Promoting inclusivity in health professions education

Clinical educators are increasingly in contact with students from a diverse range of backgrounds, who are likely to differ in their educational abilities, learning preferences, and expectations about teaching.1, 2 The changing landscape in health professions education, marked by its growing diversity, has led to growing concerns about inclusivity. Whilst conceptualisations of inclusivity vary and continue to evolve, at its very core, inclusivity involves considering good practices to widen student participation and ensure learning is relevant, meaningful, and accessible for all.3 Hockings4 defines inclusive learning and teaching in higher education as ‘the way in which pedagogy, curricula and assessment are designed and delivered to engage students in learning that is accessible to all’. We have utilised Hart et al.'s5 framework of ‘inclusive practice’ as a pedagogical lens to consider how to promote inclusivity in health professions education; see Figure 1. The way in which pedagogy, curricula and assessment are designed and delivered to engage students in learning that is accessible to all. Clinical educators must first define what inclusivity means in their own teaching context. Various definitions of inclusivity exist with differing intentions; varying from the importance of overcoming barriers to learning, widening participation or considering ways to enhance the learning capacity of all students.7 Within health education literature, there are various terms and concepts that align but also compete with interpretations of inclusivity such as ‘diversity’, ‘fairness’, and ‘equity’, to name a few. While diversity acknowledges individual differences, inclusivity moves beyond this to consider how educators engage with these differences. Inclusivity requires consideration of the plurality of ways diversity can impact a student's learning experience and how to meet the needs for wide ranging cohorts. The outcome of applying the principles of both diversity and inclusivity is to establish equity, meaning fairness (equal and full participation).8 Issues of diversity and inclusivity must be recognised as two sides of the same coin: Intertwined and inseparable (see Figure 2). These terms although distinct are intrinsically linked and essential in operationalising each concept. Diversity and inclusivity must be recognised as two sides of the same coin: Intertwined and inseparable. A pre-requisite to fostering inclusivity requires educators to first acknowledge the plurality of their own identity, interpretations of diversity, and how differences between them and students can impact learning. A few suggested reflective questions and criteria to explore inclusivity are presented in Figures 3 and 4. Advance Higher Education programme standard, which is adapted from a self-evaluation framework on how to embed inclusivity, provides a more exhaustive list of criteria to consider. Creating a more inclusive curriculum goes beyond the addition of potentially tokenistic topics on diversity; rather, it requires revisiting content and structure in ways that recognise the contestability of knowledge, wider, global perspectives, and the accommodation of students' different lived experiences.11-13 An inclusive curriculum can be established by introducing contentious topics, obtaining pluralistic views via case-based learning, through role-play exercises and feeding in student views within curriculum planning meetings. Discussing differences can be both enriching and conflicting. Creating a safe and supportive learning environment is essential for capitalising on the diversity of students' experiences and perspectives and to establish a sense of security. Safe spaces can be used by clinical educators to deconstruct student expectations and admit to uncertainty. Studies show that cultural differences exist in how learners anticipate teacher–student interactions and their expectations of classroom behaviours.14, 15 A qualitative study in Germany exploring the expectations of international medical students found that they anticipated discrimination from local patients because of their migration background and were particularly concerned about failing exams when confronted with colloquial language or dialects used in their host country.15 Establishing ‘shared expectations’ and setting ‘ground rules’ facilitates a safe learning environment. Educators are encouraged to discuss their expectations and concerns about different teaching sessions with students; clearly setting out their expectations of the teaching (i.e., interactive, didactic, and team-based) and encouraging students to do the same. Setting ‘ground rules’ is particularly important when discussing diversity issues as these conversations may be laden with sensitivity, uncertainty and political correctness. Discussion starters and ice-breaker activities may be helpful in encouraging initial conversations on diversity; the University of Lausanne, Switzerland provides some helpful example exercises.16 In practice, the authors found educator's expectations are prioritised over students as they may find it difficult to articulate their expectations regarding learning. Embedding quarterly reviews and feedback loops with programme leads can help combat this. Positive role models in can play a fundamental role in enhancing learning and shaping students' professional identity.17, 18 Cruess et al.19 suggest that the influence of role models is not only dependent on observation but also the degree of concordance perceived by the student. Personal characteristics are most frequently mentioned by medical students in determining who they gravitate towards, for example, race, ethnicity, and gender.20 Increasing students' contact with a diverse range of educators has been suggested to support students from marginalised groups to build relationships with relatable positive role models.21, 22 Various suggestions to promoting inclusivity and diversity include appointing faculty who are more representative of the study body. Some studies show that ethnic concordance between a teacher and a student can enhance rapport, sense of belonging, and support the facilitation of shared experiences.23 However, whilst increasing visibility and representation of diversity is important, supporting faculty in recognising their individual differences and how these influence their identity as an educator is equally significant. The introduction of a reverse mentoring scheme has been implemented in both of the author's educational contexts, whereby more junior clinical educators from diverse backgrounds mentor senior clinical educators, who may be less familiar with the challenges experienced by colleagues from under-represented backgrounds. The application of reverse mentoring has been piloted at the University of Birmingham where each teaching module is being co-led by a senior and junior clinical academic. Providing students with a richer exposure to the heterogeneity present in the patient population and among their local populations through different clinical placements or community visits has shown to assist their acknowledgement and understanding of diversity.24 It also supports students in considering how to meet the needs of different patients, thereby fostering an inclusive and person-centred approach to health care. Better engagement with members of the community and the broader public can bring wider socio-cultural, contextual knowledge, providing students with an authentic sense of the holistic nature and impact of health care.24, 25 Engagement with members of the community can bring wider socio-cultural, contextual knowledge, providing students with an authentic sense of the holistic nature and impact of health care. Exposing students to a variety of patient experiences helps them to consider the ways different patients can experience the same illness or condition. If practical, case studies from diverse groups should be used to introduce more heterogeneity, for example, counselling a transgender patient about breast cancer. George and Lowe26 (first author of this paper) found that adding a series of ‘what if …’ questions to case studies assists students in critically reflecting upon the uncertainties of clinical practice and how to tailor their approach to the different needs of patients26; see Figure 5 as an example. Students with protected or vulnerable characteristics (such as those protected under the UK Equality Act 2010, for example, disability, race, and sexual orientation) are more likely to struggle with integration, experience differential attainment, and are less likely to access academic support.27, 28 Each health educational institution has a unique student body with individuals whose characteristics are known or strongly suspected to alter their student experience, that is, those with English as a second language, distance learners or those who work part-time. Early identification of these students is consistent with a proactive developmental approach. Embedding practices of peer mentoring, incorporating study skills training, and setting up student support networks have been shown to increase engagement from these students.29, 30 A developmental approach also asserts that student support is a responsibility for all and advocates that anyone in contact with students should signpost support services, for example, including information on their email signatures or at open days. Another would be more contact between personal tutors and mentees where the nature of the role moves beyond responding to issues of academic performance to facilitating self-growth. Also, creating frequent opportunities within existing teaching provision to reflect upon challenging situations that may arise in the institutional culture - i.e, those that create perplexity, hesitation and doubt; or otherwise described as ‘disorientating dilemmas’,31 ‘inner discomforts’ or ‘crossroad’32 experiences, would be valuable. The authors feel such opportunities can be achieved through discussions in problem-based learning sessions/action learning sets, reflections in clinical placements (i.e., during Schwartz rounds), delivering support workshops during times of transition and change (i.e., prior to becoming a medical student or starting clinical placements), or through exercises such as situational judgement tests (see Figure 6 as an example of a challenging situation in health care). A key feature for reconsidering pedagogical methods to establish inclusivity involves discussing how faculty can increase and nuance the nature of communication they have with students.6 For example, making resources readily accessible before lectures, encouraging interaction through online forums or automated voting systems, or providing variation in the nature of clinical placements (i.e., working with third sector organisations or policy driven providers undertaking research). Traditional pedagogic methods, such as lectures, tend to monopolise teaching in health professions education; hence, introducing a more diversified model of learning has the potential to actively accommodate the range of learning preferences and educational abilities students possess, whilst making learning more personalised rather than generic.33 As authors, we have implemented with success some of the recommended resources and good practice examples shown in Figure 7. A more practical way to reconsider pedagogical methods we have found useful is the use of a web-based learning management system (e.g., CANVAS) in archiving different types of reading materials and the use of online platforms (e.g., Panopto) to record lectures. Hounsell34 states that an inclusive approach to assessment requires faculty to ‘revisit existing assessment methods and ensure that the language and format used for the assessment is accessible and explicable to all students’. Such an approach goes beyond the addition of alternative assessment methods to recognising that learning outcomes can be assessed equally using different formats. As authors, we recommend either using a range of formative and summative assessment methods over a module for all students or using different modes of assessment for a single task. Encouraging students to undertake self-assessments through online e-learning resources or supplementary assignments may create greater engagement from a wide range of students. Further, providing feedback early on through different formats such as oral, one-to-one, or group feedback, annotated exemplars, formative OSCEs, or podcasts may help clarify expectations and explain assessment criteria for students who are struggling. Rather than appreciating diversity from a distance, the practice of inclusivity involves actively engaging with difference, considering how to ensure full and equal participation and support. Establishing inclusive practices in health education professions is multidimensional; it requires a shared commitment to recognising and incorporating a diversity of perspectives, values, and experiences in teaching and learning. Clear leadership is essential in supporting faculty to actively promote inclusivity. Leadership, accountability, and responsibility should be shared and spread across a range of areas in a health educational institution for meaningful change to be made. Designating one individual this responsibility should be premised with the disclaimer that this individual is not solely accountable for promoting inclusivity; hence, diversity and inclusion is a responsibility for all. Practicing the concepts of diversity and inclusivity will support an atmosphere within which all students can experience a supportive, tailored, and meaningful learning environment. Rather than appreciating diversity from a distance, the practice of inclusivity involves actively engaging with difference. Riya E. George: Conceptualization; resources; writing—review and editing; writing—original draft. Manbinder S. Sidhu: Writing—original draft; writing—review and editing; resources. The authors would like to thank Dr Emma Kennedy and Dr Claire Loffman for their advice and guidance in developing this paper. The authors have no conflict of interest to disclose. The authors alone are responsible for the content and writing of the article. The authors have no ethical statement to declare. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.