In 2023, the Providence Oregon’s Clinical Simulation Team conducted a gap analysis to align with the Joint Commission National Patient Safety Goal 16 (NPSG 16), which mandates that hospitals improve health equity efforts by addressing health-related social needs (HRSN), which are frequently found as root causes of disparities in patient outcomes. The World Health Organization (WHO) defines ‘health equity' as providing everyone a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential (WHO, n.d.). Through this gap analysis, we identified multiple areas within our educational program that contributed to health inequity, including our manikins—almost all were homogenous. 

The United States population demographics are diversifying rapidly and necessitate the need to normalize various skin tones in clinician educational content (Pusey-Reid et al., 2023). These demographic changes impact Providence Oregon caregivers specifically, as Oregon state population continues to diversify (Coury, 2024).

In addition to an increasingly diverse population, literature continues to expose health disparities experienced specifically by people of color. Patients with darker skin are more likely to experience undetected decreases in oxygen saturations (Seitz et al., 2022) and are at heightened risk for pressure injuries (Gunowa et al., 2020). Our simulation team supports Providence hospitals across the state of Oregon, accommodating a wide range of caregivers and patient backgrounds and cultures.

To offer a more inclusive simulation experience for caregivers and to equip them to care for an increasingly diverse community, we collaborated with fellow leaders within the organization to obtain new manikins that better reflect the community we serve. We highlight the process throughout this article.

A Business Case for New Manikins

Over 2023, our team partnered with our health equity team and nursing system level leaders to draft a business case to obtain new manikins. This work is in alignment with nursing professional development (NPD) Standard 9, which calls NPD practitioners to practice, educate, and lead with cultural humility and inclusivity (Harper & Maloney, 2022).

To make our business case relevant, we utilized an environmental scan, which included description of our current, homogenous manikin fleet and out-of-date technology, information on the National Patient Safety Goal (NPSG) 16, and evidence showing the health disparities and experiences faced by patients of color. We also explained how our simulation team travels and supports nursing clinical education across all Oregon hospitals, and the manikins currently in use had reached the end of their functional lifespan and required replacement. This transition offered an opportunity to enhance the representation of our manikins, ensuring they more accurately reflected the diversity of our caregivers and the patients we care for.​

We presented our case to the executive leaders for all Oregon hospitals to garner buy-in from each hospital. This case highlighted manikins that reflect the workforce and the communities we serve, enabling caregivers to engage in simulation trainings that promote a standard of excellence and inclusivity. The NPD team's goal is to integrate discussions on minimizing health disparity risks across ages, backgrounds, and skin tones into our simulation experiences. Some of the health disparities faced by individuals of color include those with darker skin being more likely to experience undetected decreases in oxygen saturation and a heightened risk for undetected pressure injuries or other skin breakdown (Gunowa et al., 2020; Seitz et al., 2022). Having manikins that aligned with this skin tone would enable more effective training.

By leveraging evidence-based practice, NPSG 16, and with the support of our executive teams, in 2024, we were able to purchase four new manikins that reflect the diversity of ages and skin tones of those we serve. The cost for the new manikins was spread evenly across all eight Oregon Providence hospitals.

Manikins at Work

When utilizing our new manikins, our learners have responded positively and have expressed gratitude for a more realistic and holistic simulation learning environment.

One of our simulation trainings revolves around an adult female patient experiencing sepsis. This is part of a simulation in the Medical-Surgical new graduate residency curriculum to reinforce sepsis identification, treatment, and algorithm review. The debrief included discussion on assessment and care of an aging adult of color, in addition to sepsis identification, response, and algorithm review.

During one simulation experience, a learner reported that having an older manikin with dark skin helped make the training feel more realistic to the patients she sees in her practice area and prepared her for some of the changes the body experiences as it ages. She reported the simulation brought forward some of the subtleties of sepsis identification in the older adult. The learner was able to envision herself caring for a real patient on her unit due to our more realistic manikin, as well as apply her learning to future patient encounters.

This partnership, purchase, and learner example highlights the NPD practitioner roles of change agent, leader, and learning facilitator. Healthcare simulation serves as a bridge between didactic, classroom learning and real-life clinical experiences (Society for Simulation in Healthcare, n.d.). Our Simulation Program at Providence Oregon provides a safe learning environment for caregivers to practice clinical skills and scenarios, via manikin or other training equipment, prior to caring for real patients.

Our simulation team and educators are learning every day better ways to create a learning environment that embodies NPD Standard 9 and improves the patient and caregiver experience by focusing on health equity. Our system nursing leaders are creating a learning module for the new facilitation course for educators. This module and ongoing literature review will prepare our simulation team and educators to speak to specific health disparities faced by people of color.  

Our goal as a simulation program with these new manikins is to create a simulation environment that reflects the patients our hospitals are caring for and provide opportunity to enhance caregiver assessment skills when caring for patients with various skin tones and ages. An additional benefit our program is proud to offer with these manikins is opportunity for all staff, including those from underrepresented groups and different ages, from diverse backgrounds to feel seen and included during our trainings. Ultimately, this improvement fosters an inclusive setting where conversations about health disparities and equitable care can occur in a safe, low stakes learning environment.

Below are photos from our simulation lab of three of our new manikins in use:

 

References

Coury, L. (2024). Race and ethnic diversity in Oregon’s workforce. State of Oregon Employment Department. https://www.qualityinfo.org/-/race-and-ethnic-diversity-in-oregon-s-workforce

Gunowa, N.O., Hutchinson, M., Profdoc, J.B., Jackson, D. (2020). Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury. Journal of Clinical Nursing. 29(21-22). 4358-4367. https://doi.org/10.1111/jocn.15474

Harper, M.G., & Maloney, P. (Eds). (2022). Nursing Professional Development: Scope and standards of practice. Association for Nursing Professional Development.

Pusey-Reid E, Quinn L, Samost ME, Reidy PA. (2023). Skin Assessment in Patients with Dark Skin Tone. American Journal of Nursing.123(3):36-43. https://doi.org/10.1097/01.NAJ.0000921800.61980.7e.

Seitz, K.P., Wang, L., Casey, J.D., Markus, S.A., Jackson, K.E., Qian, E.T., Self, W.H., Rice, T.W., Semler, M.W. (2022). Pulse Oximetry and Race in Critically Ill Adults. Critical Care Explorations: Society of Critical Care Medicine. 14;4(9):e0758. https://doi.org/10.1097/CCE.0000000000000758

Society for Simulation in Healthcare [SSH]. (n.d.) About Simulation. https://www.ssih.org/About-SSH/About-Simulation

The Joint Commission. (2024). National Patient Safety Goal to Improve Health Care Equity. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2025/hap-npsg-chapter-2025.pdf

World Health Organization. Social determinants of health: health equity. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_3