are complex and intersectional by nature. Therefore, they require careful consideration when preparing healthcare providers for their roles. Some examples are:

Note: For the purposes of this article, the terms “diversity” and “cultural diversity” will encompass these many characteristics.

Looking at the overarching factors that affect a patient’s care, simulation cannot solve all concerns. However, it can help to change behavior faster and better than other methods used to train healthcare providers.

Compared with didactic teaching methods, such as lectures, discrimination training, and policy updates, simulation is best known as the method that makes learning “stick”. Hospitals and nursing schools that have adopted simulation training have seen the following improvements:^{1, 2, 3}

• Higher engagement
• Improved clinical retention
• Teamwork and communications
• Positive patient outcomes
• Reduced turnover
• Increased provider confidence
• Coordinated responses to low-frequency, high-acuity cases
• Better Compliance

The Knowledge Gap & the Trust Gap

In the 1990s. women’s advocates drew attention to the fact that women were largely being left out of clinical research.⁸ Although studies since then have included more women, there is still considered to be a "knowledge gap" surrounding women’s health. Diseases that disproportionately affect women (like autoimmune diseases, fibromyalgia, and chronic pain conditions) have largely been under-researched. This, in addition to anecdotes about providers dismissing female patient concerns, has resulted in a "trust gap" that affects women’s perception of healthcare services.⁹

Similarly, while most studies on gender disparities focus primarily on males and females, it is important to include transgender and intersex patients in your educational curriculum too.

Transgender people face an increased risk of HIV infection (particularly among transgender women of color) and a lower likelihood of preventative cancer screenings among transgender men.¹¹

A simulated learning experience focused on any type of gender disparities will require realistic genitalia and anatomical landmarks, as well as strong rapport-building skills. Not feeling comfortable asking certain questions (such as sexual orientation, a patient’s preferred pronouns, or whether they are taking hormones) can create a barrier to quality care, and simulation practice can help to remove that barrier.

 In addition to increasing in the sheer number of people, aging adults also experience a higher risk of chronic disease.¹² Experts have raised concerns that healthcare systems will need to prepare for increased incidences of chronic conditions as well as implement multidisciplinary approaches to managing a patient’s case.¹³ And, as the demand for home health and personal care aides also grows, there is yet another segment to incorporate in the elderly continuum of care.¹⁴

This is precisely where simulation can make the difference. One study measured the impact of simulation training on skills required to address delirium, falls, elder abuse, and breaking bad news to patients and their families.¹⁵ Using a combination of standardized patients, simulators, and simulated clinical documentation, learners significantly improved in:

• Knowledge
• Skills retention
• Positive perceptions of geriatric medicine

For healthcare providers to address unconscious biases, they must learn to recognize intrinsic blind spots. Many of these blind spots are the result of confirmation bias, which means reinforcing prior beliefs while disregarding new information that doesn’t reinforce those beliefs.

In order to teach the constant vigilance and self-awareness required to provide unbiased care, it can help to set expectations and ground rules before you begin your simulation.

Below, we provide a mock-up of what your guidelines might look like.

In healthcare, there is a known underrepresentation of cultural, gender, and ethnic diversity during training and in leadership.

To truly serve the needs of a diverse population, it is critical to implement training that will promote cultural competence, cultural humility and a strong sense of clinical empathy.

Simulation is a strong means to develop the necessary skill set to provide high-quality care for all patients. However, as we wrap-up this article, we'd like to leave you with one final thought: Implicit bias, which can stand in the way of safe patient care, cannot be eliminated overnight. Nor can it be reduced by one singular training session.

Reducing bias and providing equitable care requires a life-long commitment and unwavering vigilance.

At Laerdal, we are committed to providing you with solutions and support to help save more lives – across the entire spectrum of patients, ensuring equitable healthcare for all.