Sumaya Noor, a hospital medicine physician assistant at Regions Hospital, and Ryan Aga, director of clinical simulation at HealthPartners, discuss the origin and impact of innovative training they created after experiences Sumaya had working inside an emergency department. Listen as they share personal stories and data that highlight the importance of addressing bias in health care settings.
Sumaya Noor, a hospital medicine physician assistant at Regions Hospital, and Ryan Aga, director of clinical simulation at HealthPartners, discuss the origin and impact of innovative training they created after experiences Sumaya had working inside an emergency department. Listen as they share personal stories and data that highlight the importance of addressing bias in health care settings.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guests: Sumaya Noor and Ryan Aga
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together, we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is "Off the Charts."
Kari Haley:
Welcome back to the show. I am unfortunately not joined by my partner in crime, Steve, today. So, it is just me, Kari, but I have great guests here today with me. We are going to be talking about clinical simulation and then how we've kind of integrated some anti-racism training within that. With me today, we have Sumaya Noor, who's a hospital medicine physician assistant who's in our fellowship program here at Regions Hospital and also is formerly an emergency medicine technician here. Then also, Ryan Aga, who is the director of clinical simulation here at HealthPartners, and also a former Regions Hospital emergency department nurse manager. So, welcome, both of you to the show today.
Sumaya Noor:
Thanks for having us.
Ryan Aga:
Thanks, Kari. Thanks for having us.
Kari Haley:
I'm really glad to be able to sit down with you guys and be able to talk about this really important topic and really something that has grown so much in the last few years here at our organization. I want to maybe rewind it back a little bit to the beginning. So, what is this origin story and how did the idea of incorporating some anti-racism training into simulation start?
Ryan Aga:
The origin of the simulation really is based off of a real lived experience that Sumaya had in the emergency department as an ER technician on the night shifts. Unfortunately, Sumaya had two episodes of back-to-back racism projected upon her as an emergency room technician. I was the nurse manager at the time, and I felt this utmost responsibility to do something actionable that was different. After talking to Sumaya, it seemed like the tactics that were put in place before about how we're delivering training and education really weren't working. So, after I left the emergency department and came to simulation, it was an aha moment when I walked into simulation and I'm like, "I think this is it. I think this is the way that we can really make impactful change through the constructs of simulation," which is re-replicating reality in simulation, that it's a space that can be safe and brave, and to reproduce that in a simulated environment. So, I invited Sumaya up to our simulation team meeting and they were able to listen to her story. Since that time, that was really the genesis of the simulation work.
Sumaya Noor:
It's been a few years now, if we think about it.
Kari Haley:
It has.
Sumaya Noor:
So, I guess the time the event happened was February of 2020 and then Ryan and I, we met November of 2020. So, since then, we've been on this talk.
Kari Haley:
Yeah, I think you guys both put it pretty actionable, honestly, fairly quickly I think, because I...then the simulation really has just grown. Sumaya, if you feel comfortable, I'd love to hear maybe not necessarily all of the details, but what about these interactions do you think that you had initially is so impactful on the simulation? What is the driver, and how did it make you feel at the time, and how are you feeling about it now?
Sumaya Noor:
Yeah. So, I think that as a person of color, as a Muslim woman, events of racism, microaggressions, macroaggressions aren't new to me, but what made this specific situation unique was that I was around my colleagues and I didn't have the support that I needed at the time. So, when I shared this story with Ryan, he took it upon himself to create actionable change. It's not easy to be in a space like this, both as someone who's faced micro and macroaggressions, but also colleagues who are around don't know how to respond.
They're silent because maybe they're in shock of what they're witnessing or they're silent because of other reasons that I won't go into. So, this specific simulation helps us really learn how to react and respond when faced in a situation like this, because there's not one or two right answers, there's many ways of going about it, but silence is definitely not one of them. So, there are many different types of diversity, equity, inclusion trainings. Often, they are like myLearnings or online trainings, and so the purpose of the simulation was to really mirror the exact events and see how we can learn from that experience and how we can best respond.
Kari Haley:
Yeah. I think I've gone through the training myself, so I kind of know it feels very uncomfortable. As someone who has also experienced both micro and macroaggressions throughout my career, I think that for people who have never experienced that, it's even more uncomfortable. When you see it, you can taste it. It's palpable in the room that this is not OK and it's really interesting to hear how other people are responding to it.
I think providing people with this opportunity to learn how to respond and/or at least how to be supportive or an ally is so impactful because I think one thing notable about your experience, Sumaya, was that as an emergency medicine technician or a tech within the emergency department, where you are in terms of supervisory, not supervisory, there's a power differential for sure. You, I know with your scenario, were in rooms with people who probably "hold more power" than you did at the time in the emergency department, and to have them not speak up and not say anything I can only imagine was even more hurtful probably than it could have been had there not even been that situation as well.
Sumaya Noor:
Yeah, like you've mentioned, it's different when I'm in a room alone with a patient or with someone who's expressing those harmful words versus a room with two or three other colleagues who don't say anything, but you're right, it's uncomfortable both for the person being faced with the micro/macroaggressions, but also the people involved. It's an uncomfortable feeling and those who are involved in the simulation also expressed those same emotions. As you know, I've also been involved with at least most of the initial simulations, and it still feels uncomfortable, even though when the person acting as a patient is Ryan, and I know that it's a simulated event, but it still feels uncomfortable. But again, the purpose, and the opportunities, and outcomes that come from that are so, so powerful and so great.
Kari Haley:
Can you, Ryan, maybe talk a little bit about how this one idea...you trialed it, you did a couple really successful simulation events, has really turned now into something bigger, and how many people it's impacted, and what kind of impact have you... What's the feedback that you've gotten over now the four years that you've been doing it?
Ryan Aga:
Yeah, that's a good question, Kari. I think since the genesis of it, and it happened very organically, very passionate. I wanted to get something off the ground fast and quick and not through a lot of committees, that sort of structure, because it was so needed at the time. So, we continue to repetitively offer it at Methodist Hospital. At the same time, Methodist, or very shortly after that, really had a initiative to bring in an art exhibit of the murder of George Floyd to the campus of Methodist Hospital. I think the successes of the simulation just kept going out and getting broader tentacles per se. I think we've reached close to a thousand people now that the simulation has touched. Most notably, we are doing a pre-post survey of those that come into the simulation training and we assess really their bravery and the safe space that we create in simulation.
We just looked at this data last week from our institute's survey and evaluation team. So, out of 146 participants that took the pre-post survey, 96% of them eluded that they had comfort in that it's a safe, brave space to come in and learn under and they are also, through the data collection, showing that we need to do more of this training in this way of simulation, not passive learning, myLearning environments. They literally, viscerally need to feel it for there to be that transcendence of learning and purpose. So, it's been really good to see there's anecdotes and those out in the community, it's retraumatizing, it's so heavy that we shouldn't be doing this, but to look at the data, it's been really cool to see that the broad collective wants this and they feel even in the most emotionally charged simulation, that we're still cultivating a space of bravery and safety.
So, I think the data tells the story now, and it's been fun to really reach out to our partners across the organization to garner more support based on their expertise like our survey and evaluation team. The reason why it was grassroot, it was passionate. We needed to do something, it needed to be done now. When I was on the side of the road listening to Sumaya's vulnerability as a woman of color, it wasn't that it could go through many committees, it just needed to be done now, and I needed to be an upstander instead of a bystander saying...listening to her story and I'm like, "OK, thanks for sharing." Something had to be done. And so that's really why I think we took that approach of just that started. And since then, it's got a lot of support across the organization and also outside of the organization, which has been really great to see.
Kari Haley:
Wow, that's amazing. Just like I know even within our organization that having a thousand people touched or over a thousand people touched is huge. And then just knowing that you guys have been sharing your experiences outside the organization too, because I think what you say really rings true. I think you can read about diversity, equity, inclusion, you can read all the articles you want, you can do all the PowerPoints that you want, but unless you're actually in it it's really hard to feel the impact of it unless you're made uncomfortable. And with that, hopefully growth and learning occurs, but it's really hard. People skim all their emails, people skim their PowerPoints, we all know how it is, but putting people and making them face, it just has to be, I wish I could be on your side when you're watching people go through it, because to see people's faces and how they react just has to be very eyeopening for you guys when you're watching people go through the training.
Sumaya Noor:
Oh, for sure. And I would say the best part of it is the debrief that comes after it, because those who are involved and those who are also watching but not actually involved, all shared different emotions and different ways it made them feel to watch what happened. And there's just a lot of fruits that come out of the debrief discussions, and I've noticed, at least the times I've been a part of it, we always go over time because it's just, there's a lot to say.
Kari Haley:
There is a lot to say. And Sumaya, I would love to hear a little bit from you in terms of, I mean, one, to have to have lived through this and continue to, I mean, I'm sure, but two, also, to be vulnerable enough and brave enough to like share it with the organization and to relive it over and over and over. How does that feel for you and why? Why have you decided that this is something that I am very passionate about and why I want to share my story?
Sumaya Noor:
Yeah, so I'm not the only one going through this, and prior to this very event in February of 2020, I've had multiple events where I've been treated differently from my other colleagues. And so I think because of how severe, especially that specific event was, I've had patient, to keep it brief, I've had two patients that same night shift, say very racially charged and discriminatory charged terms to me. And because of the severity of it, and very often it's usually microaggressions that I often feel, but because of how hurtful it made me feel at the time, I felt that this was enough and it would be unjust to myself, but also other people who face similar events to let this go by and not be involved in the change.
And so I've been lucky and blessed to have an upstander like Ryan really take charge in leading the simulation. And so yes, you're right that every time I'm involved in the simulation, it reminds me of the event. I am, without lack of better words, retraumatized. I wouldn't say it to that extent, but it feels uncomfortable. But the purpose is greater with now nearly a thousand colleagues who've gone through this training I know now or I am hoping, and I'm hopeful that if other colleagues face similar situations, that they're able to stand up and be upstanders. And so I think just seeing the fruits and the outcomes of this is what allows me to continue doing this work.
Kari Haley:
I commend you for sharing it with the organization, honestly. I mean, it's a very personal thing to have had happen to you and to be able to share that experience with other people, especially in the hopes, and I'm guessing results of people are actually learning how to respond maybe, or at least thinking about, "Hmm, probably don't do that quite right," or, "I probably don't help the situation." And at least starting those thoughts and giving some tools on how you can do better has to be at least a little bit fulfilling for yourself to be able to watch that. I am curious if either of you are willing to share a most memorable reaction after going through the simulation.
Ryan Aga:
Yeah, it's been an interesting journey. For me, it was as a white privileged male looking at myself of the growth that I needed to do. So as we created the simulation, I put myself in the hospital bed to be that the actor per se, and Sumaya was the individual in the room that I was projecting these tones and micro and macroaggressions of racism. For me, very emotional. It was very draining for me after those days of going through those. And now we have a professional acting team that actually goes in and does that. But it was so purposeful and meaningful for me to be in that state working with Sumaya, it instilled just motivating passion within me.
I think the most notable simulation experience out of this, gosh, it's hard to say because there's so much emotion evoked out of this, but one of them that I'll say is that after we did the simulation, there was words out across our organization that the simulation was no longer, that it was put to rest because it was so emotionally charged. And I got a phone call from a senior leader and said, "Hey, is this true?" And I said, "Absolutely not. We're doing a simulation in 24 hours with another crew." And that senior leader was like, "Keep doing it. This is... Keep going, going, going. It's our purpose and our mission here at HealthPartners to continue on this no matter what." And so that was a very memorable portion that there was so much maybe anger or I don't know, structural racism embedded in that crew that they wanted it put to rest. And that was not true.
So that's what comes to my, in the forefront of my thinking, is that we have such strong fierce support across HealthPartners and our leaders to continue on with this work. And that's what stands most out in my head.
Sumaya Noor:
I will say I remember not the most recent one, I think sometime last year or the year before, I think this was at the beginning of the debrief where we were asking those who were involved, but also the participants of the simulation, but also those who were sitting and watching from a different room and asking, how do they feel, how did watching this make them feel? And I remember seeing two women who happened to be women of color who were nodding, and I remember one of them said, "I faced a similar situation," and I can't remember her exact story, but it was, gosh, a similar story. She's gone through similar things and it reminded her of this is not an isolated event. And so the work, there's a reason why we're doing this work and it needs to continue to happen.
Ryan Aga:
Having had the privilege to look at all of the data collected and all the words from the participants, that's probably most notable in keeping this advocacy going, to keep it expanding. So many people say, "Really difficult simulation, but keep doing this work." And there's a lot that have even talked about how we train repetitively on medical procedures or other health related things, ACLS (advanced cardiac life support), those sorts of things, that inequity and racism kills people. It creates huge structural health problems and they're like, "Keep doing this. This needs to happen all the time." And it's been very helpful. Many of the data that's collected off of the people's words are, again, "It was hard, but keep going."
Kari Haley:
I think that's a really good, probably summary of the whole experience. It's very hard, but we need to keep going. Before we close, I think maybe just if either of you have any future hopes for the simulation or future thoughts about where do you want to take this or are there other simulations that are important to include in diversity, equity and inclusion training and what should we be doing next, I think is my big question?
Sumaya Noor:
Yeah. So this simulation is probably one of the first of its time. I want to comfortably say it, but I want to say it, it's probably the first, right? And so I think there's so many routes to take from here that I'd love to see in the future. Now we've done the simulation on how to support colleagues who face micro/macroaggressions from patients. Now how do we flip it and do a simulation based off of the biases that we hold as practitioners, as providers implicit upon patients of different backgrounds. And so, this is something I've heard in passing as a clinician, and even back when I was in ER tech, I hear colleagues making comments about patients who have different cultural or religious backgrounds.
Ryan Aga:
I think we put the emergency department charge nurses through a diversity, equity and inclusion simulation. And although it was very emotionally charged and anticipated that it would be, the nurse manager of the ED reached back to me a couple of days later and said, there was actually an aware report that was put in about bias and commentary at the bedside. And she's like, "I assume it's a product of the simulation." So it's really cool to see those, there's probably many more of them. We're not soliciting those that they just, they're out there. But I think that was great to see out of that simulation experience.
Kari Haley:
Yeah, and I think that it just having the charge nurses or other leaders within the department go through the training really just sets a great tone, right? So we talk about culture change and shift and how do we start doing that? And I think we're seeing some of the fruits of the labor, even though it's only a few years afterwards now, I think that there's just, not that we're seeing everyone doing, "No, you should not do that." You know, like they're not, everyone's not speaking up, everyone's not doing things. But there has definitely been a shift in attitudes, a shift in how people feel comfortable talking about it. And at least even if they don't bring it up in the moment, someone feels safe enough to at least bring it up later or talk about it later. And I think that that is a direct result of people going through training and leaders going through training who then set the tone and expectations for how we're going to treat each other and how we're going to treat our patients.
Ryan Aga:
I agree. And I think I'll just comment on Sumaya's comment about how many people need a different simulation experience, even colleague to colleague. What does that look like? As you know, the simulation is from patient to a provider or one of our health care on the workforce, but what does it look like to have this dialogue between colleagues is what we hear repeatedly through evaluation, "Can we please get a simulation on that?" So it's definitely a journey of expansion and getting this to as many people as possible and across our 28,000 colleagues, it's an interesting journey. I will say that the specialty of simulation, it is a specialty, and I think many people don't know that the constructs of pre-briefing and debriefing and the way that we get dialogue out of people in the debriefing space is an art and a science.
And so I think it's so important, even though we have this data that tells us that we've built this space of safety and bravery, that we keep it within simulation. And I think the easy way is like, "Well, can we just do this in a role play situation and train the leaders?" And I think that is an important thing to look at when you think of growth strategy but we only have so many people on the simulation team and how does that look? So it's great to see that there's talk about that and how we're intentional about keeping it in within the simulation specialty.
Kari Haley:
Yeah, I agree. I think it's an important piece of keeping the constructs around what you're intending to do. It's like controlling the unknown a little bit because you don't know how people are going to react, but you have people who are educated and know how to respond to all of the different types of reactions that can happen.
I guess in closing, thank you for doing this and thank you so much, I think for sharing this with our organization, Sumaya, because without you being brave and bringing the shrine in the first place, I don't think we would be here today. It is impactful for everyone, but with all the people who have taken it and then people in our organization who have not, because the people who have taken it are being able to be better, do better.
Sumaya Noor:
And I'm just so grateful to be in an organization that's receptive to feedback, receptive to trying new strategies, and then also being able to publish this work and get it outside of our system. I know there's more interest in education spaces, other organizations, other health care organizations, and so getting this word out, this stuff is not limited to Minnesota or regionally, it's everywhere.
Kari Haley:
Well, thank you both for being here. I really appreciate it. Do you have any closing thoughts? Last words of advice?
Ryan Aga:
Yeah, thanks, Kari and Sumaya, humbly, eternally grateful for everything. I think keep the good work, we got it. It's going to take collective strength right now and then into the future to carry this work forward. So we're going to need everybody in this court. Thank you.
Steven Jackson:
"Off the Charts" is a production of HealthPartners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.