Microaggression, a subtle for m of discrimination, involves behaviours and comments that convey derogatory messages or insults based on race, gender, sexual orientation, religion or other social identities (Friedlaender, 2023). Despite often being unintentional or unconscious, these acts contribute to a hostile or discriminatory atmosphere, and can cumulatively impact individuals' wellbeing and sense of belonging. Microaggression put simply is the use of:
‘everyday verbal, non-verbal and environmental … snubs, insults … intentional or unintentional, which communicate hostile … or negative messages to target persons based on marginalised group membership.’
The impacts of microaggressions on both patients and healthcare staff are profound and far-reaching. Research highlights that microaggressions from health professionals can lead to poorer health outcomes for patients (Ehie et al, 2021), and healthcare workers who experience microaggressions also suffer negative effects (Carter and McMillian-Bohler, 2021; Ehie et al, 2021; Pusey-Reid and Blackman-Richards, 2022). In particular, Black students have reported experiencing microaggressions from peers, educational institutions and within clinical practice, further exacerbating the challenges they face (Pusey-Reid et al, 2022). Higher education institutions, especially in healthcare, are seen as lagging behind in providing adequate training to address microaggressions (Pusey-Reid and Blackman-Richards, 2022). Given the diverse workforce of the NHS and the increasing number of complaints and concerns related to racism and bullying from students on placement, the development of a targeted microaggression training session for students was considered timely and essential.
To address the issue of microaggressions in clinical practice, simulated microaggression sessions were introduced as part of preparation for practice for first- and second-year pre-registration nursing students. The goal of these sessions was to better equip student nurses before they enter clinical practice. The training day featured a simulated microaggression session dedicated to addressing microaggressions, with a focus on race and age as marginalised groups.
There have been increasing calls for more comprehensive microaggression training throughout nursing education (Pusey-Reid and Blackman-Richards, 2022) to not only prepare students but also empower them to address these issues effectively. Small studies have demonstrated the positive impact of such training, showing that students who receive focused instruction are better equipped to tackle microaggressions in practice (Fischer et al, 2011; Morales, 2021; Carter and McMillian-Bohler, 2021). Currently, much of the education related to microaggressions is often embedded within general equality and diversity training, delivered primarily through lectures and PowerPoint presentations. In contrast, the authors of the present study opted for simulation-based training, a well-researched pedagogical approach known for its effectiveness in fostering active learning, to specifically address microaggressions (Parker and Myrick, 2009; Tiwari et al, 2014).
The simulation session was delivered to second-year nursing students at the start of the term to prepare them for their upcoming clinical placements. It was developed based on feedback from a previous session where students shared personal experiences and observations of microaggressions in healthcare settings. The session was designed using a structured approach to healthcare simulation creation (Table 1).
| Design consultation | A review of current microaggression training and education packages for students within higher education and the NHS including continuous educational support focusing on pedagogy or andragogy based on the current ethical standards for simulation-based experiences, design principles, debriefing methods and evaluation approaches. The current most common practice for delivering microaggression training is through workshops and e-learning modules, which allow limited scope for practical application. The literature review for this simulation did not identify other microaggression simulations |
| Assessment of need | Consideration of causes of concern shared by students in a previous simulation session, sharing experiences and observations of microaggressions in healthcare settings, recent concerns raised from faculty placement partners regarding microaggressions and incidences received through faculty anonymous-reporting systems. The need was identified to provide opportunities for students to rehearse microaggression scenarios in a safe space in preparation for clinical practice |
| Measurable objectives | Development of broad and specific objectives to reflect the purpose of the simulation experience and how these relate to organisational goals (Figure 1) |
| Simulation modality | A conceptual framework was used to ensure validity, credibility, utility and feasibility of the simulation session (Figure 1). The simulated patient modality ensured authenticity and immersion to create a more real-life experience |
| Scenario design | Scenarios were co-designed by clinical experts with experience of supporting students in practice and observation of real-life microaggressions using a scripted cues framework for advancing the discussion and incorporating microaggressions either visually by eye-rolling, sighing etc or verbally, for example: |
| Fidelity | Simulated patients were used to deliver the session to provide authenticity and opportunities to rehearse responses to microaggressions. The scenario centred around a patient questioning why their relative had deteriorated to ensure that the elements of the scenario realistically related to each other. The scenario was piloted with clinical teachers to ensure conceptual fidelity Realistic conversation with the simulated patient ensured psychological fidelity. Factors considered were learner level, available time, desired outcomes and relevance |
| Facilitative approach | A Forum Theatre technique was used to deliver the session. Forum Theatre serves as a powerful tool to explore social issues, foster dialogue, evoke exploratory debate, and promote social learning (Middlewick et al, 2012) while encouraging community-driven solutions. The use of facilitator involvement was appropriate to the learner's knowledge, competency and experience of managing microaggressions. Facilitators acknowledged cultural differences, values and responsibilities within each group with an expectation that all students acted with professional integrity throughout the session |
| Pre-briefing | The pre-briefing plan included materials to guide the participants in the simulation experience to establish a psychologically safe learning environment. This included conveying ground rules, explaining the learning objectives and understanding the knowledge and experiences of the participants, including previous experiences of microaggressions. Orientation to the simulation modality and the format of Forum Theatre was provided, including ‘time-out’ and ‘pause’ signals and details about the scenario |
| Debriefing | The evaluation using MS Forms sought to understand students' experiences of the session. Questions were designed to reflect the Jeffries framework (Jeffries, 2021) to assess the simulation context, background, design, educational strategy, and outcomes and the Kirkpatrick model (Kirkpatrick and Kirkpatrick, 2006) levels 3 and 4 to assess the application, transfer of knowledge and soft skills |
Source: adapted from Watts et al, 2021
Aims
Problem
The gap in practical microaggression training.
Feasibility
To deliver face-to-face simulation sessions to large cohorts of pre-registration nursing students as part of preparation for practice.
Learning objectives
Modality
Simulated patients (actors) to play the role of the microaggressor and facilitated by an academic (simulation teacher) using a Forum Theatre approach (Middlewick et al, 2012).
Method
Feedback from the previous student session was incorporated into a realistic simulation scenario, enacted by a simulated patient, that centred around a concerned family member expressing worries about the patient's care. The scenario included microaggressions related to age, race, culture and the hierarchical structure of the NHS, as well as non-verbal cues such as eye-rolling and dismissive gestures. This allowed students to practise addressing these sensitive situations in a controlled, safe environment.
Simulation is a valuable teaching tool in undergraduate nursing education, providing students with hands-on learning experiences that build practical skills in communication and intervention. Experiential learning through simulation helps students actively engage in real-world scenarios, allowing for deeper emotional connection and understanding of the impact of microaggressions on marginalised groups (Dada and Laughry, 2023). In this session, Forum Theatre–a creative, interactive pedagogical approach–was used to empower students. It allowed them to act as ‘spec-actors’, participating in and modifying the scenario to explore different responses and outcomes, enhancing their socio-emotional skills for real-life application (Boal, 2000).
These simulations aimed to prepare students for handling microaggressions in clinical practice. Like expressionist and Jacobean theatre, this method serves as a tool for social change by raising awareness of contentious issues (Freire, 1996). The simulations followed a structured framework to ensure consistency and effectiveness, incorporating phases of preparation, delivery, and debriefing (Table 1) (Nestel et al, 2018). In the preparation phase, detailed descriptions of the learning activity, including the scenario and Forum Theatre technique, participant expectations and roles within the simulation ensured clarity and consistency for all participants. During the simulation, facilitators maintained the psychological safety of students and simulated patients, ensuring engagement and managing the pace of the activity.
This simulation model encouraged students to examine multiple perspectives, including that of individuals experiencing microaggressions. By using simulation to explore these issues, students were able to challenge their own unconscious biases, assumptions and beliefs, ultimately enhancing their cultural competence. Simulation promotes active, experiential learning that fosters empathy, skill development, and a more profound understanding of microaggressions and their effects.
Given the emotional intensity of these sessions, a comprehensive debriefing process was essential. A skilled facilitator created a psychologically safe environment for both students and simulated patients, guiding reflections and ensuring adherence to ground rules, safety mechanisms and ensuring that students worked within their scope of practice (Kang and Min, 2019). Using the Plus Delta debrief model, participants reflected on what went well, what they learned, and how they could approach similar situations differently in the future (Motola et al, 2013) (Table 2). This reflection process, grounded in Kolb's experiential learning cycle (1984), allowed students to conceptualise their learning and apply it if facing a similar situation in real life (Figure 1).
| Plus | How did you feel in the session? |
| Delta | What did you find challenging in the simulation? |
| Summary | How would you summarise this experience? (Reflect on these points and consider how you can apply the lessons learned to real-life situations and future simulations) |
Source: Motola et al, 2013
To ensure the sustainability of the microaggression session, guest facilitators were invited to observe the session to build capacity and incorporate new perspectives and experiences into the work.
Results
Many students were able to draw on their own past experiences in practice and the impact of microaggressions. Other students were unfamiliar with the term microaggression and had not attributed past experiences to this. The students commented that the microaggression simulation session provided valuable insights into handling difficult conversations, particularly when interacting with patients and their families. The students were able to identify non-verbal microaggressions as they happened. Using the Forum Theatre technique, they were able to work out ways to manage the verbal microaggressions as a group. Peer-to-peer learning through observation and active discussion was an essential aspect of this session. During feedback, one student commented:
‘[I've learnt] how to deal with difficult situations such as talking with a patient's family member.’
Participants expressed that the session improved their ability to identify stereotypes or harmful types of discrimination that are dropped into conversations and to be able to respond to them effectively. They learned practical strategies for diffusing tense conversations and ensuring respectful communication in challenging situations. Effective strategies, such as using diffusion techniques to address microaggressions in a constructive manner, are crucial in preparing students for clinical practice. These strategies include highlighting the microaggression to the aggressor in a way that improves understanding rather than conflict. To build these skills, active experimentation in a safe and supportive environment, as outlined by Kolb's experiential learning model (1984), is essential.
For instance, students practised responding to comments such as, ‘You speak English really well, but where are you really from?’ made by patients' relatives. They learned to address such microaggressions tactfully, using responses that encourage reflection without causing offense. An example of this approach is replying, ‘That's an interesting thing to point out – what made you say that?’ This type of response helps to diffuse the situation while subtly drawing attention to the underlying bias, creating an opportunity for dialogue and mutual understanding. Also considered were microaggressions concerning age, with comments such as: ‘You're so young, I'm surprised you're already in nursing school – do you think you're ready for such a big responsibility?’ and ‘You're just a student nurse; you'll understand the real challenges once you're a more senior nurse.’
In feedback after the session, students commented:
‘I know that I can try and diffuse a conversation if a patient is using microaggressions.’
‘Within the scenario of microaggression [I was] able to learn how to approach situations like this.’
‘[I learnt] how to respond effectively to microaggressions.’
During the sessions, it was acknowledged that directly addressing microaggressions may not always be feasible or appropriate in the moment. Instead, students were encouraged to foster allyship, as advocated by the Royal College of Nursing (Hollowood, 2022). This involves checking in with the victim to ensure they are okay, expressing their own discomfort with the observed situation, and explaining why it felt inappropriate. By doing so, students can create a supportive environment that empowers individuals to challenge microaggressions when they feel ready, fostering a culture of inclusivity and respect.
The simulation helped enhance communication skills in approaching sensitive scenarios, equipping participants with the tools needed to navigate such interactions. Some also noted the importance of dedicating more time to these sessions, to further build their confidence and competence.
Summary of main findings
In both clinical environments and higher education institutions, it is crucial for health professionals to enhance their understanding of microaggressions and to reflect on incidents when they occur (Hollowood, 2022). When microaggressions arise among staff or peers, it is important to escalate these issues through appropriate channels. Interactions involving patients, in particular, can serve as valuable opportunities for discussion and awareness-building. For instance, if a patient asks a student, ‘Where are you really from?’ this can prompt a team discussion to analyse how the situation unfolded and explore strategies for addressing such microaggressions constructively. By bringing these behaviours to the individual's attention in a thoughtful and respectful way, teams can develop a more inclusive environment. Ignoring or dismissing microaggressions does not resolve the issue; rather, it perpetuates harm and can have a profound and negative impact on those affected (Hollowood, 2022). Therefore, active engagement and collective reflection are essential steps toward creating a culture of equity and respect.
Limitations
The main limitation of the simulated preparation for the practice session was the limited time allocated to address microaggressions. Although the session was part of a broader student preparation programme, the 45-minute timeframe was insufficient to fully explore such a complex and serious issue. Additional limitations included the lack of dedicated pre-reading and preparation for students, which could have enhanced their understanding and confidence during the simulation.
The experience and skill of the facilitators and actors also played a critical role, as their personal backgrounds and abilities to recognise and navigate microaggressions could impact the effectiveness of the session. The contentious nature of the subject matter posed further challenges, particularly in ensuring the psychological safety of participants and the ability to facilitate a meaningful debrief afterwards. Important concepts such as managing different types of aggression and addressing the bystander effect (Dada and Laughey, 2023), which is common in collaborative healthcare settings, were only covered briefly due to time constraints. Finally, the characteristics of facilitators and actors, such as their race or gender, may add layers of complexity, particularly when guiding discussions about personal experiences with microaggressions. Topics such as cultural appropriation (McNiesh, 2015), for instance, can challenge assumptions and biases held by both students and facilitators, prompting deeper reflection and learning.
Conclusion
The simulated microaggression session provided valuable experiential learning for nursing students. The students enjoyed the opportunity to practise managing microaggressions in a safe space. Further iterations of simulated microaggression sessions could be managing different forms of aggression and the bystander effect. The success of these types of simulations depends heavily on the skills, experiences and personal characteristics of both facilitators and simulated patients. The sessions highlighted the importance of addressing microaggressions in healthcare and underscored the need for more in-depth, structured training to prepare students for the realities of clinical practice. In the future, increasing the time dedicated to these sessions, improving facilitator training, and providing students with pre- and post-session resources will be crucial in enhancing their effectiveness and impact.