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Clinical simulations help nursing students uncover their biases

7 February 2022

By Ian Evans

Prof Nicole Harder's film crew for clinical simulations.

Implicit bias is everywhere. This nursing professor uses clinical simulations to make students aware of racial and cultural biases.

Prof Nicole Harderopens in new tab/window recalls the experience of an Indigenous nursing student who went to the dentist with tooth pain:

Right at the start of the conversation, she was told, ‘I’m not going to give you any Tylenol (with codeine) for this,’ which she wasn’t asking for. There was an unspoken sense of, ‘You’re indigenous, so this is drug seeking behavior’ — which of course she found very offensive.

Unfortunately, stories like this are all too common. Insensitivity is not only offensive to patients; there is mounting evidenceopens in new tab/window that implicit bias leads to poorer outcomes for people of color. The challenge is that healthcare providers — like people in all fields — are often unaware of their own biases.

Prof Nicole Harder, RN, PhD, CHSE, CCSNE picture

Prof Nicole Harder, RN, PhD, CHSE, CCSNE

As specialist in clinical simulation, Prof Harder set out to correct this situation for clinicians.

Her recent work examines how simulations can recreate the complexities of human interaction, emotion and biases on both sides of the patient/clinician relationship, especially with regard to racial and cultural sensitivities.

Nicole is an Associate Professor in the College of Nursing and the Mindermar Professor in Human Simulationopens in new tab/window at the Rady Faculty of Health Sciences, University of Manitobaopens in new tab/window. She is also Editor-in-Chief of Clinical Simulation in Nursingopens in new tab/window, the official journal of the International Nursing Association of Clinical and Simulation Learning, which Elsevier publishes.

Speaking from her home in Winnipeg, Canada, she explained how she came to focus on addressing racism and psychological safety, and developing coping strategies through simulation:

I was looking at designing simulations that addressed interculturalism. Often, we’d create clinical scenarios and include an age, ethnicity, religious status for the patient. But then these things would fall by the wayside, and the focus would be more on medical management, symptoms and so on.

So Nicole saw the need for simulations where the focus was wholly on the intercultural elements, where clinicians in training would have to address the realities of cultural differences, unconscious biases and racism in a clinical setting.

And she realized it was something she could not do alone:

I’m a White settler in an area with a large Indigenous community. That’s the lens I have on this, and the same is true for much of the rest of faculty. So anything we created would come from that viewpoint. 

Nicole knew that simply putting together a program and then asking for a critique from the community wouldn’t address the core issues. Instead, the simulations would have to be co-created with individuals with “lived experience of racism and stereotyping and biases in healthcare services.” The participants would be able to identify some of the microaggressions they’d experienced and share what they wish healthcare providers knew about providing care in an intercultural way.

Stark examples like the experience of her indigenous nursing student provide a basis for learning. However, reliving such negative experiences can be tough for the people involved. So rather than rely on “simulated patients,” where someone might have to repeatedly role play the microaggressions they experienced in real life, Nicole and her team created the environment as a virtual experience. “That way you’re not always taxing these individuals to relive these moments over and over again,” she said.

Virtual simulations use interactive recordings that can be played individually, at a time and in an environment determined by the player. They can  be used in tandem with live debriefs, where students meet online in groups of six to eight, and trained staff are on hand to debrief the simulation shortly afterwards, to help enhance reflection and deepen learning.

Confronting their biases

The exercises can throw up some difficult moments for the trainees – often challenging their biases and assumptions. Nicole found that the experience also prompted her to consider her own communication habits:

Before doing this, I worked in the Canadian High Arctic, which is all fly-in communities with a lot of Indigenous and Inuit people. I assumed that because I had spent a decade working in these environments, I would be more sensitive to some of the things that our co-creators were identifying.

However, Nicole realized that, for example, she would use language that could be insensitive to the communities she was working with:

For example, for a meeting I might say ‘let’s have a quick pow-wow,’ or when you’re talking about your people, referring to ‘your tribe’. I would say things without recognizing that they’re culturally inappropriate.

Creating psychological safety

For many people — including the simulation participants — it can be uncomfortable to examine these habits and biases. While Nicole and her team did want to challenge people, she also wanted to make sure everyone had space to deal with the emotions the simulations generated. She explained how they used a psychologically safe debriefing framework built on the frameworks that help people deal with trauma:

The first thing you have to do is acknowledge those feelings and emotions. The biggest thing we spend our time on is those initial reactions. We explain that it’s normal to feel threatened or defensive. It’s up to the individual to unpack why that may be, but it’s important to spend time dealing with those emotions.

One of the keys to success here is repetition, Nicole said, so trainees take part in a session about twice a week for three or four weeks. “What we see by about week three is that people are able to debrief themselves,” she said. “They’re already there without our prompts to start to identify these feelings and emotions and understand what they’re experiencing.”

That is crucial because in clinical practice, there won’t always be people around to debrief staff after emotional encounters.

From that position, participants can recognize and deal with their own responses and move forward in providing care that is ever more inclusive for people from different cultures.

Simulations to deal with traumatic situations

The simulations that prompted this initiative were based on addressing intercultural interactions, but for Nicole, they also speak to a deeper need to acknowledge emotional responses in clinical settings. Doing so can help improve outcomes for patients but also help address mental health in clinicians. Nicole recalled a clinical orientation session that contained a brutal indication of how emotion was usually dealt with in a clinical setting.

I was attending a clinical orientation with my students a couple of years ago, and our course lead said something along the lines of, ‘There’s no crying in clinical — if you’re crying in clinical, hide yourself in a closet because your peers and your patients don’t need to see that.

Since then — largely due to the pandemic — Nicole acknowledges that there has greater recognition that clinicians need space to deal with emotional stresses:

People are starting to realize that clinical staff are not superhuman, they’re not robots, and that if you push emotions down, then you start to develop post-traumatic stress.

Consequently, Nicole and her team are using the same framework they use to work through cultural biases to help practitioners develop resiliency in other situations. The idea is that the same process that helps a clinician unpack and address their emotional responses to confronting their biases can be put to use elsewhere.

Instead of focusing on racism or stereotyping, we will put clinicians in simulations where there’s a pediatric death or some other traumatic situation. We then work with healthcare providers to help people address those feelings and emotions themselves.

For Nicole, these kinds of approaches can expand the remit of simulation well beyond the physical elements of treatment and help provide tools that benefit everyone:

There’s so much that we can do in simulation, not just for ultimate patient care but also to improve the mental health and wellbeing of providers.


Portrait photo of Ian Evans


Ian Evans

Senior Director, Editorial, Content & Brand


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