Simulation for diversity, equity and inclusion in emergency medicine residency training: A qualitative study

Abstract

Background

The last few years have seen an increased focus on diversity, equity, and inclusion (DEI) initiatives across organizations. Simulation has been used in varying degrees for teaching about DEI topics with emergency medicine; however, there are no established best practices or guidelines on this subject. To further examine the use of simulation for DEI teachings, the DEISIM work group was created as a collaboration between the Society of Academic Emergency Medicine (SAEM) Simulation Academy and the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM). This study represents their findings.

Method

This qualitative study was conducted using a three‐pronged approach. Initial literature search was conducted followed by a call for submission of simulation curricula. These were then followed by five focus groups. Focus groups were recorded, transcribed by a professional transcription service, and then subjected to thematic analysis.

Results

Data were analyzed and organized into four broad categories including Learners, Facilitators, Organizational/Leadership, and Technical Issues. Challenges within each of these were identified, as were potential solutions. Select pertinent findings included focused faculty development, a carefully planned approach that utilized DEI content experts and the use of simulation for workplace microaggressions or discriminations.

Conclusions

There appears to be a clear role for simulation in DEI teachings. Such curricula, however, should be undertaken with careful planning and input from appropriate and representative parties. More research is needed on optimizing and standardizing simulation‐based DEI curricula.

INTRODUCTION

Over the last decade, there has been an increased focus on the diversity, equity, and inclusion (DEI) training within graduate medical education, as evidenced by specific Clinical Learning Environment Review items as listed on the Academy of Graduate Medical Education (ACGME) website. ¹ Although ACGME requires that residents demonstrate competence in caring for a diverse array of patient populations including diversity in race, religion, age, sex, socioeconomic status, and sexual orientation, no specific guidelines on how to achieve this competency are provided. ²

Many training programs, national organizations, and health care systems have made particular efforts to embrace DEI through implementing a wide range of activities ranging from mandatory trainings on relevant DEI issues to implicit bias testing to dedicating special conferences and publications to relevant DEI topics. ³ , ⁴ , ⁵ In recent years there have also been a handful of simulation curricula published addressing specific topics within the broader umbrella of DEI education specific to emergency medicine. ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ Nearly all the publications cited before are descriptive ones that portray the use of simulation for very specific topics, such as caring for transgender patients, ¹⁰ but they do not clearly define the role of simulation for DEI education. In fact, very few studies examining the role of simulation within DEI training and how to best incorporate simulation for DEI have been published to date. ¹¹ , ¹² Fewer still provide specific guidelines/best practices on the use of simulation for DEI training, including guidance on appropriate debriefing techniques, modalities, ¹² logistics, anticipated controversies, or most productive ways to explore the psychosocial contextual aspects of using simulation for DEI education. Thus there is an unmet need for clearly defining the role of simulation best practices/guidelines for DEI training within emergency medicine. Therefore, the Society for Academic Emergency Medicine (SAEM) Simulation Academy collaborated with the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM) to further investigate this topic by forming the DEISIM workgroup. This study represents findings of the investigations of the DEISIM work group.

METHODS

This was a qualitative study that was deemed exempt by a local IRB committee. The SAEM Simulation Academy collaborated with SAEM's ADIEM to create a collaborative work group, DEISIM, to examine the role of simulation in DEI training. Five members of the simulation academy and four members of ADIEM comprised DEISIM. The main objectives of this study were (1) to investigate the role of simulation in DEI education within emergency medicine residency training, (2) to identify best practices in the conduction of simulation‐based DEI training, and (3) to identify challenges and barriers in the use of simulation for DEI. The overall study design is illustrated in Figure 1. A literature search was conducted using terms: “simulation,” “diversity, equity, inclusion,” “cultural competency,” “residency training,” and “emergency medicine.” The listservs for Council of Residency Directors in EM, SAEM Simulation Academy, and the Society for Simulation in Healthcare Emergency Medicine section were queried for examples of existing simulation curricula covering DEI topics. Given the limited publications on the subject, focus groups were conducted examining the role of simulation in DEI within EM residency training.

FIGURE 1.

Study design. DEISIM, Diversity, Equity, Inclusion through Simulation Workgroup; Sim, simulation.

Literature search and call for sim curricula

Initial literature search and call for simulation curricula revealed five curricula in emergency medicine specifically relevant to DEI education (Table 1). Simulation curricula was defined as any educational intervention related to a topic within DEI that included some evaluation of the intervention. Evaluations of curricula included but were not limited to observer checklists, feedback from standardized patients, and learner attitudes towards the experience. While there were many curricula identified in other specialties, within undergraduate medical education, and other disciplines such as nursing, most topics were limited to one specific aspect of DEI such as caring for transgender or gender‐nonconforming patients or caring for patients with limited English proficiency (Appendix S1). ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶

TABLE 1.

Existing diversity, equity, and inclusivity related simulation curricula for emergency medicine residents.

Paper	Description	Themes covered
Teaching emergency medicine residents health equity through simulation immersion (Ward‐Gaines et al. 6 )	Multiple scenarios implemented during singular event utilizing standardized patients	Racism Housing inequality Limited English proficiency Substance use disorders Religious beliefs Gender bias Microaggressions Caring for transgender/nonbinary patients
Promoting affirmative transgender health care practice within hospitals: an IPE standardized patient simulation for graduate health care learners (McCave et al. 7 )	Interprofessional simulated patient encounter	Caring for transgender/nonbinary patients
A novel simulation to assess residents' utilization of a medical interpreter (Zdradzinski et al. 8 )	Single standardized patient encounter completed on biannual basis	Limited English proficiency
Pediatric rattlesnake envenomation: a simulation scenario with optional health equity, virtual facilitation, and senior learner modifications (Joseph et al. 9 )	Single scenario using simulated patient and/or virtual reality Diversity equity inclusion/health equity component optional	Socioeconomic challenges Migrant/immigration
Hennepin somali cultural competence curricula (submitted through call for curricula)	Multiple scenarios using high fidelity patient simulators and standardized patients	Limited English proficiency Religious beliefs Cultural practices

Focus group

Focus groups were conducted utilizing Association for Medical Education in Europe guide on conducting focus groups in medical education research. ²⁷ Briefly, incorporating input from ADIEM and Simulation Academy members (NN, SB, AB, AW), a series of questions was drafted. Questions were open ended to generate a broad but structured discussion. The questions were reviewed by the members of the DEISIM workgroup, further refined, and finalized (Appendix S3). A call‐out for focus groups, specifically seeking participants with experience in DEI education and simulation, was circulated on the listservs for Council of Residency Directors in EM (CORD‐EM), Simulation Academy, ADIEM, and SAEM Resident and Medical Students (RAMS). These organizations were particularly selected as they are well established within academic EM and offer a diverse pool of focus group participants to draw from. A total of 52 faculty, physicians, and learners with experience in simulation learning for DEI responded. Focus group participants self‐selected to participate in the discussions and included medical students, residents, simulation experts, residency leadership, and core faculty.

A total of five focus groups, with 10 to 12 participants/session, were conducted virtually between April and June of 2020. Focus groups were run until theoretical saturation with respect to emerging themes was met. Size of each group was limited to foster meaningful dialogue with ample time for each participant to contribute to the discussion. Each group was facilitated by groups of two trained facilitators (SB, SH, NJ) who were trained by an experienced qualitative researcher (NN) for 4 weeks prior to the start of the focus groups. Verbal consent from all participants was obtained at the beginning of each session. The focus group discussions were recorded and transcribed.

Data analysis

Data were analyzed using content analysis ²⁸ , ²⁹ and a grounded theory approach was employed to generate categories, subcategories, themes, and subthemes. Briefly, analysis was performed by trained evaluators (NN, AW, SB, SH) through the electronic online coding platform Taguette (https://www.taguette.org/). Each transcript was read independently by at least two evaluators. New ideas and themes were presented after transcript analysis and used to inductively generate a unified coding system. Each code was agreed upon by at least two evaluators and any conflict was resolved by consensus amongst all evaluators. Codes thus generated were applied to each transcript. Particular care was taken so that repeated occurrences of a specific idea by the same participant was coded only once. Identified codes were further refined, collated, and merged to synthesize the final categories, subcategories, themes, and subthemes. The final draft was shared with the focus group participants for feedback that was incorporated into the final version. Categories and themes thus generated are summarized in Figure 2.

FIGURE 2.

Challenges and solutions emerging from focus group thematic analysis. ACGME, American Council on Graduate Medical Education; CLER, Clinical Learning Environment Review; DEI, diversity equity inclusion; HFPS, high‐fidelity patient simulators; SP, standardized patients/participants; VR, virtual reality; WPV, workplace violence.

RESULTS

A total of 105 thematic codes were generated and applied a total of 756 times. Initial analysis yielded nine themes: Simulation Programming Strategies, Innovations, Existing Sim DEI Curricula, Simulation Modalities, Debriefing, Faculty Development, Challenges, Evaluations, Implicit Needs (Appendix S2).

In general, our analysis suggests that simulation is being used to address various aspects of DEI education, and focus group participants consider it to be a suitable tool for DEI education, in particular, practice of difficult conversations surrounding DEI issues such as “speaking up” and “allyship.” Recommended preparation for DEI simulation‐based curricula include appropriate learner preparation; attention to sensitive cultural, gender‐based, and/or religious issues; and inclusion of representative parties as content experts during case creation and debriefing. It is worthwhile to note that focus group participants identified varied topics within the larger DEI umbrella amenable to simulation training and these are listed in Table 2.

TABLE 2.

Diversity, equity, and inclusion topics amenable to simulation training.

Workplace microaggressions, discriminations, violence (experiencing and witnessing)

LGBTQ

Race

Religion

Gender

Gender‐based clinical leadership

Health care disparities

Patients with disabilities

Prison populations/detainees

Homeless populations

Sexual harassment

Substance use disorders

Domestic violence

Food insecurity

Limited English proficiency

Abbreviation: LGTBQ, lesbian, gay, transgender, trans, bisexual, queer.

Further analysis of the nine themes above additionally yielded four broad categories that included learner, faculty, logistical/technica,l or organizational/leadership‐based challenges and potential solutions (Figure 2) and two subcategories, “minority tax” and “professional development on workplace microaggressions, biases and violence.” There are unique challenges, barriers, and contextual nuances relevant to each category and subcategory and these are further addressed below.

Faculty

Lack of faculty preparedness and limited faculty development were identified themes that factored largely into the best practice recommendations for targeted faculty/professional development for DEI. Simply put, faculty felt underprepared and uncomfortable in debriefing DEI issues as illustrated by the following statements:

so the big barrier for me is I'm not an expert on this topic. I feel honestly like a fraud when I even think about including …, you have to be prepared to debrief it, you have to do it in a nuanced kind of way, you have to have some content expertise on it. And I'm a little scared of that. (Participant F1.S6)

One of the things I have noticed is that faculty are willing to show up and receive said information, no one feels comfortable leading the discussion or trying to teach said information …. I've had a lot of people say that they feel like it is necessary to be included in the curriculum but they have no clue how to do that, and they don't feel super confident in their abilities to deliver said information. (Participant F3.S4).

I think these topics (DEI) are really hard for people to talk about. I think it makes people uncomfortable. There's a subset of people who sim makes uncomfortable to begin with … and especially for faculty who were raised for lack of better word doing sim. I think that makes it really hard. (Participant F3.S5)

There appeared to be a general consensus that simulation for DEI should be attempted only with very careful and thoughtful planning and inclusion of appropriate representation– specifically in the curation and creation of simulation content that was likely to bring up sensitive cultural, gender‐based, and/or religious issues. The concept of including representative (gender, religion, culture etc.) parties as content experts within case creation, deployment, and debriefing was deemed integral to the success of simulation sessions.

Specific programming, scripting, and debriefing strategies that could be effectively deployed by faculty for simulating DEI cases are depicted in Figure 2. Briefly, strategies for case creation focused on adding pertinent DEI elements to existing simulation cases, keeping the clinical content simple, and varying objectives by PGY level. Strategies for effective and meaningful debriefing included the use of appropriate representative content experts in case development and also co‐facilitating the actual debriefing.

Minority tax

One specific concern as regards to faculty development, recruitment, and retention that was brought up repeatedly was the concept of “minority tax.”

it's very tough being the only one … cause you're constantly that voice … when you become the voice for everybody else, which is completely unfair to the person checking the box of other. (Participant F3.S3)

…a lot of things, to women or persons of color, that they express interest in this, and then it gets handed to them … so it's like now their responsibility to be the DEI person or on the DEI committee. (Participant F4. S1)

I think, cultivates a problematic encounter a lot, where our physicians of color are expected to stand up and demonstrate the discrimination that we're talking about. (Participant F2. S3)

Sort of undue tax on people who come from marginalized communities, so that they must therefore bear witness to the trauma of … Be traumatized, but also bear witness to their own trauma and then teach other people how to see their trauma. (Participant F5.S2)

The general consensus was that there needed to be increased awareness of the toll of this phenomenon, especially as it was perceived as contributing to an increased rate of burnout amongst minority faculty. Potential solutions discussed included dedicated time buy‐down for minority faculty involved, recruitment of more representative minority faculty, and expectation of sharing the agenda amongst all faculty.

Professional development on workplace microaggressions, biases, and violence

The vast majority of curricula reported in Table 1, as well as those discussed in the focus groups, focus on the experience of bias from the patient perspective. Based on analysis of focus group transcripts, health care professionals and learners also experience significant biases from peers and patients; however, there was little targeted training on how to best deal with this and it is contributing to burnout in physicians of color in particular.

We need to do a better job of teaching people to stand up, not only for themselves, but especially for others … because if we can call out bad behavior or discriminatory behavior in our department, I think that's the first step to making the department itself a more inclusive place. (Participant F4.S4)

I think it really hasn't been talked about as much that patients have biases against physicians and that can make your life as a female physician or as physician of color, it makes it difficult … I've never experienced a formal program on how to handle that in the ER. (Participant F3.S4)

running up on somebody who doesn't want X, Y, Z (for their provider) for whatever reason is actually way more common … than even me telling somebody they have cancer … so I do think it is possible to do it in the simulation room and that it is a place we should be looking at going forward.” (Participant F3.S3)

Where it comes up the most is in how I mentor, coach and teach and I see people abusing our residents or mentees in ways that I sometimes feel like I don't have the words to express or the experience or the position to comfort them. I wish I could—obviously we do the best we can but I've often had residents who don't wanna be seen by a patient or who are specifically insulted by a patient based on their gender or race. (Participant F4.S2)

In addition, patient satisfaction metrics make it challenging for a health care professional to self‐advocate at the risk of personal or professional liability:

…but with Press‐Ganey and everything, I agree, I think a big barrier to doing this, and maybe almost a first step, is that the local institution level is understanding where your policy and your culture lies. (Participant F4.S4)

What can we do to make you comfortable in calling out bad behavior if you see it as opposed to experiencing it …. How many of us feel confident in calling that out or how to do it appropriately without worrying about Press‐Ganey scores … (Participant F3.S4)

Therefore, a need for specific training in self advocacy and allyship when experiencing or witnessing microaggressions and discrimination was identified. Simulation was felt to be an appropriate tool for this, given the utility and role of simulation training specifically for difficult communication and teamwork.

Learner

Learner‐specific challenges included lack of learner readiness for simulation exercises specifically due to the possibility of learners having experienced previous related emotional trauma and also unintentionally precipitating further emotional trauma through simulation experiences. Additionally, the nuances of each learner's psychosocial contextual lens through which they may receive simulation training was also brought up as potential challenges.

I had at least three residents that were like, … I didn't expect to be talking about that …. I wasn't ready for that. I felt really uncomfortable, and now I feel like I'm supposed to hate myself. (Participant F3.S2)

…so when I have placed only the diversity topic in the simulation environment … one of my residents said “I felt like I was tricked because I immediately got debriefed on how I did the pronouns wrong.” (Participant F4.S1)

you could blow people's mind with some cases and fall totally on your face, probably offensive … some people have never experienced any of this and are not aware of the privileges. (Participant F5.S1)

To counteract this, some sensitive debriefing strategies suggested include pre‐learning assignments, robust pre‐briefing, and consciously appropriate and sensitive debriefing strategies. Advance preparation for the kind of simulation exercise expected would allow learners to come in mentally prepared instead of feeling as if they had been put on the spot.

Technical challenges

Challenges with technical issues include lack of representation in current simulators, lack of representative media (e.g. visual diagnostic cue such as skin rash availability across a variety of skin tones), as well as standardized patients/participants (SP). (Standardized patients/participants refer to dedicated actors who receive focused training on portraying scripted roles of patients, family members, in some instances clinicians within simulation cases.) The suggested solutions included a representative library of simulation media resources, simulation case scenario, and available standardized patients/participants.

Standardized patients/participants were felt to be ideal for having difficult conversations that are expected in such cases. However, cost and lack of SP diversity can make such a resource inaccessible. In these cases, it was suggested that appropriately representative, trained faculty may be utilized to portray standardized roles, if they volunteered to do so and with special attention to the issue of minority tax mentioned earlier. Another subtheme that was relevant in this context was the potential for harm, specifically the inadvertent reinforcement of biases and stereotypes, in simulation cases that were facilitated inappropriately, or by inadequately trained faculty, thereby fostering the exact opposite of the objectives of such DEI cases.

So even if the case has been written about a diversity and inclusion topic, it will have biases inherent in it. And that's why …. Having an external perspective is really important… (Participant F3.S1)

one of the concerns we have is any time you have a (specific) sim case (for example) the patient is gay, the answer is always HIV. We have tried really hard to not making that not the case …. I think a lot of us feel that the (traditional) NBME anchors on your board exams … makes this more normalized …. (Participant F4.S1)

There were also concerns about how to simulate DEI topics when appropriate representative faculty were not available at all. The suggested solution to this was to reach out to the office or organizational diversity and inclusion well ahead of time for planning and logistics purposes.

Assessment of such DEI‐focused cases was considered to be particularly difficult and some solutions that were introduced included reflective writing, assessment of performance with case repetition, and implicit bias testing (with the understanding that even though implicit bias testing may make a learner aware of their biases, it does not necessarily translate to behavior change).

Organizational/departmental leadership

Lack of organizational or leadership support for use of simulation specifically for DEI was universally recognized as a barrier to the use of simulation for DEI training. The status quo with respect to DEI training was felt to be inadequate. Many organizations were felt to superficially embrace the concept of DEI without working towards meaningful, actionable change.

These (organizations) are all just paying lip service to concepts and ideas, but this is exactly where you need to redefine and say, “Look, this is the kind of culture (cultural) competency that is required.” Not just going through a PowerPoint and reading or looking at it online. (Participant F5.S5)

hospital's competency annual packet that we have to go through, and there's a lot in there that you're like, “Oh my God, I can't even believe that this is what we're doing.” So I think even though the intent, right, what they intended might not have been to insult an entire group of people, but it definitely seems a little tone‐deaf and anachronistic to what's going on. So even the best intended learning activities or trainings can come off very inappropriate. (Participant F5.S3)

We don't get protected (time) to do a lot of these things. It's in the ACGME guidelines that we must respect diversity and inclusion and health disparities in our didactics or what not. But it doesn't talk about what it is they are actually expect or what the takeaway is supposed to be. It's like broad overarching statements … lets be real. Nobody knows what to do with that. So there is not a lot of guidance in that arena … so if you look at it from that standpoint, then how do you get protected time in order to create content. (Participant F3.S2)

To this point, a need for better advocacy for the role of simulation in DEI training was noted, specifically simulation training because many of the previously mentioned experiences of microaggressions and biases are forms of difficult interactions and communications for which there is already a precedent set for the use of simulation. The use of existing ACGME and other guidelines were recommended in support of simulation utilization in DEI training. Finally, a focus on the implementation of “allyship” more globally through focused training, as opposed to piecemeal annual competency training, was suggested as another potential solution.

Limitations

The main limitation of this study is that the focus groups had only 52 participants and even though theoretical saturation was met, the themes generated may not be applicable to academic emergency medicine at large. Furthermore, all participants self‐selected, which may have contributed to specific themes being more prevalent.

DISCUSSION

The need for expanded DEI education and training is clear, with many GME training programs, national organizations such as the ACGME, and health care systems making focused efforts to increase programming around DEI. The most impactful training strategies, however, remain unclear, with many organizations taking a variety of approaches to training in this area from implicit bias training to online modules to dedicated DEI conferences. The incorporation of simulation into DEI training remains variable and somewhat limited within EM training, with great need for delineation of how best to approach inclusion of simulation to augment teaching on DEI. Thematic analysis of the included focus groups reveal current simulation practices for DEI training, elucidate barriers and challenges, as well as many solutions and opportunities for maximizing the role of simulation, and define best practices for simulation for DEI training.

Simulation appears to offer great opportunity for translating DEI training to help learners gain actionable change, especially in the form of simulated communication training on speaking up and standing up for oneself, one's patients, and each other when facing or witnessing microaggressions, biases, or violence. While it is noted that some institutions are already using simulations in DEI training, examples on best case types and standardization of cases are lacking. Fifteen DEI subjects are offered as overarching topics from this study, each addressing unique populations or potential situations, and most amenable to training utilizing simulation. The results highlight, however, that designing and standardizing such cases is no easy task. We suggest that the use of simulation for teaching DEI should focus on best practices such as standardization of cases, potentially via tight scripting, and use of appropriately representative standardized patients/participants portraying highlighted DEI topic in simulation cases in addition to the use of content experts for case creation and implementation. Additionally, use of pre‐learning materials, robust pre‐briefing (with emphasis on psychological safety and conscious attention to potential for discomfort from participating learners and possibly faculty alike), and appropriately sensitive debriefing practices must be emphasized and iteratively revised/expanded.

Challenges to implementing simulation‐based training appear to be four pronged in nature, involving issues specific to the faculty/or perceived leader‐specialists, learners/participants, general logistics, and organizational/departmental.

It is hard to imagine having an effective session when the faculty do not themselves feel prepared or comfortable with the topic or situations; thus institutions should be mindful to extend implementation of simulation training as well as DEI training to faculty themselves who will be leading DEI‐focused simulations. Institutions must be aware of potential need to call on and utilize external or visiting faculty or content experts when developing, deploying, and debriefing simulation curricula related to DEI. Not all institutions will naturally have faculty and content experts appropriate to teach DEI‐related simulations and we must proceed cautiously and work to avoid the precedent of simply using whatever faculty are available, regardless of comfort and expertise levels with DEI content. On the logistics side, standardized patients/participants are considered ideal, with recognition that a lack of standardized patients/participants coupled with a lack of appropriately versed faculty to lead the simulation cases may pose a significant challenge to the implementation of a successful training. Additionally, it was discussed that there is potential for harm if these factors are not taken into account and mitigated, such as potential for reinforcement of biases if cases are not facilitated appropriately, thereby fostering the exact opposite of the objectives of such DEI cases. Outside facilitators or innovative collaborations may be considered to help overcome these potential barriers; however, faculty recruitment into such roles must be balanced fairly with benefits to faculty and done in avoidance of imposing “minority tax.” Potential solutions for “minority tax” that can be employed include dedicated time buy‐down and recognition for minority faculty, targeted recruitment of representative minority faculty, and sharing of the responsibilities with nonminority faculty.

A significant logistical challenge was highlighted with regards to best practices for assessment. Due to the complex nature of human interactions, a one‐size‐fits‐all approach to evaluation simply cannot apply. Observations to complete a checklist of presence or absences of critical actions or behaviors performed by the learner during the case, as commonly employed in assessment for other simulation uses, most likely will not be amenable in DEI focused cases. Furthermore, in the early stages implementing these types of trainings, it may actually cause undue emotional stress to the participants. Creativity in evaluation is therefore needed, and more reflective exercises may be the most beneficial to participants. Further research into best practices for assessment, including how, when, or if to consider creation of point‐based assessments for behavioral change is needed. Finally, issues relating to organizational/departmental support for the incorporation of simulation for DEI topics for both faculty and learner development needs to be more broadly emphasized. There appears to be a very particular perception regarding the utility of simulation in residency training, resulting in limited support for simulation for DEI and other “softer skills” training. Anecdotally, many focus group participants noted a recurring theme of issue with residency leadership, faculty, and resident learners with potentially constricted perceptions that simulation was most useful in the context of technically challenging clinical cases and for procedure education, with underemphasis on the buy‐in of simulation's utility for communication, teamwork, and in this case topics focused on DEI. This emphasis needs to further prioritize inclusion of DEI topics into simulation and its benefits. Additionally, this limited perception may be a true belief or perhaps this may have been shared as a reason to explain their lack of buy‐in and full commitment to participating in DEI‐focused simulations due to discomfort with the topics being simulated and discussed. Regardless of why, this perception needs to be altered in order to increase participant and leadership buy‐in and, perhaps most importantly, emphasis on the existing evidence for benefits of education utilizing simulation training to communication and teamwork improvement. ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸

Additionally, organizational/departmental support of the use of simulation for faculty professional development is crucial, for all DEI topics but most specifically with regards to facing microaggressions, biases, and workplace violence. Increased support and development in these commonly faced DEI issues was believed to be likely to contribute to faculty retention, engagement, as well as decrease the moral injury experienced as faculty noted commonplace experiences of physicians experiencing all of the above.

More studies are needed to further define the impact of all four categories of challenges, as well as successes and opportunities with offered solutions from this study.

Supporting information

Appendix S1.

Appendix S2.

Appendix S3.

Nadir N‐A, Winfield A, Bentley S, et al. Simulation for diversity, equity and inclusion in emergency medicine residency training: A qualitative study. AEM Educ Train. 2023;7(Suppl. 1):S78–S87. doi: 10.1002/aet2.10870