Exploring Newborn Health Disparities through Simulation

By: Desiree Díaz, PhD, RN-BC, CNE, CHSE-A, ANEF, FAAN; Valerie Martinez, DNP, APRN, CPNP-PC; Andrew Todd, MLIS, BSN;  Charlize Soto, BSN; Anna Cook, BSN; Ilisha Strassler, BSN

Health disparities related to infant mortality are rising in the United States, and infants of non-Hispanic Black women have the highest mortality rates (Ely & Driscoll, 2020). Despite the increased use of simulation-based learning experiences in prelicensure nursing education (Hayden, 2010), there are few simulations centered around infant mortality and health disparities. To address the need to recognize signs and symptoms of newborn distress, a team of nursing faculty and undergraduate prelicensure students at the University of Central Florida developed a simulation involving a Black pregnant woman with gestational diabetes.

Infants born to mothers with gestational diabetes are at risk of being born large-for-gestational-age (LGA) with congenital anomalies, and of developing hypoglycemia, hyperbilirubinemia, and respiratory distress after birth (Campbell et al., 2017). To address the risks for infant mortality in the context of health care disparities, we developed an evidence-based simulation involving the 12-hour-old infant of a Black mother with gestational diabetes. The simulation explored caring for the infant with previous hypoglycemia who also had difficulty latching. The learners were required to recognize the need to perform a point-of-care blood glucose check on the infant and complete a thorough assessment before returning the infant to the mother’s chest for breastfeeding. Learners were also expected to provide education to the mother on topics of bonding, breastfeeding, circumcision, hypoglycemia, and sleep. Presimulation activities were selected based on gaps in knowledge for undergraduate nursing students related to the care of newborns (Díaz & Anderson, 2020).

This simulation provided an opportunity for students to discuss and reflect on issues related to race and ethnicity in health care settings. During the pilot, facilitators ensured a psychologically safe environment for all students to share their personal reflections related to the content. Facilitators reminded learners that the content of the reflection and discussion could elicit personal memories and responses. Learners were encouraged to discuss the feelings and emotions they were comfortable sharing with the group. They were not required to respond with personal anecdotes. This allowed students who may have had previous situations affected by bias to opt out of sharing.

Some discussions about implicit bias and health care disparities elicited visceral responses from learners. The educators were prepared for potential dissonance, having read recent literature on current national trends, relevant issues, and evidence-based data prior to the simulation experience. All facilitators were reminded to review the Society for Simulation in Healthcare (SSH) Healthcare Simulationist Code of Ethics (2018) and INACSL Standards of Best Practice (2016) to learn about expected behaviors and set the stage for deep discussion.

Simulation settings may be limited in their ability to alter or change the physical characteristics of a manikin. Settings with access to lighter skin tone manikins may want to consider other options to incorporate diverse backgrounds into a scenario. One suggestion is to include family dynamics that may be encountered in the birth of a first born. Another option is to shift the culture of the patient. Changing the race or ethnicity of the mother and baby in the scenario provides an opportunity to explore culturally congruent care.

Simulation provides an opportunity for students to practice care for marginalized populations in a safe environment. Our hope is that diverse simulation scenarios aimed at newborn health disparities will be a catalyst for improved patient outcomes.

The University of Central Florida College of Nursing thanks Laerdal Medical for their generous support of this project.


Campbell, S.H., Del Angelo Aredes, N., Mara Monti Fonseca, L., & de Salaberry, J. (2017). Chapter 20: End of life care with limited English proficient (LEP) patients. In S.H. Campbell & K. Daley (Eds) Simulation scenarios for nursing educators: Making it REAL (3rd ed, pp. 217-233). Springer Publishing.

Díaz, D. A., & Anderson, M. (2020). Pre-briefing and Debriefing – Key components promoting student engagement. In P. R. Jeffries (Ed.), Clinical simulations in nursing education: From conceptualization to evaluation (3rd ed.). National League for Nursing

Diaz, D., Damato-Kubiet, L., Todd, A., Gilbert, G., Harris, M., Lee, M.H., Kurtek, A., Jaromin, G.M., Jarocha, M., Magana, C.L., & Newhouse, B. (submitted). Exploring healthcare disparities in maternal-child simulation-based education.

Ely, D.M., & Driscoll, A.K. (2020). Infant mortality in the United States, 2018: Data from the period linked birth/infant death file. National Vital Statistics Reports, 69(7), 1-17.  https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-7-508.pdf.

Hayden, J. (2010). Use of simulation in nursing education: National survey results. Journal of Nursing Regulation, 1(3), 52-57. https://doi.org/10.1016/s2155-8256(15)30335-5.

INACSL Standards Committee. (2016). INACSL standards of best practice: SimulationSM: Simulation design. Clinical Simulation in Nursing, 12(S), S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005

Leighton, K., Ravert, P., Mudra, V., & Macintosh, C. (2015). Updating the simulation effectiveness tool: Item modifications and reevaluation of psychometric properties. Nursing Education Perspectives, 36(5), 317-323. https://doi.org/10.5480/15-1671

Society for Simulation in Healthcare. (2018) Healthcare simulationist code of ethics. https://www.ssih.org/SSH-Resources/Code-of-Ethics

2 thoughts

  1. Great article. So what is the solution to solve the increased prevalence of disparities amongst minorities? What actions should nurses engaged in to combat disparities?

    Dr. Barbara Miller DNP, EdD, MSN, RN

  2. Dr.Miller, I believe the solution is a multifaced issue. We need to educate and train all healthcare members on the risk and what is going on in the country. Understanding the detrimental effects negative care or negligence has on people esp. people of color is needed since some healthcare member s are literally unaware. This allows people to act if they see something. It then goes systemically. We need to have things in place to augment insurance coverages and care, working with policy and community workers. I wish it were an easy issue to solve. I do know it takes one ripple to eventually change the current. Dr.Diaz

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