In this special bonus episode of The Forum Podcast, Samreen Vora (Children’s Minnesota) and Brittany Dahlen (Children’s Minnesota) answer questions from listeners that attended our August 19, 2021 webinar Using Innovative Simulation Strategies to Dismantle Systemic Racism.
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Samreen Vora and Brittany Dahlen answer questions from our listening audience around these talking points:
- Bias mitigation strategies, evidence and effectiveness
- Measurable outcomes with simulations performed and the impact on participant behaviors
- Examples of bias mitigation strategies and simulation used outside of bedside care and outside of the healthcare setting
- How to prepared facilitators for simulation sessions
- Recommendations for those who may have more limited resources and how they can bring this to their own organizations
For additional context and insight into this topic and conversation, watch the replay of Using Innovative Simulation Strategies to Dismantle Systemic Racism.
The following is an uncorrected transcript generated by a transcription service. Before quoting in print, please check the corresponding audio for accuracy.
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Ben: Hello, and thank you for tuning in today’s special Forum on Workplace Inclusion Podcast Using Innovative Simulation Strategies to Dismantle Systemic Racism continued with Dr. Samreen Vora and Brittany Dahlen of Children’s Minnesota. I’m Ben Rue, the Program Manager here at The Forum. This is a continuation of our August webinar Using Innovative Simulation Strategies to Dismantle Systemic Racism. If you haven’t watched that yet, I would highly recommend that you do.
There were so many great questions that we weren’t able to get to during that webinar so Dr. Vora and Brittany were gracious enough to come back and answer a few of them. Let’s get started.
Thank you both so much for being back Dr. Vora and Brittany. I really enjoyed the last webinar and I’m really happy that we are able to continue this conversation, because there were so many great questions and so much more information that we weren’t able to get to so thank you both for being back with us.
Samreen: Thank you for having us.
Brittany: Yes, thank you for having us.
Ben: Definitely. Our pleasure. Let’s just hop right in. These are some of the questions that we weren’t able to get to in the webinar but also questions that people sent to you afterwards via email. There’s points that I wanted to get at. Topping right in, you mentioned in the webinar bias [00:04:00] mitigation strategies that were used as part of your simulation sessions. Could you share more about these strategies? What are they and what is the evidence of their effectiveness?
Samreen: Absolutely. This is one of the things as we designed our simulations in our curriculum, and we looked at other implicit bias trainings around the country, one of the things we really wanted to be mindful of is taking things and doing trainings that we knew had some evidence to show their effectiveness and so what we run across in the psycho-social literature, that it’s actually been adopted into a variety of places across the healthcare field as well like the Institute for Healthcare Improvement and other– The Aspen Institute.
These bias mitigation strategies that have, in a variety of studies, have shown effectiveness in changing people’s behaviors. We focused in on a few that we used during our simulations and that we helped people learn and practice. There’s others that we didn’t necessarily focus on that can be done individually as well. Maybe I’ll give a couple of examples.
One example that we didn’t cover in our webinar or using our simulations is an easy one for people to do called counterstereotype imaging where you purposely identify, look at a member group that may have either systemic racism where, think about the Black member group or a member group that you know you might have biases against and you look at images from that group that replace your automatic biases in your brain. For example, going and looking at pictures of really successful Black males to change the automation that has been built into us by being part of this American society growing up here.
You’ll go look at pictures of Obama or Oprah and use that as a bias mitigation strategy. Over time, that’s been shown that you slowly start to shift to what you associate with that group automatically. [00:06:00] Other strategies that we did use in our simulation, one really great one was individuation. It’s a little bit different than [unintelligible 00:06:10] imaging. You’re focusing on a group that you think you may have biases towards and you’re trying to shift that in your mind, shift that automation in your mind.
Individuation is actually taking people from any member group and thinking of them as individuals and not part of this bigger group. In healthcare particularly, it’s to be very mindful to see patients as individuals instead of as a member of a stigmatized group and then create that patient-centered care, create some partnership building with them which is another bias mitigation strategy.
For example, there’s a lot of bias in our society. Within healthcare, there’s been data that’s shown that we’re less likely to believe when patients of color particularly Black patients report pain, we’re less likely to give pain medication. Now, using the bias mitigation strategy– Knowing that data, even if you say that, “I don’t believe that and I don’t feel that way” but when you go into a patient’s room, you know that data. You know that there is that type of bias that happens.
Then to actively use the bias mitigation strategy and use individuation, I’m going to look at this patient and hear their history and their story, look at their injury or what they’re complaining about and practice that bias mitigation strategy in that moment. Those are two examples of– There’s a variety of other strategies. We talked a little bit about mindfulness as another bias mitigation strategy. Another really good one is perspective taking. I actually use this in my daily life too. It helps with your significant others or your children.
So really just take a pause and do some perspective taking. I often use it with my 13-year-old. I think, “I know she’s giving me an attitude,” but if I use perspective taking and I think, “What is she feeling now? From her perspective, what did she just experience that’s causing her to react this [00:08:00] way?” It’s really helpful in that way and really helps to mitigate some of our own biases that we bring into that picture.
In that example, “Are my biases coming in?” “My 13-year-old is really immature. She doesn’t get this.” Then I do some perspective taking and I’m like, “Actually,” if I take a moment to think from her perspective– Similar in the healthcare setting, do some perspective taking from the patient’s perspective like, “Gosh, yes, they are loud and screaming.”
If I do some perspective taking, you have a child that’s dying. Maybe that’s what I would be doing in that situation or they just experienced as they walked in from the front desk, they were stopped as the Black father and some multiple other white patients walked right through.
They bring that experience up. Doing some perspective taking can really help me, then again do some partnership building and understand the patient’s perspective or the caregiver’s perspective better. Those are some examples of bias mitigation strategies that we incorporated into our simulation that could be incorporated into daily living for a lot of people as they are on their anti-racism journey. Really deliberately practicing those can change behaviors that are related to our implicit biases.
Ben: Thank you so much Dr. Vora. That’s such a good point, perspective is so important. Brittany, is there anything you would like to add to that?
Brittany: Yes, I think that the main point to remember with any of these strategies is you’re trying to slow your thought process down. Giving yourself enough time to counter some of those snap assumptions, that fast thinking that is embedded in all of us. There’s different things that are embedded in all of us. All the strategies Dr. Vora listed are things that you can integrate into your daily life that just helps you get that extra time to pause before reacting.
Ben: Thank you. Can you share what outcomes you were able to measure with the simulations [00:10:00] you did, and if you were able to see the impact on your participants’ behaviors?
Brittany: Yes, we’d be happy to. We looked very intentionally at what outcomes we could measure before we did this intervention, our first intervention with this course. Most importantly, we wanted to partner with our family satisfaction survey results. At our organization, we stratify those by race, as well so that we can further understand any disparities that are existing across the organization. That was really important to us, is to look at the translation to the bedside.
So clinical nurses and providers coming in through our course, then going back to their bedside work, and what is the actual experience of families that are getting the care? That is something that we’re still actively tracking, but early indications are showing us that there is an impact for families. We are looking primarily at Black families because both of our scenarios were focused on the experiences of two Black families, simulated cases that we had designed, and the biases that those families face. What we’ve noticed so far is that the family satisfaction scores in general are actually improving across the board, but specifically when stratified by race as well.
We also are looking at participant perceptions. We’ve looked into the literature, in social psychology literature, and use the internal and external motivation scale, which helps understand how prejudices are enacted. Is it an internally motivated person to not be prejudiced? Or is it more of an external motivation? That scale helps us understand. We did it at three different time points, [00:12:00] pre-intervention, immediately post the course, and then a follow-up three months survey.
In conjunction with that, we even looked at situational judgment test as well. Something that we designed to measure, what is someone’s perceived behavior in this scenario? If they observe bias statements during a conversation with a colleague, how would they respond, for example? Those two measures helped us understand the participants’ perceptions, as well as them recording at the three-month follow-up. Were they using these bias mitigation strategies? What we’ve seen so far is that the participants are using it overwhelmingly. About 97% of those who’ve responded are using the bias mitigation strategies at the bedside.
We also looked at several other measures that we’re still analyzing about things that people might consider in their own workplace. At our institution, we have behavioral contracts and deny entries that sometimes are applied for families if there is a concern about who is visiting the patient or the behavior of the family member or visitor who’s visiting the patient. This can be really biased when it comes to who was getting these behavioral contracts or deny entries. Our organization has a commitment to make sure that these are applied more equitably, and only when necessary.
That’s another piece that we’re looking at, stratified by race to see what the impact might be to those families and those experiences. Samreen, anything that you would add around the outcomes piece?
Samreen: No, I think that was a great summary. We tried to look at a lot of different pieces to see where are we impacting things. The only thing I would say is, as we said, [00:14:00] our cases did focus on Black families because those were the cases we designed for our simulations. That isn’t to say– I think when we center on the margins, we make things better for all patients and families. As we saw in our results and our family satisfaction surveys too, is that’s what happened. It’s not to say there aren’t tons of other– We’re talking about racial bias, but there’s so many other places, right?
Gender, and just so many places where patients experience that bias or discrimination really, at times. It’s not to dismiss any of that or not recognize that. I would say when we call out this kind of racial bias, we get into in general– It’s really what Brittany said earlier, right? We get into, “Well, how do our biases work? How do our lived experiences contribute to these biases and where might they be?” To get people to do the practice of the strategies, not necessarily for one specific group but in general, to say, “How do I identify?” Slow down my thinking process, identify my bias and then mitigate it in my actions.
Ben: Thank you so much for that. Thank you for the work that you’re doing. I know, we mentioned this before pre-recording. My mother, who is a Black woman is going through a bit of an issue with facing racial bias with a now ex-doctor, which is just so, well, shocking to hear in this day and age. Yes, just the perceptions they had about her and her perceptions going in about like, “Oh, this can’t be that. This can’t be racial bias. This is an educated doctor who’s been taking care of me for years now.” Yes, it’s just so important that even educated people, like doctors, you can continue to keep learning and you have to learn to identify your own bias.
Ben: I feel this training is– [00:16:00] I feel more important than ever these days, especially with COVID going around. There’s a great deal of racial bias when it comes to how different COVID cases are being handled, as we are aware. How it’s affecting different groups so differently, and part of that very well could be that some certain patients aren’t being believed, like the case with my mother when they say that they are having these symptoms, because of racial bias against them, or against their racial group. Or also, in the case of my mother, there’s a bias towards women too in the healthcare, which is surprising because this doctor in point was also a woman.
Yes, but it’s still just– The intersectionality is just so important as this training goes. It definitely starts with race, but yes, there’s definitely a lot more that can be tied into this. Back on track. [laughs] I’m sorry.
Samreen: Well, to add to– Thank you for being vulnerable and sharing that Ben, because for people to hear the real stories is really important, right? I would say that not just– You hit on a couple of things that are really important, where we think, “Well, because I’m a woman, I can’t be biased against women.” Not true, right? Because we all grow up with certain frames in our systems in our society that we then internalize as well. That’s important to remember.
Then you talk about physicians and providers and healthcare professionals in general, I think it’s not just that, well, we’re so educated, but it’s also it’s hard for healthcare professionals to see it in themselves, because most people are really well-intentioned too. Especially in the healthcare field, almost everybody I’ve spoken to is like, “Yes, I became a nurse, a doctor, a social worker, because I want to help people.” Then now you’re saying, “Wait a minute, I’m harming people?” That’s a really hard pill to swallow and understandably [00:18:00] so.
We absolutely don’t want to be harming people and so then, recognizing that bias is even harder. Well-intentioned and then well educated, and then compound that with maybe I carry one of those identities, “Of course, I can’t be biased against that identity.” That’s just not true and it’s really hard to put all those things together. Thank you for sharing that and putting it into context of why we’re doing these simulations. We’re trying to get people to self-reflect and be like, “Hmm. Aha.”
Ben: No, you’re welcome. It’s even more– Yes, the whole situation is even more upsetting because my mom herself is a nurse. There was a lot of her being like, “I know these doctors. They are well-intentioned.” No one goes into the industry that they’re in wanting to be like, “Oh, I’m going to deny service to these people,” or “I’m going to provide inadequate service to someone.” You don’t go into the medical field to do that, but definitely, it’s still happening. It’s really great that there’s this training to help people address their biases and work through that.
That’s my personal rant. [laughs] Yes, just like I said, thank you for this work. It’s not only important out in the hospital, but it’s important outside as well in regular daily life. Can you give us some examples of how these biases, mitigation strategies, and simulations can be used outside of the bedside care, or even outside of healthcare setting in general?
Brittany: Yes, we’ll be happy to. There are several opportunities where I’m sure some of The Forum listeners have done DEI work in general, and we would say you could use simulation in those instances. For example, hiring or interview processes are a great [00:20:00] opportunity to design cases where bias may be slipping in and have people pause and start to use these mitigation strategies.
Consider perspective-taking, consider emotional regulation during that interview when maybe you’re interviewing somebody who doesn’t hold the same identities as you or has just maybe said something biased, how are you reacting to those conversations? Hiring is probably a big one. Any customer interaction or even office interactions between colleagues could be simulated using the same kind of structure. I think the main thing we want to get across is these bias mitigation strategies can be used in your personal or professional life.
Just like Samreen was saying earlier, perspective-taking is a great one for personal life. I use it with my family often as well. Thinking about integrating it into your day to day but if people are interested in doing a more formal structured course that uses some of what we’ve described ,it also could be used in other settings. Samreen, anything that you would add to that?
Samreen: I think it’s great that you brought up– anytime you’ve got people that are interfacing with customers or outside of your company to train them to be prepared to be able to think about those things. You could simulate any kind of group settings as well. If you’ve got group meetings, it’s not uncommon for women to be interrupted in meetings. There’s a lot of different biases that can come out in that space. To do some simulations, to get people to slow down their thinking, use a bias mitigation strategy, would be a great way to utilize this in an office setting as well.
We’ve gotten a couple of people who’ve reached [00:22:00] out with some great ideas of what they’re doing as well. I was going to look up who it was, but somebody had reached out and said, “Hey, we’re going to try some of this for people who are doing consenting for research studies.” We know in certain communities, there’s a huge distrust of the medical system. When you go out– when you mentioned COVID earlier, there is a huge disparity in care and that leads to further distrust and so how do you then make sure you’re getting people– we show studies that are people of color and diverse so that we can get the right data to make sure we’re treating people equitably, that we have the right information? We need to do that.
Somebody had thought about using simulation to train their people that are going to be consenting families. How do you interact with those families to help answer some of those questions about distrust? I think there’s a variety of ways, whether at the bedside or in the healthcare field in general or outside of healthcare across the areas where you’re doing trainings. I would say another way of incorporating even a low fidelity, just role-playing. I know there’s a lot of implicit bias trainings where you just listen to someone, share a lot of information, but incorporating some of the interactives, some role-playing would be great if you’re doing any implicit bias trainings within your organizations. Trying to include at least some piece of it to be a simulated encounter really pushes people.
The goal is to make people uncomfortable and to push them to actually practice what they’re going to say because it’s easy for me to be like, “This is what I would say in this situation.” It’s much harder to actually say it and then say, “Oh, that sounds awkward. Or, “Oh, that didn’t quite come out.” Then, practice it. Practice it again. I think that’s really where we would push people to practice those bias mitigation strategies, try to incorporate them in a way that you’re getting people to actually use them. It’s a muscle, right? Build that muscle
Ben: Practice does make perfect. Definitely, if you don’t use it, you lose it. Simulated practice of these strategies can help change discriminatory [00:24:00] or biased behaviors, but I imagine those facilitating these types of simulations would need some practice as well. You’re the doctor, [laughs] can you share more about how you prepared your facilitators for the simulation sessions?
Brittany: We’d be happy to. We were pretty intentional with designing our facilitator development program. We recognized, especially in our own setting, that we had some people with facilitation experience, perhaps not ENI facilitation experience, but they did other kind of education work. Then, we also had people who had never facilitated before, let alone simulations, and had a little more robust [unintelligible 00:24:51] inclusion background. We really thought as multiple objectives when we brought this facilitation group together, we wanted to make sure we had a shared mental model around systemic racism, implicit bias, and release that foundational knowledge on health equity as well to make sure that everybody had a common language and could discuss together as facilitators and really understanding the white racial frame and how that shows up in our institution.
Additionally, we wanted to give people that practice. Just like we just talked about with our learners going through and being able to practice things and try again, we also wanted our facilitators to have that opportunity. We gave them opportunities to practice in a simulated setting and really get that opportunity to pause a simulated class and give feedback and then restart the scenario and even challenging microaggressions that might come up during the scenarios because we [00:26:00] knew that that was likely to happen. White fragility was going to come up. How would they as facilitators navigate that and giving them the opportunity to practice?
We also were really intentional about ongoing support, just recognizing the emotional labor of this work. Especially for our facilitators of color, we wanted to make sure that there were regular check-ins. Our co-facilitator pairs always checked in with each other at the end of the class and debriefed. Then, we had regular large group debriefs and as-needed debriefings offered just to help people process what may have come up during those classes. Samreen, anything you would add about our facilitator development?
Samreen: Well, I guess I would add just that fact that we were deliberate about who they were, who we asked to do the facilitation. We wanted to make sure there were people that either had started their own work or were willing to do the work. We tried to be deliberate about the diversity of our facilitators which sometimes can be challenging. You might be asking people of color. I never want to put people in a position where they’re feeling like they’re retraumatized because like Brittany said, they might see microaggressions in these training sessions and we’d have to address them. We were very deliberate about who we asked.
We also made sure we provided support for all our facilitators, and specifically our facilitators of color. We partnered them up and said, “Okay,” we were very explicit, which when I say this outside our organization, people are like, “Really? You called that out?” We’re like, “Yes.” That was the only way I think we were able to be really successful as we said, “You know what? This particular point, really the white facilitator should be the one to call this out or make this point because it lands better.”
Or “We don’t want to put that on this facilitator of color.” That sort of thing. We tried to balance things and be very deliberate and explicit in our discussions with the people that would be facilitating these [00:28:00] sessions because it was really important to us to protect our facilitators. I would add that we also– It was really important because these were live simulations, we actually had professional actors that were being the caregivers. Same rules apply there where we were very deliberate about making sure– Because although they were playing a role, they were still bringing their whole selves.
We had a Black father that was playing in a case. It was during the George Floyd trial actually that some of our cases were going on. To hear from our actors saying– they’re bringing their whole selves, their Black male identity that they walk around every day with. We were very deliberate about providing a space for debriefing, providing an opportunity if they ever needed a timeout or they needed to step out, or they needed to not do that that day. Really giving them that liberty was really important as well to us.
Ben: Thank you so much for sharing that. Sorry to say, this is our last question because I’ve really enjoyed this conversation and having you both back so thank you both for coming back. I think this is a really great question to end on which is, do you have recommendations for those who may have more limited resources and how they can bring this to their own organizations?
Samreen: I think that’s– Really try not to get overwhelmed by– Even in the healthcare field and outside for sure, if you’re not used to simulation, even that word sometimes can be like, “I can’t do that.” Really thinking– there’s a whole variety. It doesn’t have to be super high complicated. You set up a little space that recreates a certain environment, two chairs or desks if it’s an office environment.
I know we said we hire professional actors, but role play. I think the professional actors does bring this level of raising your cortisol and your stress hormone and really gets you to a place where you practice how you would feel in the real environment. There’s ways of doing that if you don’t have those resources, you role-play or you train somebody to play a role [00:30:00] so maybe someone that’s unknown to the people that are doing the simulation. Sometimes even that gets that objective.
The fidelity, the realism, can be pretty– sometimes that’s more important than having any kind of high technology or that sort of thing. Just see how much you can recreate the situation and then push people to act [inaudible 00:30:21] actually do a fiction contract. We do this with all our simulations and say, “Okay, I recognize this isn’t real, but I’m going to buy into the reality and act as I would in the real space.” The literature has shown that if people buy into that fiction contract and you create that space, they actually do act as they would in a real environment.
I would push people to not get overwhelmed just by the word simulation or thinking about creating a simulation and use the resources you have and try to be creative with that to really get to that objective of having people be in the space, get uncomfortable, and practice strategies to mitigate their bias.
Brittany: I would agree. I think that the most important thing is also pushing people to really use the words that they would use. That fiction contract is really critical. Often people will say, “Well, I would say this in this situation.” We’re like, “Great. All right, let’s time in and try it out.” Really even if you’re doing role play in a course where people are partnered or something, really pushing them to use the words that they would use in real-life and try to really buy into that fiction contract as Samreen described because then, they can try these bias mitigation strategies on and really get the words into their own language. I think that that is key, really not being intimidated by the scene as you both have said.
Ben: Well, great. Thank you both so much again for coming back and yes, [00:32:00] I’m always so thrilled to have you both here and it’s always just a pleasure working with you and learning from you. Just thanks for coming back and having this awesome conversation.
Thank you so much, Dr. Vora and Brittany for coming back for this wonderful podcast and answering these important questions. Thank you to our listeners for joining. If you’d like to learn more about using simulation strategies to fight systemic racism in healthcare, you can email both Dr. Vora and Brittany at samreen.vora@childrensMN.org and brittany.dahlen@childrensMN.org. New episodes of The Forum podcasts are available at forumworkplaceinclusion.org/podcast. Episodes can also be found on Apple Podcasts, Spotify, Anchor, and Stitcher. Thank you again for listening. Have a great day.
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