Skip to main content

PCRF Research Alert: Cultural Humility in Simulation-Based Education

How often has literature cited the use of simulation to teach cultural competency and humility? What are simulation best practices for underrepresented students?

This ongoing series from the Prehospital Care Research Forum combs the literature to identify recent studies relevant to EMS education practices.

Foronda CL, Baptiste D, Pfaff T, et al. Cultural competency and cultural humility in simulation-based education: An integrative review. Clinical Simulation in Nursing, 2018 Feb; 15: 42–60.

Healthcare disparities have been documented in the research literature for decades. Recently several EMS studies revealed disparities in the provision of care in the field based on patients’ race and gender. These results mirror those found across other healthcare settings and compel further research to better understand and eliminate such inequities.

One direction is to integrate the principles of cultural humility into competency evaluations during healthcare professionals’ initial training. A growing body of research on the science of simulation supports its expansion as a means of teaching and assessment in healthcare education programs. But how often has the literature cited the use of simulation to teach and evaluate principles of cultural competency and cultural humility? Similarly, what are simulation best practices for underrepresented students in healthcare education programs?

Researchers from the University of Miami and Johns Hopkins conducted an integrative review of existing literature to examine the state of the science of cultural humility in simulation-based medical education. Unlike a systematic review, which examines quantitative experimental studies, an integrative review includes nonexperimental research and qualitative studies and may include practice analyses, theory, and guidelines. In both types of reviews, the researcher follows a carefully prescribed protocol for literature search, data collection and analysis, and assessment of validity.

In this research lead author Cynthia Foronda, RN, PhD, and colleagues searched four major databases for literature published between 2010–2015 using search terms related to cultural competence, cultural humility, and simulation. Initial screening resulted in 227 publications. After removing 105 duplicates and excluding non-English publications, case studies, and abstracts, only 16 articles remained for full text review. Data were abstracted, coded, and evaluated for quality using validated and accepted research techniques.


Results showed that simulation participants varied widely, as did the methods and reasons for integrating cultural competency and/or humility into simulation. Participants included nursing students, nurses, medical students, pharmacy students, global health and public health students, and ESL students. Results varied also in methods of simulation (virtual, role-play, standardized patients, manikin), concepts (sensitivity, humility, attitudes, care of special populations), and contexts (critical care, rural/remote areas, poverty, birthing, home care).

Four common themes emerged from the synthesis of learning outcomes data: 1) cultural sensitivity and competence; 2) insight and understanding; 3) communication (with the team and patient); and 4) confidence and comfort. Although the authors were excited at the success of these studies in linking simulation to improvements in cultural competence and sensitivity learning outcomes, their optimism was cautious, since the wide range of applications limits depth of analysis and generalizability of the results.

They also noted none of these studies used simulation to teach cultural humility, a process that reinforces self-reflection, open-mindedness, and lifelong inquiry. Directions for research and practice include developing measurable learning outcomes that integrate cultural humility and creating a thread of diversity throughout all simulations rather than selecting a single cultural theme or patient in a simulation.

The authors also suggested providing faculty and students with training on cultural humility could promote the ability to examine healthcare encounters from multiple perspectives. Perhaps this is the path that will improve diversity in the healthcare workforce and ultimately eliminate health inequities. That’s a hypothesis worth researching.

Join us along with the primary author Dr. Cynthia Foronda for more discussion on this article during our PCRF/NAEMSE Education Research podcast on Friday, Oct. 26 at 10 a.m. PT/noon CT.

Megan Corry, EdD, EMT-P, is the program director and full-time faculty for the City College of San Francisco paramedic program and on the board of advisors of the UCLA Prehospital Care Research Forum. 


Back to Top