Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants

Abstract

Healthcare learners can gain necessary experience working with diverse and priority communities through human simulation. In this context, simulated participants (SPs) may be recruited for specific roles because of their appearance, lived experience or identity. Although one of the benefits of simulation is providing learners with practice where the risk of causing harm to patients in the clinical setting is reduced, simulation shifts the potential harm from real patients to SPs. Negative effects of tokenism, misrepresentation, stereotyping or microaggressions may be amplified when SPs are recruited for personal characteristics or lived experience. Educators have an ethical obligation to promote diversity and inclusion; however, we are also obliged to mitigate harm to SPs.

The goals of simulation (fulfilling learning objectives safely, authentically and effectively) and curricular obligations to address diverse and priority communities can be in tension with one another; valuing educational benefits might cause educators to deprioritise safety concerns. We explore this tension using a framework of diversity practices, ethics and values and simulation standards of best practice. Through the lens of healthcare ethics, we draw on the ways clinical research can provide a model for how ethical concerns can be approached in simulation, and suggest strategies to uphold authenticity and safety while representing diverse and priority communities. Our objective is not to provide a conclusive statement about how values should be weighed relative to each other, but to offer a framework to guide the complex process of weighing potential risks and benefits when working with diverse and priority communities.

Case studies

The following two case studies exemplify how diversity and inclusion in simulation might affect simulation participants.

Case study #1

You have been asked to add a simulation scenario to the curriculum on using motivational interviewing to help patients manage their diabetes, and to recruit simulated participants (SPs) who are ‘overweight’ to ensure the portrayal is authentic. This recruitment strategy makes you uncomfortable; in the past, two of your SPs have declined invitations to work on scenarios when they were recruited for their body habitus, saying it made them feel embarrassed and shameful. Your primary concern is the recruitment of SPs based on a stigmatised habitus when that habitus is not required for the learner to achieve the scenario’s learning objectives. Your secondary concern is the perpetuation of ideas that only overweight people have diabetes, or the connotation that all overweight people must have diabetes.

Case study #2

You are part of an educational team working on a curriculum refresh with the intent to identify equity, diversity and inclusion in the curriculum. As part of your review, you recognise trans health is only minimally addressed in the curriculum; last semester, learners interacted with members of the transgender community through the volunteer patient programme. The team decides to develop a simulation scenario for an upcoming formative assessment, and you decide to recruit SPs with transgender identities to support the concept ‘nothing about us without us’. You currently do not have a sufficient pool of transgender SPs. You are worried about bringing new SPs into your programme just for this scenario, especially because a newly recruited SP may not have the experience to anticipate how this role might affect them, despite providing consent to participate. You have concerns about how to approach this population without making individuals feel tokenised. You are not sure you will be able to find enough SPs who identify as transgender, and wonder who else you could recruit, and how. You also wonder what aspects of the scenario development and training will need to be considered when working with this population of interest who may or may not identify with the role they are being asked to portray.

Introduction

There has been a significant focus on promoting diversity and inclusion in healthcare education with the intent of acknowledging health disparities and increasing the quality of care and health outcomes for groups outside of dominant power structures.^1–3 ‘Historical and social factors influence what diversity refers to or prioritises’,⁴ and in this paper, we use the term diverse and priority communities to reflect people from underserved, underrepresented, minoritised, marginalised, stigmatised and vulnerable populations—populations of interest when working with equity, diversity and inclusion in healthcare education. Educators must train health professionals to engage with the social and structural determinants of health, systematic racism, inequity and caring for diverse and priority communities.

One of the benefits of simulation is providing learners with practice where the risk of causing harm to real patients in the clinical setting is reduced; ironically, simulation shifts the potential harm from real patients to simulated participants (SPs). While simulation can provide healthcare learners with experience working with diverse and priority communities, developing scenarios that specifically identify race, ethnicity, gender and other minoritised characteristics raises concerns around safety and the potential for harm to participants.

Safety is a central ethical commitment in simulation, and Park et al ⁵ have issued a call for simulationists to lead safely and ethically as a profession. The Association of Standardized Patient Educators Standards of Best Practice⁶ advocates for a psychologically safe learning environment for all simulation stakeholders, and requires simulationists to anticipate and recognise potential threats to participants’ safety. Similarly, the Society for Simulation in Healthcare Code of Ethics⁷ outlines obligations for the safe practice of simulation: to eliminate unnecessary harm, to honour the value and vulnerability of participants, to honour diversity and foster inclusion and to maintain vigilance against potential unintended consequences of simulation itself.

A safe learning environment is characterised by professionalism, support, mutual respect, integrity, trust and transparency among all participants, including educators, staff, faculty, clinicians, learners and SPs.^6–8 Psychological risk exists when participants perceive or feel a ‘mental threat as a result of participation in a simulation which can mean feeling unsafe. Examples include feelings of shame or humiliation’,⁸ and might also include retraumatisation, threats to dignity or acts of discrimination based on race, ethnicity, appearance, gender identity, or social affiliation.

The overarching goals of healthcare curricula, learning objectives, authentic simulation and safety sometimes align and at other times conflict. While an authentic ‘diversity and inclusion’ simulation might help learners understand diverse and priority communities, it can also have complex and unintended psychological effects on SPs.⁹ Because the potential for these harms generates tension with commitments to providing a safe educational environment, simulationists can feel uncertain about whether they are acting appropriately when developing and implementing scenarios addressing diverse and priority communities.

Engaging members of diverse and priority communities in simulation poses both risks and benefits that must be weighed against each other, and values can help answer two central questions: should simulation educators engage more extensively with diverse and priority communities, and if they do, how can they do that safely and respectfully? Similar questions have been addressed regarding the participation of diverse and priority communities in clinical research, and our discussion will draw on the ways research can provide a model for how ethical concerns can be approached in simulation. We will then illustrate how these ethical commitments translate into simulation practice.

Human simulation

Our focus is on simulation in healthcare involving SPs, and providing a learning environment where all participants feel psychologically safe. Working with SPs involves human role players portraying patients, family members or health professionals who interact with learners to provide hands-on experiential practice in a safe and controlled environment.⁶ Simulation scenarios are developed to align with the curriculum and to specific learning objectives, to provide safe, effective and guided practice.

Although SPs receive both financial compensation and unintended benefits (altruistic benefits of helping the community, empowerment and greater insight into healthcare education) for their participation in healthcare simulation, they have also reported negative and residual psychological effects of portraying complex roles.^9–14 Of particular concern for this discussion, SPs from diverse and priority communities have reported experiencing microaggressions during simulation⁹—interactions described as negative, invalidating, biased and discriminatory, based on presumed differences in identity.¹⁵

With increasing focus on diversity and inclusion in healthcare curricula, simulationists need to consider SPs’ ‘degree of vulnerability’¹⁶ and the potential for psychological harm which might arise when SPs are asked to bring their appearance, identity or lived experiences into simulation. Simulationists need to adopt practices that facilitate safely working with and empowering SPs, including those who exist outside of dominant power structures. It is important to recognise that SPs may feel tokenised when they are cast in specific roles because they are, for example, black, indigenous or a person of colour, live with obesity or identify as gender diverse; they may also feel excluded if SPs who do not identify with the diverse or priority community represented in the scenario are included instead. The obligation to ensure simulation is a safe and authentic space for all participants remains paramount, but providing learners with authentic opportunities to interact with individuals from diverse and priority communities generates additional burdens and risks that must be addressed.

Ethical values in simulation

Values, broadly defined, are things that we deem important, that give us reasons to choose one action over another and which are the focus of ethical inquiry.¹⁷ Beauchamp and Childress¹⁸ have identified four central ethical principles—autonomy, beneficence, non-maleficence and justice—which help orient us to the relevant values in healthcare. In determining an ethically justified course of action, we have a moral obligation to recognise the full spectrum of values relevant to that action,¹⁹ and key values in our discussion about the inclusion of diverse and priority communities in simulation include:

• Safety (avoidance of harm)

• Risk

• Informed choice

• Transparency

• Empowerment

• Trust

• Respect

• Inclusion

• Diversity

• Equity

Our objective is not to provide a conclusive statement about how these values should be weighed relative to each other, but to offer a framework to guide the complex process of determining a course of action that achieves the best possible outcome for all stakeholders. For example, valuing educational benefits in simulation might cause us to deprioritise safety concerns and vice versa. Final decisions matter, but our focus here is on how any particular decision about how to conduct a simulation is justified after considering relevant values.

Risk versus benefit

We are concerned, as a matter of ethics, about risk and benefit and the distribution thereof. It is important to identify who is assuming risk, the degree of that risk, who stands to benefit and the degree of that benefit. This can help to answer the question of whether engaging diverse and priority communities in simulation is justified.

It is useful to examine parallels with how ethical tensions between safety and risk are managed elsewhere in healthcare. Patients receiving treatment often assume significant risk to achieve their goals (e.g., a patient may choose a treatment with significant side effects to prolong their life). In contrast, research participants may assume similar risks without corresponding benefit, whether from their participation or from the knowledge gained. Researchers must therefore demonstrate that the knowledge they seek is important and that the benefits of the research cannot be obtained through a means that has lower risk for participants.^{20 21} Given this, researchers and research ethics boards have had to grapple with questions around engaging marginalised and vulnerable populations in research.²²

There is a long history of diverse and priority communities being exploited and harmed by their participation in research, but the consensus among researchers is that the harms of being excluded from research are greater than the risks, especially when appropriate strategies are used to manage and mitigate risks for research participants.²³ We suggest that the same is true in simulation: diverse and priority communities who are not represented in simulation have a greater likelihood of experiencing harm when seeking healthcare due to providers’ lack of familiarity in caring for underrepresented groups. Additionally, there is a risk of harm if protecting members of diverse and priority communities involves not respecting their ability to make their own informed choice about risk. There needs to be careful consideration of risks, benefits and their distribution in any simulation.

Determining that benefits outweigh risk does not exhaust educators’ ethical obligations in simulations addressing diverse and priority communities. When an individual takes on risk in the context of either clinical care or research, clinicians and researchers have ethical obligations to minimise risk for patients and participants as much as possible. They are also required to ensure that risk is freely chosen; informed consent processes are used to ensure that patients and participants understand and appreciate the potential risks and benefits of treatment or participation. Individuals can then determine whether the risk–benefit ratio aligns with their personal values. The more significant the risk of harm, however, the more attention must be paid to the quality of the consent process and the individual’s ability to provide informed consent. These two strategies, of minimising risk and ensuring robust informed consent, are applicable to addressing risks in simulation.

SPs are like human subjects in research; simulation is not designed to benefit SPs directly (although we acknowledge it is a transactional relationship where there are financial and secondary benefits to SPs). Learners are the primary recipients of the intended benefit simulation is designed to achieve (e.g., improvement in the learner’s performance in clinical practice), and their current and future patients are secondary recipients. Yet SPs incur the burden of risks to safety, especially psychological safety, that result from participation in simulations that address issues related to diversity and inclusion. SPs who are members of diverse and priority communities might be motivated to participate to secure benefits for others in the future, or to ensure that others do not have the same negative or difficult experiences that they had. They might be motivated to ensure the inclusion of their particular social context or experience into the curriculum. Any burden or risk may be justified by an SP’s own social values. Simulationists and SPs are in a relationship of trust where the obligation is to ensure that SPs are not exposed to unnecessary risks and that SPs understand the relevant risks, including those affecting psychological safety, but whether to assume those risks lies with the SP and reflects values of autonomy, informed choice and empowerment.

Implementing values in simulation practice

It is important to recognise that simulation exists within a broader curricular structure, which will affect the degree to which increasing diversity and inclusion in simulation can be done safely and effectively. Curricula need to establish a foundation around diversity and inclusion through lower-risk activities such as presenting diverse voices through assigned materials, panels and lectures and encouraging self-reflection,²⁴ which may help reduce the risk of, for example, bias and microaggressions. However, when diversity and inclusion are involved in simulation, simulationists must consider processes to balance risk and benefit and mitigate harm. When risks are well-managed and benefits are clearly articulated, engaging diverse and priority communities can be more readily justified.

The remaining sections (summarised in table 1) outline common areas where risks of harm to SPs arise and how they can be intentionally addressed. Our work here is aligned with and expands on elements of the Association of Standardized Patient Educators Standards of Best Practice⁶ and the Society for Simulation in Healthcare Code of Ethics,⁷ and is also framed within diversity practices, ethics, and values.

Table 1.

Implementing values in simulation practice

Simulation practice	Values	Contextual considerations	Strategies
Developing simulation scenarios	Safety Risk Trust Respect Inclusion Diversity Equity	What degree of curricular exposure and preparation do learners have for the simulation? What are the learning objectives of the simulation? What are the risks and benefits of including the simulation in the curriculum? What diversifying traits are required to meet the learning objectives?	Explore how diversity is relevant to the scenario. Include community members with lived experience and embodied knowledge alongside educators when developing scenarios. Balance threats to safety against the degree of authenticity required. Normalise diverse SP encounters without diversity as a major focus of the scenario.
Targeted SP recruitment for diversity	Safety Risk Trust Respect Inclusion Diversity Equity	What populations make up your community, and how is this reflected in your SPs? What community resources already exist? What relationships can be developed?	Include SPs who represent the diversity of our community. Develop relationships of trust with specific communities and community groups. Allow SPs to self-identify their gender identity, diversity (racial and ethnic group membership) and ability status. Cast diverse SPs when their membership is not the focus of the scenario.
Targeted SP recruitment for identity, appearance and lived experience	Safety Risk Informed choice Transparency Empowerment Trust Respect Inclusion Diversity Equity	Is the SP portraying a health condition or an identity? How important is appearance to meet the learning objectives? For this scenario, how can you balance authenticity and realism with the avoidance of risk? What degree of standardisation is required? Is the potential for risk unavoidable and necessary to meet the curricular objectives? When is your recruitment exclusionary?	Consider recruiting SPs who identify with the role, especially when identity is central to the scenario. If you have exhausted your resources, it may be justifiable to recruit SPs from other communities (who do not identify with the role). Screen for each role that might pose a risk, including an explanation of the potential for harm. Gain informed consent.
Attending to SPs’ psychological safety	Safety Risk Informed choice Transparency Empowerment Trust Respect Inclusion Diversity Equity	What is the type of harm that might be encountered (e.g., stereotype, microaggression, etc.)? How might you address the potential for psychological harm during recruitment, training and the simulation?	Screen for each role that might pose a risk, including an explanation of the potential for harm. Gain informed consent. Empower SPs to opt out at any time (during recruitment, training and simulation) for their own psychological safety, without punitive results. Be present during the simulation to observe and support SPs. Provide frequent breaks and/or rotations to limit the number of learner/SP interactions.
The value of a prebrief and debrief	Safety Risk Transparency Empowerment Trust Respect Inclusion Diversity Equity	How might you mitigate the emotional impact on SPs? How might you attend to unanticipated consequences of the simulation, such as students’ response to the simulation?	Plan for a prebrief to ensure participants are clear about the goals, expectations, guidelines, rules of engagement and parameters of the simulation. Plan for a debrief with trained facilitators to allow SPs to derole and to allow participants to reflect on their actions, impact and feelings of the simulation. Evaluate SPs’ experience with the simulation.

SP, simulated participants.

Developing simulation scenarios

Simulation scenarios include a patient’s demographics, presenting concern and backstory (a narrative history and background created for the SP).⁸ Scenarios aim to present an authentic patient voice and psychosocial characteristics of the patient.²⁵ This information is important to reflect diverse and priority communities within the simulation curriculum. However, Zanting et al ²⁶ point to the tension between ‘how to deal with the omnipresent paradox between “paying no attention to diversity” and “paying stereotypical attention to diversity”’. Simulation scenarios addressing diverse and priority communities risk participants feeling tokenised, problematising and essentialising culture and potentially reducing culture to an ‘unreflective label, a stereotype misrepresented as absolute, real and sufficient for the description of another person or group’.²⁷

Simulation scenarios are often developed by healthcare professionals in conjunction with SP educators, and guides have been developed to consider the complexity of including race and culture in the curriculum.^{24 28} However, because scenarios are often written by socially advantaged or cultural majority groups, there is a risk that including diverse and priority communities in healthcare education can unconsciously construct the ‘exotic other’,²⁸ reinforce stereotypes and biases^{3 29} and confirm prejudices about minority groups.³⁰

One strategy to minimise these risks is involving community members with lived experience^{31 32} and embodied knowledge³³ in scenario development, to collaborate with educators who might have clinical experience working with the priority community, but do not themselves identify as part of that community. Community members with lived experience provide the opportunity for appropriate and authentic representation of the population of interest addressed in the scenario, and may help to prevent biased assumptions and stereotypes.⁶ Community members should receive financial compensation for their expertise and contribution to curriculum development.

Including irrelevant characteristics (e.g., race, body habitus and gender) in scenarios can limit SP recruitment, and can also reinforce ‘normativity’ of the cultural majority. Omitting these characteristics facilitates including SPs from diverse and priority communities in scenarios that are not intended to directly address issues of diversity and inclusion. This effort helps to normalise and embed diversity throughout the curriculum, as opposed to treating it as a discrete issue, which can contribute to the othering of diverse and priority communities.^{24 26}

In short, simulationists need to ensure that scenarios respect the individual population represented, do not promote stereotypes and that both inclusion and exclusion of diverse and priority communities has been thoughtfully considered. We recommend an active effort be made, whenever possible, to include SPs from diverse and priority communities in all aspects of curricular programming.

Targeted SP recruitment for diversity

To achieve values related to inclusion and diversity, SPs should represent the diversity of our community and the world around us.⁶ This might be achieved through targeted recruitment, partnering with community groups to foster inclusive partnerships, developing relationships of trust with specific communities, ‘word of mouth’ among diverse and priority community members who are already involved in your programme and working with your institution’s Office of Equity, Diversity and Inclusion. Ensuring diversity in simulation can be also be achieved by casting members of marginalised communities in scenarios where their membership in that community is not the focus of the scenario.

Recognising that group membership cannot be ‘read’ from an individual’s appearance, it is imperative for SPs to self-identify their gender identity, diversity (racial and ethnic group membership) and ability status, as well as their physical characteristics and health conditions. Educators need to be transparent about why these traits matter in simulation and remember that harm can occur if SPs are only ever recruited for simulation scenarios because of their lived history, appearance, race or ethnicity. Anecdotally, we have heard SPs remark that their participation feels tokenised, and that they exist beyond their underrepresented identity. In addition, assuming an individual SP can represent a collective group identity is impossible, as individuals’ experience of group membership is variable and intersectional.

Targeted SP recruitment for identity, appearance, and lived experience

Generally speaking, SPs are not meant to bring their personal history to a simulation, but instead to portray a specific role to fulfil learning objectives. However, based on the simulation scenario, SP educators often get requests for SPs who appear ‘overweight’, can represent a patient from a specific geographical region, or identify as a minority gender, among others. While SPs might identify with aspects of the specific scenario they are working within, the degree of standardisation is dependent on the educational setting. For example, high stakes assessments might require a higher degree of standardisation and strict adherence to the role, whereas in formative contexts, ‘carefully trained SPs are able to respond with more authenticity and flexibility to the needs of individual learners’.⁶ In this latter context SPs may, consciously or not, reflect on their own experience. Simulationists need to pay attention to reconciling simulation’s goals of authenticity and realism^{6 8 34} with the avoidance of risk.³⁵

Simulationists might choose to avoid recruiting SPs who personally have a health condition from portraying a patient with that same condition—for example, avoid recruiting SPs who live with depression to play a patient with depression—to eliminate the risk of the SP bringing their own health history into the simulation, to mitigate the risk that they may not be able to separate their role portrayal from their lived experience, and to prevent potential emotional distress. However, portraying a simulated identity is different than simulating a specific health condition and calls for a balance of informed choice, empowerment, inclusion and safety. The option to participate should be provided to SPs who may otherwise not be considered for these opportunities because of the potential for harm.

In a study by Bokken et al,¹⁰ SPs reported differing opinions on portraying roles for which they had lived experience. While some felt ‘the closer a role resembled their personal life, the harder it was to portray that role and the greater the impact of performance’,¹⁰ others found increased difficulty in portraying roles for which they had no personal experience. In order to address this dichotomy, screening SPs for their comfort with each scenario’s content is of particular importance. While simulationists may avoid recruiting SPs with lived experience to mitigate retraumatisation, this may be better balanced by inviting SPs with relevant identity, empowering them to make an informed choice about their participation rather than excluding them entirely.

It is necessary to justify why the potential for increased risk to the SPs is both unavoidable and necessary for meeting curricular objectives. It is incumbent on simulationists to specify the curricular benefits that are sought through the involvement of SPs with lived experience as members of diverse and priority communities. How to balance the risk associated with these features may differ when identity is central to the experience (e.g., a transgender patient encounter with a social worker to acquire resources) versus when identity is not the focus of the case (eg, a transgender patient with knee pain).

Varying and limited resources can shift how simulationists balance these risks and benefits. In contexts where, despite best efforts, it is impossible to recruit SPs who are willing and able to participate in simulations that may reflect aspects of their personal identity, it might be justifiable to recruit SPs from other communities to portray a patient who does not reflect the SP’s own identity. For example, asking an SP to portray an immigration history that is not their own needs to be likely to result in an outcome that, overall, is better than not including the simulation in the curriculum. Careful consideration is needed in such circumstances to consider who benefits from being included or excluded, and to ensure that the risks to SPs who may be from diverse and priority communities do not outweigh the potential benefits of the simulation.

Attending to SPs’ psychological safety

To accommodate values of informed choice, respect and trust, it is a standard of best practice to screen SPs for simulation scenarios that might affect their safety.⁶ Transparency, through an explanation of each specific role’s anticipated cognitive and psychological challenges is necessary during recruitment to allow SPs to make an informed choice about their participation. Even if an SP has participated in a similar role in the past, they should still provide informed consent before participating each time. SPs’ lives and their interpretation and construction of their own identity are not fixed; people exist and change on a continuum, might change with context and personal histories can change over time.²⁶ The intent is not for SPs to divulge personal history, but to identify their comfort level with complex topics and for educators to respect their self-identified boundaries⁶ and vulnerability.^{7 16}

As SPs are trained, SP educators might consider adding extra time to training to openly discuss the identity of the role and the potential for harm based on how learners might respond to the simulation. If SPs do relate to the role through their own lived experience or identity, they should be assured that they do not need to openly reflect on their own identity or experience during training or the simulation, unless they choose to.

SPs should be provided the opportunity to opt-out of a specific role that threatens their psychological safety, at any given time, without their decision affecting future work assignments.⁶ SPs should also be empowered to terminate a simulation at any time if they deem it harmful or potentially traumatising. To monitor and respond to any emotional or psychological concerns, SP educators should be present during events to observe and support SPs.

During complex simulations, SP educators should consider how scheduling might attend to psychological safety: implementing rotations (e.g., recruiting and training two SPs to share one role), limiting the number of learner/SP interactions and providing frequent health breaks throughout the simulation.^{6 11}

The value of a prebrief and debrief

When including SPs with specific diversifying traits is necessary to achieve learning objectives, how can we support our SPs in mitigating emotional impact? While simulationists need to be attuned to values of autonomy, respect, safety and trust, it is impossible to predict all the potential harms that might arise for a particular SP during simulation; in addition, the reactions of all participants, including learners, educators and faculty cannot always be anticipated. The content of the simulation scenario may lead to potential triggers for those with lived experience, and simulationists must maintain vigilance regarding unintended consequences of the simulation.⁷ Leyerzapf and Abma³⁰ specifically cite cultural minority students’ experience with intercultural competency curriculum resulting in them feeling unsafe, vulnerable, segregated, and stigmatised.

To prepare for unanticipated consequences, a simulation prebrief is important for both SPs and learners to ensure all participants are clear about the goals, expectations, guidelines, rules of engagement and parameters of the simulation, including the commitment for all participants to be respectful in communication and curiosity.^{6 34 36} In addition, providing an opportunity for debriefing and deroling (detaching themselves from the role) postsimulation can allow SPs and learners to reflect on their actions, impact and feelings during a simulation and can improve future simulation.8 25 37 38 It is important to include trained facilitators who can navigate the complex conversations that might arise during a debrief.

As part of the debrief, evaluating SPs’ experience with the simulation and the success and limitations of the scenario and learning objectives can benefit and improve future simulation,²⁵ and can help identify stereotypes, bias, overt aggressions and microaggressions that might have arisen within the scripted scenario or the learner encounter. This can help to identify areas for improvement in the scenario development and may potentially identify gaps in the curriculum. It is also important for SP educators to reflect on their own recruitment and training practices for future improvement.⁶

Conclusion

We are strong advocates for the inclusion of diverse and priority communities in healthcare curriculum to reduce the risk of harm to vulnerable and marginalised populations, increase quality of care and achieve better health outcomes. Despite the psychological risk that comes with portraying complex scenarios, SPs are motivated to contribute to healthcare education and receive both financial and unintended benefits. While simulationists may never completely mitigate SPs’ risk and the potential for psychological harm, we must create an environment where participants are well-informed and feel safe enough to contribute.³⁴ Simulationists must also recognise that SPs will respond differently when asked to represent diverse and priority communities, and what might feel safe to one might not for another.

An ethical framework to balance the risks and benefits of diversity and inclusion in simulation brings to the forefront the importance of ongoing reflection to ensure that values are reflected in practice. As educators, we need to critically reflect on how we can foster a safe environment using standards of best practice. We have provided concrete strategies for working in partnership with SPs from diverse and priority communities: careful development of simulation scenarios, ensuring SPs represent the diversity of your community, screening SPs for comfort with specific scenarios, transparency of the potential of psychological risk, empowering SPs to opt-out of any scenario at any time, simulation prebrief and debrief, deroling strategies and limiting the number of role portrayals in one day.

Using the framework of diversity practices, ethics and values and simulation standards of best practice presented in this paper, we would like to reflect on the case studies presented at the beginning. We have summarised one way they might be resolved in tables 2 and 3, using our framework for implementing values in simulation practice. However, as this paper demonstrates, there may not be one simple way to conclude these complex issues.

Table 2.

Application of table 1 to case study #1

Simulation practice	Contextual considerations	Strategies	Case study #1
Developing simulation scenarios Values: Safety Risk Trust Respect Inclusion Diversity Equity	What degree of curricular exposure and preparation do learners have for the simulation? What are the learning objectives of the simulation? What are the risks and benefits of including the simulation in the curriculum? What diversifying traits are required to meet the learning objectives?	Explore how diversity is relevant to the scenario. Include community members with lived experience and embodied knowledge alongside educators when developing scenarios. Balance threats to safety against the degree of authenticity required. Normalise diverse SP encounters without diversity as a major focus of the scenario.	The learners have had lectures on motivational interviewing earlier in the curricular year, but have not yet put this technique into practice. This will be their first time using motivational interviewing as a strategy with a patient. After further discussion with the educator in charge of this programming, you discover that the simulation’s learning objectives are more focused on motivational interviewing rather than on diabetes care. You both determine there are strong benefits to this simulation session for learners to practice their motivational interviewing skills. Your concerns about harm and perpetuating stereotype and stigma are legitimate; recruiting a specific body habitus is not necessary to achieve the case’s learning objectives, and in fact having a range of habitus helps to emphasise that diabetes can affect anyone.
Targeted SP recruitment for diversity Values: Safety Risk Trust Respect Inclusion Diversity Equity	What populations make up your community, and how is this reflected in your SPs? What community resources already exist? What relationships can be developed?	Include SPs who represent the diversity of our community. Develop relationships of trust with specific communities and community groups. Allow SPs to self-identify their gender identity, diversity (racial and ethnic group membership), and ability status. Cast diverse SPs when their membership is not the focus of the scenario.	Because this scenario’s learning objectives are focused on motivational interviewing, and diversity is not the focus of the case, you make an effort to include diverse SPs, especially because their membership is not the focus of the scenario.
Targeted SP recruitment for identity, appearance and lived experience Values: Safety Risk Informed choice Transparency Empowerment Trust Respect Inclusion Diversity Equity	Is the SP portraying a health condition or an identity? How important is appearance to meet the learning objectives? For this scenario, how can you balance authenticity and realism with the avoidance of risk? What degree of standardisation is required? Is the potential for risk unavoidable and necessary to meet the curricular objectives? When is your recruitment exclusionary?	Consider recruiting SPs who identify with the role, especially when identity is central to the scenario. If you have exhausted your resources, it may be justifiable to recruit SPs from other communities (who do not identify with the role). Screen for each role that might pose a risk, including an explanation of the potential for harm. Gain informed consent.	You articulate your concerns about targeting SPs who represent people living with obesity and request flexibility in recruiting SPs across a range of body habitus into the role. You are careful to screen SPs with their comfort about the topic and the ways learners might interact with them during the simulation, empowering them to consent to their participation. You are sure to mention that learners might specifically reference their body habitus.
Attending to SPs’ psychological safety Values: Safety Risk Informed choice Transparency Empowerment Trust Respect Inclusion Diversity Equity	What is the type of harm that might be encountered (eg, stereotype, microaggression, etc.)? How might you address the potential for psychological harm during recruitment, training and the simulation?	Screen for each role that might pose a risk, including an explanation of the potential for harm. Gain informed consent. Empower SPs to opt out at any time (during recruitment, training and simulation) for their own psychological safety, without punitive results. Be present during the simulation to observe and support SPs. Provide frequent breaks and/or rotations to limit the number of learner/SP interactions.	You are careful to screen SPs with their comfort about the topic and the ways learners might interact with them during the simulation, empowering them to consent to their participation. You are sure to mention that learners might specifically reference their body habitus. You remind SPs they can opt out at any time if they feel unsafe. You ensure you are present for the simulation, and you take advantage of your ability to remotely watch one of your newer SPs. As each SP is only interacting with two learners per session, you feel adding breaks is not necessary.
The value of a prebrief and debrief Values: Safety Risk Transparency Empowerment Trust Respect Inclusion Diversity Equity	How might you mitigate the emotional impact on SPs? How might you attend to unanticipated consequences of the simulation, such as students’ response to the simulation?	Plan for a prebrief to ensure participants are clear about the goals, expectations, guidelines, rules of engagement and parameters of the simulation. Plan for a debrief with trained facilitators to allow SPs to derole and to allow participants to reflect on their actions, impact and feelings of the simulation. Evaluate SPs’ experience with the simulation.	You organise a prebrief for learners, as an opportunity to remind them of the learning objectives for the simulation. You remind them of the need for respect of all participants. After the simulation, while the learners are debriefing with a facilitator, you have a separate debrief with the SPs to provide them with the opportunity to reflect on the impact of the simulation, and to discuss how they felt during the simulation. You provide the SPs with a link to an anonymous survey, allowing the SPs to evaluate their experience with the simulation.

SP, simulated participants.

Table 3.

Application of table 1 to case study #2

Simulation practice	Contextual considerations	Strategies	Case study #2
Developing simulation scenarios Values: Safety Risk Trust Respect Inclusion Diversity Equity	What degree of curricular exposure and preparation do learners have for the simulation? What are the learning objectives of the simulation? What are the risks and benefits of including the simulation in the curriculum? What diversifying traits are required to meet the learning objectives?	Explore how diversity is relevant to the scenario. Include community members with lived experience and embodied knowledge alongside educators when developing scenarios. Balance threats to safety against the degree of authenticity required. Normalise diverse SP encounters without diversity as a major focus of the scenario.	Trans health has only minimally been addressed in the curriculum; last semester learners had a lecture on trans health, and interacted with members of the transgender community through the volunteer patient programme. You know that trans health is an important curricular initiative, identified through a curriculum refresh as being a large gap in the education programme. Students have reported feeling they are not prepared to enter clerkship without first practicing working with the trans community safely, in simulation. You notice that the learning objectives directly address the patient’s identity, not disease state and reflect on the importance of including the transgender community in your recruitment. You encourage the faculty member to collaborate on scenario development with someone who identifies as transgender, so that they can look for bias and stereotypes that might exist in the scenario.
Targeted SP recruitment for diversity Values: Safety Risk Trust Respect Inclusion Diversity Equity	What populations make up your community, and how is this reflected in your SPs? What community resources already exist? What relationships can be developed?	Include SPs who represent the diversity of our community. Develop relationships of trust with specific communities and community groups. Allow SPs to self-identify their gender identity, diversity (racial and ethnic group membership) and ability status. Cast diverse SPs when their membership is not the focus of the scenario.	Two years ago, your programme changed their application form to allow SPs to identify their gender. You ensured all SPs had the opportunity to self-identify using the updated application form, so you feel you know their gender status. You recognise the need to expand your pool of SPs to represent the diversity of your community, and partner with an LGBTQIA community group to start building relationships. You also reach out to some of your transgender and non-binary SPs to ask them if they know of anyone who might be interested in participating in your programme.
Targeted SP recruitment for identity, appearance and lived experience Values: Safety Risk Informed choice Transparency Empowerment Trust Respect Inclusion Diversity Equity	Is the SP portraying a health condition or an identity? How important is appearance to meet the learning objectives? For this scenario, how can you balance authenticity and realism with the avoidance of risk? What degree of standardisation is required? Is the potential for risk unavoidable and necessary to meet the curricular objectives? When is your recruitment exclusionary?	Consider recruiting SPs who identify with the role, especially when identity is central to the scenario. If you have exhausted your resources, it may be justifiable to recruit SPs from other communities (who do not identify with the role). Screen for each role that might pose a risk, including an explanation of the potential for harm. Gain informed consent.	You maintain a level of concern about your ability to recruit enough SPs who identity with the role to fully staff this event. You are also uncomfortable with casting new SPs who have not yet worked with a learner because a newly recruited SP may not have the experience to anticipate how this role might affect them, despite providing consent to participate. Whatever solution you come to may be imperfect, but given the values you prioritise you first recruit from your pool of experienced transgender SPs; not all feel comfortable participating. Because the role is representing a transmale who has not started hormone therapy or surgery, you decide to also recruit SPs who identify as gender diverse or cisgender female, who are also empowered to determine their comfort with the role. You ensure you screen all SPs for this role, letting them know that students may feel inexperienced with trans health, and that students may use incorrect pronouns, incorrect language and could potentially introduce bias and/or stereotypes. You ensure informed consent.
Attending to SPs’ psychological safety Values: Safety Risk Informed choice Transparency Empowerment Trust Respect Inclusion Diversity Equity	What is the type of harm that might be encountered (eg, stereotype, microaggression, etc.)? How might you address the potential for psychological harm during recruitment, training, and the simulation?	Screen for each role that might pose a risk, including an explanation of the potential for harm. Gain informed consent. Empower SPs to opt out at any time (during recruitment, training and simulation) for their own psychological safety, without punitive results. Be present during the simulation to observe and support SPs. Provide frequent breaks and/or rotations to limit the number of learner/SP interactions.	You ensure you screen all SPs for this role, letting them know that students feel inexperienced with trans health and that students may use incorrect pronouns, incorrect language and could potentially introduce bias and/or stereotypes. You ensure informed consent. You decide to expand your training time from 2 hours to 3 hours, to ensure time to provide your cisgender SPs with some education on trans health. You also want to ensure ample time to discuss the risks in person, once the SPs have had the chance to review the case. You remind SPs they can opt out at any time if they feel unsafe, and you ensure you are present for the simulation. You put the SPs on rotation, as it is a long workday. You have SPs rotate every three learners, so they get a break. During their breaks, you check in on them to informally debrief.
The value of a prebrief and debrief Values: Safety Risk Transparency Empowerment Trust Respect Inclusion Diversity Equity	How might you mitigate the emotional impact on SPs? How might you attend to unanticipated consequences of the simulation, such as students’ response to the simulation?	Plan for a prebrief to ensure participants are clear about the goals, expectations, guidelines, rules of engagement and parameters of the simulation. Plan for a debrief with trained facilitators to allow SPs to derole and to allow participants to reflect on their actions, impact and feelings of the simulation. Evaluate SPs’ experience with the simulation.	You organise a prebrief for learners, as an opportunity to remind them of the learning objectives for the simulation. You remind them of the need for respect of all participants. After the simulation, while the learners are debriefing with a facilitator, you have a separate debrief with the SPs to provide them with the opportunity to reflect on the impact of the simulation, and to discuss how they felt during the simulation. You provide the SPs with a link to an anonymous survey, allowing the SPs to evaluate their experience with the simulation. Some note stereotypes written directly into the scenario, and you forward-feed this feedback directly to the case authors.

SP, simulated participants.

The authors acknowledge that they are writing from a place of privilege (white, able-bodied, cisgender, educated) and of limited lived experience, and our voices do not represent or replace those of diverse and priority community members. Rather, we see this paper as preliminary work creating space for discussion and collaboration. Our next step is to research SPs’ experiences with being recruited for their identity, appearance and lived experience, to amplify and further explore their perspectives on how we can safely incorporate diversity and inclusion into simulation and how to better advocate for and meet the needs of SPs.

Although this paper specifically considers SPs’ psychological safety in simulation scenarios addressing diversity and inclusion, these strategies can also be applied to all participants in simulation, including learners, staff, educators, clinicians and faculty. These principles are also applicable to SPs who undergo physical examination during a simulation. A discussion of SP feedback and its effect on psychological safety is beyond the scope of this article.

Data availability statement

No data are available. Data availability is not applicable as no data sets were generated or analysed for this essay.

Ethics statements

Patient consent for publication

Not required.