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The Alarm Has Sounded for Equity in Health Care Simulation. Now What?

By: Desiree A. Díaz, Crystal (Graham) Murillo, Kelli Bryant, Konal Bajaj., Cynthia L. Foronda, & Christine Park

The call has long sounded for threading concepts of health care disparities (HCD), social determinants of health (SDOH), social justice advocacy, and diversity, equity, and inclusion (DEI) into health professions curricula. However, despite numerous efforts, much work remains.

An early call to action for health professions educators happened in 2007 during an open forum at the NLN Education Summit when national leaders were confronted with the issue of variable pricing for high-fidelity patient manikins. Until that time, all major distributors based their prices on the manikin’s skin tone. After the Summit, immediate action was taken. By 2008, pricing by major distributors was the same for all skin tones.

Unfortunately, racial and ethnic diversity continues to be missing in simulation resources and pedagogical practices (Conigliaro et al., 2020; Foronda et al., 2017). There remains a crucial need to incorporate diverse and inclusive learning experiences in nursing education.

Murillo and Bryant (2022) and Shirani (2021) have also put forth calls for action and offer recommendations to achieve racial equity in simulation leadership. They posit that our leading simulation organizations must develop intentional recruitment and retention strategies to ensure that their composition accurately represents the diversity of our organizations and community. The development of targeted mentorship programs to spearhead a pipeline of future leaders is one recommendation. Gathering demographic data on membership now, to be able to evaluate for change in the future, is another. 

The International Nursing Association for Clinical Simulation in Learning (INACSL) has taken a strategic approach to improve DEI efforts, revamping the strategic map to include diversity, spearheading a DEI committee, putting out a call to end structural racism, initiating scholarships for the underrepresented, providing implicit bias training to members, and critically examining policies. INACSL’s flagship journal, Clinical Simulation in Nursing, placed a call for a special issue directed toward DEI to be released this year. As a lack of underrepresented nurse faculty in leadership permeates many professional organizations, it is important that all organizations recognize that countering the effects of systemic injustice requires a team, a strategy, and time.

Defining terms is an important first step. Definitions provide clarity and transparency about the intentions of the initiative. For example, cultural humility (Foronda, 2020) and cultural congruence (Schim & Doorenbos, 2010) are two concepts that are necessary when employing strategies to explore HCD and DEI initiatives. Cultural humility serves as a foundation to both the learner and facilitator to deepen their understanding of diversity and power imbalances. Cultural congruence is the framework in which a provider delivers care, respecting the impact of culture on care.

Educators should take advantage of DEI training and workshops. Preparation by educators is needed to adequately prepare learners to mitigate bias and be catalysts for change. Empowerment to be a social justice advocate requires deliberate steps by all educators.

We recommend taking some initial action steps, including volunteering to serve on the boards of professional organizations and delving into the literature regarding the latest evidence about increasing diversity within the curriculum. All of us can ensure that the simulation scenarios we use represent diverse populations, and co-constructing scenarios with representatives of underrepresented groups is one way to make that happen. We must continually reflect and learn from others and examine the simulation-based learning environment for signs of inclusion. Ask learners what faculty can do to improve DEI at your institution. Critique current guidelines and policies. Work to diversify the simulation curriculum.

The alarm is not new but it has been noticed. There remains a lot of work to do, but the interest and momentum for change are palpable. Importantly, as educators, we need to stay connected as we learn from each other’s lived experiences and knowledge.


Conigliaro, R.L., Peterson, D.K., & Stratton, T.D. (2020). Lack of diversity in simulation technology, An educational limitation? Simulation in Healthcare, 15, 112–114. DOI: 10.1097/SIH.0000000000000405

Foronda, C.L.(2020).A theory of cultural humility. Journal of Transcultural Nursing, 31(1), 7-12.

Foronda, Baptiste, D.-L., & Ockimey, J. (2017). As simple as black and white: The presence of racial diversity in simulation product advertisements. Clinical Simulation in Nursing13(1), 24–27.

Murillo, C.L., & Bryant, K. (2022). A DEI call to action: Racial equality in simulation leadership: Beginning the conversation. Clinical Simulation in Nursing, Https://

Schim, S.M., & Doorenbos, A.Z. (2010). A three-dimensional model of cultural congruence: Framework for intervention. Journal of Social Work in End-of- Life and Palliative Care, 6(3-4): 256–270. doi:10.1080/15524256.2010.529023.

Shirani, F. (2021). Integrating diversity in simulation-based education: Potential role of virtual reality. Academic Emergency Medicine, 5, e10608.

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