Diversity, equity, inclusion, and antiracism (DEI-A) are crucial to health care delivery and patient well-being. A 2003 report from the Institute of Medicine indicated that "evidence of racial and ethnic disparities in healthcare exists consistently across illnesses and healthcare services" (Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care et al., 2003, p. 5). Nearly two decades later, minimal progress has been made, with deleterious consequences for minority groups (Centers for Disease Control and Prevention, 2021). Close examination of this lack of progress exposes deeply embedded systemic issues (National Academies of Sciences, Engineering, and Medicine, 2021). One factor is conscious and unconscious racial bias that may influence provider behaviors, treatment choices, and outcomes (Hall et al., 2015). Furthermore, providers may differ in how they acknowledge the role of racism in health disparities, which can impact their commitment to address the issue of health inequality (Gollust et al., 2018).
As educators, we have the responsibility to prepare the future workforce to meet the needs of the patient and society. This project, the culminating work of the Adelphi University Teaching Fellowship: Advancing a Diverse, Equitable and Inclusive Curriculum, focuses on educating students about the impact of racism and provides strategies to enhance racial justice and equity in clinical practice through simulated experiences.
A National League of Nursing (2016) vision statement called for nursing programs to "commit to diversity and inclusivity in the academic mission, leadership, faculty, students, and curricula and for nursing faculty to provide curricula that includes culturally appropriate health care of diverse populations with attention to health disparities" (p. 9). Nursing education provides a strong foundation in teaching the theoretical aspects of cultural competence under the umbrella of transcultural nursing. However, to change the climate, we must move beyond theory toward action. Innovative teaching strategies, such as simulation, that enhance competency learning with skill transfer into the clinical setting are essential. Through simulation, educators can foster a culture of DEI-A by actively training and immersing preservice nurses into realistic patient care scenarios.
PROJECT OVERVIEW
The ongoing mission of our university is to become a model of DEI-A. A notable goal is to dismantle bias, inequity, and racism in individual departments, academic curricula, and the student experience. The lead faculty, a university teaching fellow and member of the DEI-A Council, conceptualized the project. In partnership with the chair of the Nursing Specialty Department and the director of the university simulation laboratory, the council developed the Community Health Clinical Day.
The day, which took place over a period of two weeks, involved the participation of 150 community health students. Because of COVID-19 restrictions, just two high-fidelity simulations and three video scenarios were logistically feasible. For the development of the video scenarios, two student members of the DEI-A Council met with lead faculty to discuss DEI-A in the clinical setting. The students focused on two key areas: 1) providers, including nurses, behaving inappropriately toward patients and 2) patients behaving inappropriately toward nurses. The high-fidelity simulation scenarios were written by staff and faculty based on their lived experience. One focused on racial bias in pain assessment; the other focused on the health care consequences of violence toward the Asian community.
The three role-play scenarios were filmed by the university Faculty Center for Professional Excellence production team. The actors were faculty involved with development of the project. After the videos were developed, they were reviewed by the lead faculty, student writers, and members of the DEI-A Council. The project leaders also met with the university Title IX coordinator and antiracism trainer to review student training materials.
To ensure rigor for the clinical day, a step-by-step schedule was developed, and a PowerPoint debriefing guide was created to ensure fidelity and guide discussions. When clinical instructors received orientation to the educational intervention, some expressed anxiety regarding the content and discomfort with regard to facilitating discussions. They were reassured that the project team would be on hand to provide support.
IMPLEMENTATION
The clinical day started with guidelines for creating a safe and brave space. The guidelines stressed active listening, questioning instead of reacting, respect for different perspectives, and openness. Students were told that the activities and conversation might make them feel uncomfortable. To provide for psychological safety, students were reminded to be mindful, to take breaks, and to recenter when conversations felt uncomfortable or unproductive. In addition, for all simulated experiences, the students were given a safe word that would allow them to opt out of an activity with no questions asked.
To examine the historical context of racism in health care, students were shown a YouTube video titled "The US Medical System Is Still Haunted by Slavery" (Black Matters, 2019). The video unveils root causes and systemic factors that underpin contemporary racism. Students were asked to write a brief reflection about their feelings after viewing the video; then, faculty led discussions on health outcomes for patients of different races. Following these preliminary activities, students participated in or observed the two high-fidelity simulations. The first simulation focused on a Black veteran, admitted to the emergency room, who returned from Afghanistan with posttraumatic stress disorder, amputation, and pain crises. Students were asked to assess the client's pain, including how the client's experience of bias in the outpatient setting led to his admission. In the second simulation, students participated in a home visit of an elderly Asian man with chronic obstructive pulmonary disease who was afraid to leave his home for medical care.
In the next part of the clinical day, racism in nursing was explored through faculty-developed videos. Two videos compared and contrasted behaviors of overt and subtle racism by a provider. In the third video, the patient told the nurse that he did not want a Black nurse. The purpose was to discuss strategies to manage racist patients and support colleagues who experienced microaggressions and racism in the clinical setting. Students were asked to take notes while viewing the videos about what stood out to them.
DEBRIEFING AND STUDENT FEEDBACK
Debriefing as a process of guided reflection is a vital component of simulation (Dreifuerst, 2015). Both faculty and student reflections were key components of the clinical day. After a slow start, students and faculty began sharing their thoughts and discussing the effects of microaggressions and racism on health care. Suggestions for dealing with racism in professional practice were offered. Strategies were discussed, including understanding institutional practices, responding in a clinically responsible way, addressing comments by naming behaviors, and refocusing the conversation on the patient's health (Overland et al., 2019).
Reactions were positive, and students expressed appreciation for the activity. However, students stated they would have liked additional preparation for the two high-fidelity simulations. The team realized that a simulation focused on psychosocial aspects of the human experience is hard to create and prepare for, a limitation of the project. Another concern was that certain students did not provide feedback; it was not possible to understand their perspectives and feelings. An institutional review board study has been approved to examine the effectiveness of the project.
CONCLUSION
By 2045, more than 50 percent of the US population will be members of minority groups (Vespa et al., 2020). We have the responsibility to act to reduce health care disparities and prepare the future workforce to mitigate the impact of racism. This requires commitment and active change, with training beginning in the academic setting. With uncomfortable conversations and intentional approaches, students can begin the journey toward health care equity by understanding how biases and perception influence their behaviors, treatment choices, and patient outcomes. In the words of the Reverend Martin Luther King, Jr., "Of all forms of discrimination and inequalities, injustice in health is the most shocking and inhuman" (King, 1966).
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