Promoting Psychological Safety through the Incorporation of Diversity, Equity, and Inclusion (DEI) throughout Simulation Centers’ Operations > The Society for Simulation in Healthcare

Promoting Psychological Safety through the Incorporation of Diversity, Equity, and Inclusion (DEI) throughout Simulation Centers’ Operations


Laura Daniel, PhD1; Therese Justus McAtee, DNP, RN1; Donamarie N-Wilfong, DNP, RN1

1The Simulation, Teaching, and Academic Research (STAR) Center at Allegheny Health Network (AHN), Pittsburgh, Pennsylvania

Conflict of Interest Statement

The authors declare no conflicts of interest.

Corresponding Author

Laura Daniel, PhD, The Simulation, Teaching, and Academic Research (STAR) Center at Allegheny Health Network (AHN), Pittsburgh, Pennsylvania


Brief Description

Simulation centers have an obligation to provide a psychologically safe environment for all users. Many simulation centers have standard policies and procedures or confidentiality agreements and publicity release forms to aid in creating a psychologically safe environment. However, this article challenges simulation operation administrators to go beyond overt forms and describes more covert ways in which simulation centers can promote a psychologically safe environment by incorporating aspects of diversity, equity, and inclusion (DEI) throughout the center. DEI helps people of all backgrounds and life situations feel represented, comfortable, and welcome and therefore will likely increase the psychological safety of the environment. Simulation administrators can integrate DEI throughout the course development and implementation process from start to finish to foster a psychologically safe environment for all.


The importance of a psychologically safe environment for simulation education cannot be overstated. Such an environment is professional, supportive, respectful, trusting, and transparent among all simulation participants and facilitators (Picketts, Warren, & Bohnert, 2021). A safe learning environment enables learners and standardized patients (SPs) to perform in reliable ways, free from fears of ridicule, embarrassment, or other negative emotions. Helping simulation participants feel comfortable in the simulated environment aids in lessening potential sources of internal error.

Many simulation centers require learners to sign confidentiality agreements to promote a psychologically safe environment. In fact, confidentiality mechanisms in the form of policies and procedures are a required piece of the Society for Simulation in Healthcare’s accreditation standards (2021). Through these forms, all parties involved in the simulation including learners, facilitators, and/or standardized patients pledge not to judge their peers’/learners’ performances, not to discuss the performances outside of the simulation center, and/or not to divulge simulation information to other potential participants, helping to establish a psychologically safe environment. These forms will also advise learners of the confidentiality of the data collection tools and video recordings, giving them security in knowing what purpose the recordings serve, how they are stored, and how long they are retained. These overtly signed documents directly contribute to the center’s perceived level of a psychologically safe environment.

While deliberate paperwork and signatures are important and fulfill a formal dedication to a psychologically safe environment, this article challenges simulation centers to go beyond rote forms and describes indirect ways in which simulation centers can incorporate DEI methods throughout daily operations to consistently contribute to a psychologically safe environment. Creating a psychologically safe environment begins before any learners set foot in the center during the simulation design phase, is maintained during the course, and is even important when the course is over.


When course facilitators and/or simulation educators develop a course, they often use course development worksheets or templates. Simulation design templates are used to document the details of the simulation including the specifics of the simulated patient. Many existing templates ask the course developer to articulate only the very basic demographic information about the patient such as age, gender, and/or weight (Northern Virginia Community College, 2023 and Medical College of Wisconsin, 2023). Other templates incorporate additional patient attributes such as ethnicity and/or religion (Texas Tech University, 2023). Nonetheless, several important classifications have typically been omitted from existing simulation design templates.

For simulation centers to truly reach their potential for a diverse and inclusive culture, the simulation design templates need to include more demographic categories, such as their patient’s sex assigned at birth, preferred name, pronouns, sexual identity, native language, disabilities, religion, marital status, and educational level. The National League for Nursing’s (NLN, 2023) recently revised simulation design template is one of the most diverse design templates to date. The first page of the template asks course facilitators to articulate 26 variables to represent a “brief description of [the] patient.” The NLN included the diverse fields of sex assigned at birth, pronouns, gender identity, sexual orientation, marital status, racial group, language, religion, and insurance status. When course facilitators state these additional patient details, it is likely that DEI will surface to the forefront of their minds. It is likely that course facilitators will have a heightened sense of DEI and may choose a variety of patient attributes.

In fact, Laerdal, a world leading medical company, recommends designing entire simulations based on patient populations rather than on a specific clinical task or teamwork strategy to create authentic and diverse simulations (n.d). Laerdal purports many biological and social health determinants are often overlooked but they affect patients in ways that ultimately shape health outcomes. For example, these determinants may affect patient stress levels, access to care, and/or nutrition to name a few. Designing simulations around these often insidious yet powerful factors will help create a wholistic learning environment, appreciative of patient diversity.

Furthermore, many researchers also recommend co-creating simulations with individuals from the community being portrayed in the simulation (Foronda, Everett-Thomas, & Diaz, 2022 and Ibrahim, Lok, Mitchell, et al., n.d.). This real-life content expert can provide genuine insight to the simulation’s validity, can help identify potentially offensive language or materials, and/or may help reduce implicit biases that some simulationists may inadvertently overlook. In fact, one of the standards of best practice of the Association of Standardized Patient Educators (2017) reads, “2.1.3 Ensure that cases are based on authentic problems and respect the individuals represented in a case to avoid bias or stereotyping marginalized populations.” Therefore, working with standardized patients who have lived through the simulation’s problems is an effective way to meet this standard, as they bring genuine insight and authentic guidance to simulation design.

Another way to promote DEI and psychological safety before the simulation begins is by taking inventory of the center’s simulators and task trainers. Many of these machines come in different skin tones and ethnicities. One subtle but effective way to help promote a psychologically safe environment is to utilize simulators and task trainers of a variety of races and of both sexes. Indeed, the International Nursing Association for Clinical Simulation and Learning (INACSL)’s healthcare in simulation best practices (2021) for simulation design recommends using manikins with the race and culture of the simulated patient to aid in the fidelity of the simulation.

Similarly, simulation centers can incorporate DEI by diversifying their SP pool as much as possible. A diverse pool of SPs makes it inherently easier for course facilitators to create diverse simulations. Some visual/auditory patient characteristics cannot be simulated such as race and ethnicity, which highlights the need for a large pool of SPs. For example, international patients may have different customs or expectations of healthcare delivery, may speak English as a second language, and/or may speak in heavily accented English. Furthermore, some non-visual attributes are also difficult to simulate, justifying the need to have true SPs of various communities to bring first-hand experiences and lived emotions to the simulation. For example, marginalized and/or vulnerable populations, such as those living under the poverty level and/or transgender patients, may carry rich healthcare experiences that would add value to a simulation. This assertion is parallel to the INACSL’s (2021) simulation design best practice of using simulators of varying skin colors and tones to respectfully represent patients’ race and culture to promote simulation fidelity. SPs play a vital role in the success of a simulation, and it is essential that they represent all crafted patients well.

Lee Ann Miller, the Assistant Director of Education at West Virginia University’s simulation center (2021) articulated the importance of increasing diversity in standardized patient pools, “It is important for the students to experience a diverse patient pool in order to develop cultural competence in a safe environment.” Cultural competence has been defined as the delivery of “effective, quality care to patients who have diverse beliefs, attitudes, values, and behaviors” (Tulane University, 2021). Gaining cultural competence is a lifelong process in which healthcare providers continually practice active listening, empathy, and engagement (Guzman, Durden, Taylor, Guzman, & Potthoff, 2016) and diverse simulations can be one outlet to refine such skills and improve interpersonal relationships.

Nonetheless, it would be amiss to think that enrolling diverse SPs will seamlessly promote DEI while also maintaining high psychological security without any additional concerns. SPs themselves are not immune to psychological risks. In fact, Picketts, Warren, and Bohnert (2021) have claimed that enrolling SPs for certain physical characteristics may leave them with feelings of tokenism, misrepresentation, stereotyping, and/or microaggressions. In other words, they may feel like they were only recruited for participation because of their unique heritage rather than their acting abilities. Ethnically rich SPs are not solely defined by their ethnic or cultural membership, and simulationists need to take care in the enrollment of diverse SPs. In fact, ASPE’s standards of best practices purport that safe work practices, confidentiality, and respect are the three pillars of safe work environment for SPs (Lewis, Bohnert, Gammon, et al., 2017). For example, these principles assert that SPs need to feel the liberty to opt out from participating if they view it as inappropriate or harmful and need to be aware of the process to report adverse effects.

Course Implementation

There are also methods to incorporate DEI throughout simulation-based education courses. Prebriefing sessions are designated time periods before the simulation to orient learners to the equipment, environment, simulators, roles, time allotment, objectives, and patient situation. INACSL’s Healthcare in Simulation Best Practices (2021) for prebriefing, criterion nine, purports that this initial time among facilitators and learners is the ideal setting to “establish a psychologically safe learning environment” through activities that promote integrity, trust, and respect. One such activity that course facilitators can do is to call attention to the diverse attributes of the simulated patient. With pointed attention to certain characteristics and life contexts of the patient, learners may likely feel more comfortable and included if they too in fact, share some of the same diverse attributes as the patient.

Another way course facilitators can nurture a positive learning environment is by structuring the prebriefing in a cultural humility framework (Foronda, Everett-Thomas, & Diaz, 2022). This framework helps facilitators appropriately and sensitively set the tone for controversial topics such as bias or racism through Ground Rules, Acknowledge, Safe Psychological Environment, and Define (GRASPED) (Foronda, McDermott, & Crenshaw, 2022). When course facilitators take care to highlight key aspects of DEI that may affect the patients medically, they also help initiate the establishment of a positive, welcoming, and engaging learning environment for all, thus contributing to learners’ psychological safety.

Once the simulation begins and is underway, course facilitators have the obligation to ensure learners’ psychological safety throughout the education. Course facilitators with keen situational awareness of the simulation’s progression may more easily identify triggered learners. According to Ohio State University (2022), to be triggered means to have an intense, emotional response to some kind of stimuli. It may result when reacting to something that is reflective of past trauma. Being triggered may result in both emotional and/or physical responses, such as feelings of fear, increased heart palpitations, and/or sweating. Course facilitators can become more sensitive to triggered learners through emotional intelligence (EI) training. Positive Psychology (2023) has defined emotional intelligence training as “a set of practical knowledge and skills that help individuals to become fluent in understanding the language of emotions.” The objectives of EI training are to develop self-motivation, productivity, commitment to profession, confidence and flexibility, empathy, communication skills, long lasting and strong interpersonal relationships, self-awareness, and self-control.

Simulation based educators can access virtual emotional intelligence training through reputable universities such as Yale, the University of Michigan, and the University of California Davis or through LinkedIn Learning. These courses are online, self-paced modules in which simulation-based education (SBE) course facilitators complete at their convenience for a nominal fee. Simulation course facilitators who are skilled in recognizing and attending to triggered learners in their own courses would help foster a psychologically safe and inclusive learning environment for learners of all backgrounds and experiences.

Lastly, debriefing sessions are a post-simulation, guided review that provide an outlet to promote learners’ psychological safety even after the simulators are powered off. Indeed, INACSL (2021) standards of best practice purports that debriefing sessions must be conducted in ways that preserve learners’ psychological safety. Debriefing sessions provide an opportunity to explore learners’ emotions and reactions to the simulation and to analyze their performance, in a safe, judgement-free zone. Foronda (2021) described the need for educators to structure debriefing sessions in the transformative learning framework regarding cultural humility. Within this framework, simulationists focus on the idea that learners can change their thinking. When these sessions are consciously conducted in the framework of DEI, more focus will be placed on including all learners, and examining the life variables that affect patient outcomes that may not necessarily be included on the medical chart.


At the conclusion of the course, facilitators often administer evaluations to their learners. In fact, evaluating educational activities is a standard for teaching/education accreditation by the Society for Simulation in Healthcare (2021). Evaluative surveys are best anonymous and confidential to decrease social desirability bias and acquiescence. The anonymity of surveys provides learners with a safe venue to voice concerns and/or accolades. Survey items can include questions about the perceived level of psychological safety before, during, and after the course and the perceived level of diversity, equity, and inclusion in the center’s operations and facilities. Evaluations can be administered in paper and pencil or electronic formats.

If simulation centers have more time and resources available, Foronda, Everett-Thomas, and Diaz (2022) purport that learner interviews or focus groups are another viable way to glean learner perspectives about the center’s culture. These more personal data collection methods may yield rich discussions and/or impactful anecdotes. These meetings can be conducted in-person or virtually. Nonetheless, regardless of the methodology, soliciting first-hand data from the learners will help simulation center administrators gauge the culture of the center and garner ideas for DEI improvement from the perspective of its main users. Similarly, the perspectives of course facilitators are often overlooked but also important. Center administrators can implement similar data gathering methods with facilitators as they do with learners via anonymous evaluative surveys, interviews, and/or focus groups.

By triangulating data from multiple sources, center administrators will likely gain a more holistic perspective. As center operators make a dedication to consistently administer and analyze data from its users, it demonstrates a vigilance to self-reflection and a drive toward improvement. Such good-natured activities may help to build a culture wherein learners and facilitators feel psychologically safe. Moreover, Buchanan and O’Connor (2020) also claimed that gathering such needs assessment data will help simulation administrators create strategic actions to enhance the DEI of their center.


Incorporating DEI into simulation centers not only satisfies today’s societal demands but also helps the learners feel more comfortable, likely yielding more valid performances. By recognizing and appreciating the differences among patients and learners, being culturally sensitive to marginalized groups, and making a genuine effort toward equity and inclusion, the psychological environment becomes safer for all. Without the burden of feeling misrepresented, unequal, and/or excluded, learners experience the freedom to participate in the simulations in a more positive and relaxed state of mind, thus contributing to more reliable and valid experiences.


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