Introduction

Themes of equity, diversity and inclusion (EDI) arise within healthcare simulation independent of scenario design and regardless of whether we as faculty feel equipped to address them. Though faculty development guidance and standards increasingly reference EDI, we see this as relatively broad brushstrokes. There is a dearth of information on how simulation faculty can develop in this area [1,2,3,4]. With increasingly formal expectations being placed on simulation educators to adhere to EDI principles, we must obtain a better understanding of the developmental needs of educators in this area. The gap in both clarity and specificity in guidance risks creating confusion amongst simulation practitioners and holds a latent risk of unintentional harm. This paper seeks to address these issues to enable educators to rise to the challenge of incorporating EDI in simulation, better meeting the needs of learners and their future patients.

Equity, diversity and inclusion (EDI)

Equity, diversity and inclusion are terms that refer to different aspects of interactions between people and within groups [5]. It is well established that those who identify as members of marginalised and underrepresented groups, and those exposed to social and economic disadvantage, experience barriers, both systemic and structural, which prevent them from receiving safe, effective and equitable care [6,7,8].

NHS Education for Scotland provides this definition of EDI in their Advancing Equity in Medical Education resources [9]: equity — creating a fairer society where everyone has the opportunity to fulfil their potential; diversity — recognising and valuing difference in its broadest sense; and inclusion — celebrating individual differences to ensure everyone feels welcome and accepted. Different conceptions and definitions exist; for the purposes of this study, we have used the definitions provided above. We acknowledge that other combinations of related concepts are encountered across academic fields (e.g. equality, diversity and inclusion; justice, equity, diversity and inclusion (JEDI)); however, ‘EDI’ is the prominent lens through which academic discourse in simulation-based education (SBE) has been framed and the lens through which we consider simulation faculty development in this study.

EDI in simulation-based education

The reason

Over recent years, increasing light has been shone on EDI within SBE literature. This is in relation to simulation with specific EDI learning objectives and the consideration of EDI in all SBE programmes in healthcare [5, 6, 10,11,12,13]. SBE in healthcare has been described as a time of ‘cultural compression’, where ideologies about the healthcare professions can be reinforced, and values and beliefs can be transmitted to learners with intensity [14]. When EDI themes are explicitly incorporated into simulation education, numerous positive impacts on participants are reported. These include the following: increase in self-awareness, enhanced communication, enhanced insight and knowledge, strengthening in EDI-related self-efficacy and increased EDI-related competence and skills [10]. This concept of cultural compression as it relates to simulation also supports the need for educators delivering SBE without the explicit incorporation of EDI themes to have awareness, knowledge and skills in this area to avoid causing or perpetuating harm. The growing attention to EDI within simulation has been backed by increasing calls within professional standards and codes of conduct for consideration of EDI [1,2,3,4].

The Association for Simulated Practice in Healthcare (ASPiH) includes equity, diversity and inclusion as a core value in their ‘Standards guiding simulation-based practice in health and care’ and calls for continuing professional development in EDI to be part of all simulation faculty development programmes [1]. They outline that training should ‘as a minimum’ result in faculty who can promote EDI within the design and delivery of simulation, prevent harm arising from ‘tokenism, misrepresentation, stereotyping or microaggressions’ and highlight the importance of diversity in improving the learning environment [1]. Honouring diversity and fostering inclusion are part of the values within the Healthcare Simulationist Code of Ethics [3]. The Academy of Medical Educators includes ‘Demonstrates respect for others’ as a core value of medical educators, further outlining the expectation that educators will ensure ‘equality of opportunity for patients, students, trainees, staff and colleagues’ and ‘actively promote[s] and respect[s] diversity in discharging their educational responsibilities’ [4].

The challenge

Many simulation teams recognise the need to incorporate EDI into their programmes and are motivated to make improvements. Initiating this shift however presents a significant challenge. Studies of simulation educators report a perceived lack of cultural knowledge and confidence, a lack of clarity on where to focus their efforts and a lack of understanding of how to meaningfully address EDI in simulation without causing harm [13, 15, 16].

Purdy et al. highlighted this gap between academia and action [13]. They argued that development opportunities for faculty are crucial to empower them to incorporate EDI meaningfully and safely [13, 17]. Despite the increasing discussion of a need for the incorporation of EDI within simulation, and the recognition that we must upskill our educators to address EDI, there are currently no frameworks that outline EDI competencies for simulation faculty development.

Methods

Aims

The aims of the study were twofold.

  1. 1.

    To explore the extent to which an existing competency framework for medical teachers to teach ethnic and cultural diversity is relevant for simulation educator competency in EDI.

  2. 2.

    To construct a modified competency framework in EDI for simulation educators.

Study design

In this constructivist study, participants (simulation faculty) were engaged in a 5-month period of enhanced consideration of EDI. This involved using the SIM-EDI tool [13] to support faculty debriefing conversations focussed on EDI within a pre-existing programme of simulation. Study participants were interviewed individually at two timepoints to explore their understanding of EDI concepts, their experiences and perceptions of EDI within simulation and their views on faculty development in EDI. Interview questions were designed to draw out data of relevance to Hordijk et al.’s teaching competency framework [18]. Analysis was completed using template analysis, employing an amended version of Hordijk et al.’s framework as the initial coding template. Competencies were modified by the data, and new themes were developed inductively to construct a new competency framework in EDI for simulation educators.

The SIM-EDI tool

SIM-EDI [13] is a tool designed to prompt and guide reflexive conversations amongst simulation faculty following the delivery of simulation sessions. It guides simulation teams to consider EDI in the design, delivery and debriefing of simulation and prompts discussion of missed opportunities, harms, potential biases and action items as they relate to the simulation session just delivered. Participants were introduced to the tool by J. M. in an information session in December 2022 and were supported directly by J. M. and S. G. during early uses of the tool. The EDI debriefing conversations involved faculty only (no learners) and took place following simulation sessions delivered as part of a regular programme of education running within the department of medical education. SIM-EDI is considered a methodological tool [19] in this study. Use of the tool enhanced awareness amongst participants of EDI within simulation, familiarised them with relevant concepts and provided the vocabulary to be able to identify and describe experiences and developmental needs as they relate to EDI. Thus, the use of SIM-EDI supported the collection of meaningful data in the second set of interviews.

Setting

The study was conducted in NHS Lothian, a National Health Service (NHS) Board in the Southeast of Scotland. The simulation team sits within the Medical Education Directorate and provides a variety of simulation programmes for a range of healthcare professionals.

Simulation

The study involved use of SIM-EDI within the pre-existing core simulation programme in NHS Lothian. This programme consists of a series of simulation sessions delivered for doctors in their foundation years, the first 2 years of postgraduate medical training in the UK. A range of topics are covered within the programme including acute medical assessment, psychiatric assessment and management and challenging communication scenarios.

Interviews

Semi-structured interviews were conducted in accordance with interview schedules developed by the research team based on Hordijk et al.’s teaching competency framework (Additional file 1). All interviews were conducted via video call using Microsoft Teams. Interviews were transcribed verbatim directly through Microsoft Teams and checked for accuracy by the interviewer, with clarifications made directly with the participant where required. Initial interviews in January 2023 were conducted by J. M. who was a medical education fellow known to the participants. Interviews at the second time point, April 2023, were conducted by C.H.X.C., at the time a clinical teaching fellow working in a different Health Board and not known to the participants. The aim of this design (with interviews at two time points) was to try and capture perceived developmental needs or established competencies that faculty ‘arrive with’, developed through professional and personal experiences, and subsequently to capture those that are recognised and/or developed during the early stages of using a reflexive tool. The choice of interviewer was made with the aim of promoting open and uninhibited discussion in the second set of interviews, where reflections on the process of enhanced consideration of EDI in the team were sought (a process which J. M. and S. G. had supported). Individual interviews were chosen to allow exploration of sometimes challenging and sensitive topics [20] and to support open reflection on individual values and beliefs.

Analysis

Hordijk et al.’s framework for medical teachers’ competencies to teach ethnic and cultural diversity [18] (hereafter referred to as the ‘original framework’) was used as the initial coding framework. This framework, developed by a Delphi method, was the only faculty development framework relating to EDI that we identified in the literature. We considered the original framework as a robustly developed set of educational competencies on which to build our study. The 10 competencies were used as predefined themes, which were amended for our context prior to analysis and modified further during analysis based on the emerging data creating an ‘amended framework’. This is in line with a template analysis approach [21]. New themes emerging from the data were coded inductively [21]. Details of the amended framework, with timing and justification of amendments, can be seen in Additional file 2. J. M. and S. G. coded each transcript independently. Discrepancies in coding to the amended framework and emerging themes were discussed and agreed before recoding of all transcripts in accordance with the newly developed definitions and shared understanding. E. P. and V. T. each independently coded one randomly selected transcript from the January interviews and one from the April interviews. Any discrepancies in coding were discussed with J. M. and S. G. before final coding was agreed. Amendments to the original framework based on the data, in addition to new themes emerging from the data, formed the basis of a new ‘Developmental Framework for Simulation Educators in EDI’. The new framework developed in this constructivist study is J. M. and S. G.’s conceptualisation of the data produced through interactions between J. M., S. G., co-researchers and participants. The concept of an objective reality is rejected in this work.

Ethics

Ethical approval was received from the University of Edinburgh Medical Education Ethics Committee (reference number: 2022/37). Written consent was obtained from all participants for audio and video data collection and publication of anonymised results. All participants were free to leave the study at any time.

Results

All 10 members of simulation faculty involved in the delivery of the core simulation programme at the time of the study consented to take part. Seven were medical education fellows, and three were simulation technicians. Some of the participants had additional experience as faculty in other simulation programmes. The participants had a range of simulation experience and professional backgrounds, though relatively limited diversity in age, LGBTQ, religion and ethnicity. Demographic characteristics of participants can be seen in Table 1.

Table 1 Demographic characteristics of participants
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Participants used the SIM-EDI tool to guide 23 EDI debriefing conversations between January and April 2023. Each EDI debriefing conversation involved between two and five participants. Nine of the 10 participants used the SIM-EDI tool on more than one occasion. Interviews were conducted with all participants (P1 to P10) at two timepoints (I1 and I2); in January, interviews lasted between 18 and 37 min (mean 27 min) and in April between 12 and 26 min (mean 17 min).

Relevance of an existing teaching competency framework for medical teachers in ethnic and cultural diversity to simulation educator competency in EDI

The competencies in the amended framework are presented in Table 2 alongside findings from the interview data and illustrative quotes.

Table 2 Amended framework competencies, findings from interview data and illustrative quotes
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Inductively developed themes

Illustrative quotes for the following inductively developed themes can be found in Table 3.

Table 3 Illustrative quotes from interviews for inductively coded themes
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Theme 1: Team reflection on EDI

Participants highlighted the benefits of group reflection on EDI issues within simulation faculty. This was identified as an area worthy of development, in addition to personal reflection on values and beliefs (Competency 1) and reflection with students on social and cultural contexts (Competency 7). Participants spoke of reflective team conversations serving to highlight unconscious biases. One (P3) highlighted the process of group reflection as having given people more confidence to discuss EDI issues and ‘permission’ to address them openly. They also spoke of the process giving a voice to faculty members who may not otherwise contribute their ideas to programme development and how group reflection had positive impacts on personal reflection. Several (P2, P3, P4, P7, P10) spoke of the power of protecting time and space for team reflection in leading to action, for example through identifying and addressing unmet developmental needs of faculty or tackling EDI issues within programme design.

Theme 2: Collaboration

Participants discussed the importance of collaborating with others in the development of simulation programmes in order to ensure that changes made, and programmes developed, are informed by, and reflect the experiences of, the groups we are aiming to represent. Participants (P1, P3, P7, P8, P9) recognised the limits to their own awareness and understanding of EDI issues and the role that collaboration with patient groups, colleagues and learners, including co-creation of simulation programmes, plays in ensuring continued improvements within the education delivered.

Construction of a modified competency framework in EDI for simulation educators

Through the analysis described above, and using data from interviews at both timepoints, we constructed a Developmental Framework for Simulation Educators in EDI (Table 4). Explanatory notes for the development of the framework can be found in Additional file 3. This framework differs from the original framework in that it is not focussed on competency to teach (or design) simulation specifically addressing EDI issues but rather as a basis of the competencies (or developmental areas) we feel are required to incorporate EDI into simulation programmes during the design, delivery and debriefing phases. We incorporated two additional themes of relevance to simulation faculty development in EDI which emerged inductively from the data (see above).

Table 4 Developmental framework for simulation educators in equity, diversity, and inclusion
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Discussion

In this study, we explored the relevance of a competency framework for medical teachers to simulation educators looking to incorporate EDI into their programmes. Through semi-structured interviews analysed using template analysis, we developed a new framework incorporating additional developmental areas identified from the data.

Reflections on developing a modified framework in EDI

Intersectionality

Excerpts relating to 9 of the 10 competencies within the amended framework were present within our interview data, highlighting their relevance to the simulation context experienced by our participants. One competency, ‘Awareness of intersectionality’, had no excerpts coded to it. This does not, in the view of the researchers, mean that this competency is not relevant to simulation educators. On the contrary, we feel that an awareness of intersectionality is extremely important, and this finding may primarily represent a gap in awareness and knowledge amongst our participants. Hordijk et al. describe awareness of intersectionality as an ‘essential teaching competency’ in their discussion of the original framework [18]. Intersectionality describes the interaction between cultural and ethnic identity, gender, race and other categories of difference in people’s lives, social practices, institutional arrangements and cultural ideologies and the outcomes of these interactions in terms of power [18, 22]. The importance of integrating intersectionality into medicine and medical education has been presented by several academics [22,23,24,25] with reflexivity being identified as an integral process [24]. In our framework, we have incorporated intersectionality alongside knowledge of ethnic and social determinants of health. We feel this is appropriate as, in our experience, simulation educators are more often looking to consider EDI within their simulation programmes and debriefings, rather than necessarily deliver simulation addressing EDI-specific learning outcomes. We also incorporated reflection with colleagues into our framework. We would suggest that teams consider using the SIM-EDI tool [13], to promote and guide team reflexivity through structured conversation, as part of this reflective process.

Collaboration and co-creation

Two related themes that we incorporated into our framework are collaboration and co-creation within simulation education. Here, we recognise two important and interrelated issues. The first is the need for collaborative effort within simulation teams, and across institutions, to share innovations and best practice to promote educator development with respect to EDI. Simulation is inherently reliant on team delivery, and this, we feel, cannot be an individual endeavour. The second is the need for co-creation with minoritised and marginalised groups in all simulation education, not just those designed specifically for EDI learning outcomes. It is well established that the involvement of those with lived experience, and from the communities being represented within simulated scenarios, is imperative to authentic and non-tokenistic development of educational programmes [10, 26]. The addition of this to our developmental framework is important.

Translating increased awareness to sensitive facilitation

Increased awareness and recognition of EDI issues arising within simulation sessions was  evident within our participants over the course of the study period. The translation from increased awareness to the ability to address EDI issues when they arise remains a greater challenge. Ensuring a psychologically safe learning environment is maintained within sessions, through the appropriate and sensitive facilitation of discussions relating to EDI, is something that participants identified as an area where they lacked confidence. We propose that use of our framework to underpin faculty development in EDI will help support collaborative efforts within teams leading to identification of specific areas for development and local strategies to address these.

Nomenclature

The original framework used as a basis for this study was Hordijk et al.’s framework for medical teachers’ competencies to teach ethnic and cultural diversity [18]. In line with current thinking in this field, we consider the framing of knowledge, understanding and skills relating to EDI in medical education as ‘competencies’ to be problematic [10, 13, 27,28,29]. Rather than being areas in which competence can achieved and then ‘ticked off’ in checklist fashion, we propose a shift to considering ‘developmental areas’, aligned more closely to the concept of cultural humility [30,31,32]. This approach recognises that progress can be made, but that ongoing self-awareness, openness and reflection are required [33], and that gaining confidence in EDI is an iterative process of lifelong development. A general feeling of low confidence and lack of expertise in EDI was a common concern amongst participants; this shift in nomenclature may also help to encourage those who feel under-skilled or lacking knowledge in this area to begin a journey of self-development

Strengths and limitations

This is the first study that has proposed a developmental framework for simulation educators in EDI constructed through the exploration of faculty viewpoints using semi-structured interviews. Our framework incorporates the views and competencies that faculty ‘arrive with’ as well as those that they develop and/or become aware of during a period of enhanced consideration of EDI using a freely available reflexive tool, SIM-EDI. Therefore, our framework is designed to be relevant for simulation faculty at any stage of their career, including novice simulation educators. Though the number of participants is small, the use of individual semi-structured interviews allowed researchers to elicit rich narratives that informed the construction of our framework. Building on a pre-existing related framework, which had been developed in a Delphi study, provided a robust basis for our study.

The framework is the conceptualisation of the authors based on their interpretations of the interview data and their assimilation of the literature. The research team has some degree of diversity in ethnicity, gender, LGBTQ, religion and professional background. The interview data constitutes the perceived needs of faculty participants and cannot be interpreted as objective developmental needs. The study is limited by the small numbers of participants and the limited diversity within the participant group. All participants were working within the same simulation team and delivering the same simulation programme in one Health Board at the time of the study. A wider breadth of experience was shared in the interviews by some of the participants who have been involved in other simulation programmes. The input of members of the research team who work, or have worked, in other medical education settings (C. H. X. C., V. T., E. P., N. O.) has also, we hope, ensured broader relevance of the resultant framework.

Areas for future work and research

This is the first iteration of a Developmental Framework for Simulation Educators in EDI. An area of potential focus henceforth is the development of guidance on how simulation educators and teams may address the developmental areas presented within the framework, outlining resources and educational activities of relevance to each area. A key avenue for future research lies in the use and study of the framework in other contexts, exploring its relevance and applicability. Exploration of how use of the framework influences faculty development, as well as subsequent impact on the development and delivery of simulation programmes, are other interesting areas for future research. Consideration should also be given to the incorporation of this framework into guidance and standards for simulation faculty development.

Conclusion

Medical simulation educators must be equipped to address EDI in their simulation programmes. There is a recognised gap between acknowledgement of this and feeling empowered to act which has implications for faculty development. Here, we present work which has sought to close this gap through exploring the relevance to the simulation context of an existing competency framework and proposing a new Developmental Framework for Simulation Educators in EDI. We encourage simulation teams to utilise this framework within their faculty development programmes and report on their experiences.