Students with manikin.

Columbia Nursing’s Third Annual Innovations in Simulation Summit Addresses Systemic Racism in Health Care

December 17, 2020

The imperative to eliminate systemic racism from the health-care system drew nearly 500 nurses, doctors, administrators, and social workers from around the world to Columbia Nursing’s Third Annual Innovations in Simulation Summit in November. Against the surging COVID-19 pandemic and its exacerbation of racial injustices and health inequities, the virtual summit and its exploration of educational strategies to identify and dismantle structural racism in health care was both timely and critical. 

Three panels of professionals with expertise in simulation education; inclusion, diversity, and equity in health care; and minority health emphasized the importance of creating a safe environment where students, learners, and practitioners can identify stereotypes, challenge racially-driven assumptions and biases, and enhance their cultural education, awareness, and humility. “It is important that we as educators and health-care providers provide education about the history of racism; discuss systemic racism in the health-care system and the impact of implicit and explicit bias; and provide our students with tools to advocate for health equity,” said Columbia Nursing’s Kellie Bryant, DNP, an assistant professor and the executive director of the Helene Fuld Health Trust Simulation Center.  

Calling systemic racism a “public health emergency,” the panelists urged health-care leaders—administrators, providers, and faculty members—to sensitize themselves to cultural, ethnic, racial, gender, and other differences among their patients, colleagues, employees, and students. Such sensitization requires acknowledging unintentional blind spots can lead to unconscious bias, said Sharon Washington, EdD, an expert on the impact of race, historical trauma, and social inequality on health outcomes. “We’ve largely been socialized to not talk about race, religion, sex or sexuality, or politics, which not only primes us to have these deep blind spots, but also deprives us of the language we need to name them,” said Washington, a consultant on organizational optimization who was previously a member of the faculty at Temple University.

However unintentional they may be, blind spots can occur when providers focus intensely on tasks related to patient care. “If you are focusing on protocols, responsibilities, the pandemic, and other stressors, then it can be easy to miss salient acts of racism, sexism, homophobia, transphobia, or discrimination,” Washington said. It can also be easy to unwittingly perpetuate microaggressions—subtle expressions or acts of discrimination—that can affect hiring, work assignments, evaluations, and promotion practices, she added. “Not believing that someone is from the U.S. just because they have an accent sends the underlying message ‘You don’t belong’ or ‘You’re other,’” she explained.

These subtle messages reinforce negative racial stereotypes that can make students of color self-conscious, hypervigilant, anxious, or emotionally fatigued and, in turn, undermine their confidence, motivation, and performance, Washington pointed out. Such students commonly—and unjustly—acquire the label “learners in difficulty” and do not receive the same amount of pedagogy and practice time as white students. “Over the course of multiple years, that’s a lot of practice that minority providers are missing because of personal biases,” she said. Facilitators whose students express anxiety, depression, hypervigilance to threats, or emotional fatigue should initiate a safe dialogue to help them cope with the factors that are limiting their performance and elicit their actual medical knowledge and abilities, Washington said.

Creating a safe learning environment is pivotal for maximizing students’ and learners’ education, which should show them how their own implicit biases contribute to systemic racism, said Julia Iyasere, MD, vice president of the Center for Health Justice and associate chief medical officer at NewYork-Presbyterian Hospital and an assistant professor of medicine at Columbia University Irving Medical Center. “When we think of implicit and unconscious bias, the recognition and understanding of cultural sensitivity is vitally important,” Iyasere said. 

Such understanding is needed to avoid making assumptions about people based on racial or cultural stereotypes, said Desiree Diaz, PhD, an associate professor at the University of Central Florida.  “It’s our responsibility as facilitators and educators to allow time and space for learners to ask questions and then challenge their assumptions,” Diaz said. “We need the next generation of health-care providers to realize that their assumptions might be wrong and to have a safe environment where they can say ‘I didn’t know.’ If there’s no safe space, then our students have no way to safely express their thoughts and concerns.” 

Simulation is poised to create such an environment, where practitioners, students, and learners can safely observe biased behaviors and practice strategies for interrupting them; in doing so, they can increase their cultural competence, awareness, knowledge, and humility—characteristics that are essential to rendering effective and culturally responsive care, said Josepha Campinha-Bacote, PhD, the president and founder of Transcultural CARE Associates, a private consultation service that focuses on issues in transcultural health care and mental health. Campinha-Bacote coined the term cultural competemility to describe the integration of cultural competence and humility, which she urged clinicians, students, and learners to practice by asking questions like these:  

  • Do I know about different cultures’ worldviews, diseases and health conditions, health disparities and inequities, and social determinants of health? 
  • Do I know how to conduct a cultural or racial assessment in a sensitive manner? 
  • Have I humbly asked my patient the right questions? 
  • Am I aware of my biases and the presence of “isms” such as racism? 

Key to achieving cultural awareness, competence, and humility is exposure to populations that are inclusive and diverse. Simulation can provide such exposure by using mannequins of different ages, genders, gender identities, ethnicities, races, and cultures, and incorporating props that make scenarios realistic without creating stereotypes. “Every prop should have an objective,” Diaz said, pointing to a mannequin of a Black 8–year-old with asthma and her Black doll. Simulations should facilitate discussions of how ethnicity and social determinants of health inform patients’ illness and care. “We should be linking everything we use in the scenario to standards of best practice,” she said.  

Simulations should also utilize additional resources, such as minority health statistics from the Centers for Disease Control, to counter claims of stereotyping, Diaz added. “If you’re covering men’s health and prostate cancer, then use the statistic about Native Americans being twice as likely as whites to die from prostate cancer so you can back up what you’re doing,” she said. Partnering with community groups that have expertise in racial or cultural health issues is another way of ensuring a simulation’s accuracy and sensitivity. Diaz said she partners with an LGBTQ group to help her conduct simulations on transgender health. “This way you have support for what you’re doing and why.” 

Faculty can make simulations feel safer for students by sharing experiences from their own practices, including their mistakes and biases, Iyasere said. “Use your experiences as a jumping off point for conversation,” she said. “Then it becomes real.” 

Practitioners can also use simulation to explore how their power as health-care providers may affect their ability to connect with others, said Bart Bailey, MBA, owner and principal consultant of Courage to Care, LLC, and a Justice, Diversity, Equity, and Inclusion (JEDI) facilitator of unconscious bias and cultural competency workshops. “It’s important to know who we are as health professionals,” Bailey said. “What aspects of your identity as health professionals give you power? What diminishes your power? It’s important to know your role as it relates to causing no harm.”  

If practitioners are to help eliminate systemic racism in health care, then they must address their biases with courage, Bailey added. Immersive virtual reality can help them do this by providing an immersive, real-life experience in which participants embody a computer-generated figure who encounters—and learns how to respond to—various forms of racism, said Assistant Professor Courtney D. Cogburn, PhD, from Columbia’s School of Social Work. Like her research, Dr. Cogburn’s presentation showcased IVR as a tool for health-care education, and eliminating racism and racial inequities in health.

Ultimately, any efforts to address and eradicate structural racism from health care and educational settings need organizational backing, Iyasere said. “It must come from leadership,” she said. “When challenging things are optional, many people opt out.”  

Tackling racism is challenging, the panelists noted. “It’s a hard conversation to start and takes willingness to be comfortable with being uncomfortable,” Iyasere said. Campinha-Bacote agreed: “We’re going to have to start stepping on toes,” she said. 

Yet as Bryant noted, there really is no other choice. “Ignoring the topic because it’s uncomfortable will not make racism disappear.” 

Said Iyasere, “We all entered health care to improve the health and well-being of our patients. Simulation—through the development of a safe, low-risk learning environment and repeated deliberate practice—allows us to be innovative in our approach to the elimination of health-care inequities and to ultimately make the undiscussable discussable.”