Principles for inclusion in health professions education

Consider…

• ‘assigned female at birth’
• ‘social/physical transition’
• ‘gender affirmation’

Why is this important? What can I do?

• Avoid language which misgenders or undermines an individual’s gender or sexual identity.
• Familiarise yourself with LGBTQIASB+ terminology, recognise that language changes over time, and learn to respectfully ask what language individuals would like you to use.

Consider…

• ‘person with/living with diabetes’

Why is this important? What can I do?

• Use person-first or identity-first language (according to the individual’s preferences). Common practice in a healthcare setting is to emphasise the person first and the condition or personal circumstances second.
• Note that there are exceptions where groups or individuals prefer identity-first language (e.g Deaf/Autistic); if this is not clear, ask the individual.

Consider…

• ‘lives with…’
• ‘He uses a wheelchair for mobility’

Why is this important? What can I do?

• Use inclusive terminology that does not judge, stigmatise or stereotype, including in documents or other communication.

Consider…

• Addressing the individual directly, in your normal tone and voice. (Note that this includes paediatric patients.)

Why is this important? What can I do?

• Inclusive practices in communication are essential, recognising that people may communicate in a variety of ways. Whilst carers, family members or other support people may be invited into the conversation, the individual should be the focus. This video from the Office of the Public Advocate highlights the experiences of people with a disability and their communication preferences.

Consider…

• ‘Review Rebecca Goh in bed 3’.

Why is this important? What can I do?

• Avoid depersonalising language and focussing on the condition, not the person, when addressing an individual’s care needs.

Consider…

• Aboriginal and/or Torres Strait Islander
• Indigenous
• First Nations

Why is this important? What can I do?

• Inclusive language in the written form, including capitalisation and avoiding the use of acronyms (e.g. ATSIC).

  The inclusion of and/or in Aboriginal and/or Torres Strait Islander avoids giving the impression that these Communities are one and the same. Some key terms (e.g. Elders, People(s), Community and Country) require capitalisation.

Consider…

• ‘An interpreter was engaged to support a non-English speaking patient’

Why is this important? What can I do?

• Critically examine assumptions and socially constructed concepts such as race.
• Consider whether identification of race or ethnicity is relevant or helpful to achieve the clinical or teaching objectives, and if so, how the discussion might move beyond the stereotype (for example here relevant in the context of requiring an interpreter). If race or ethnicity is identified, avoid using vague groups (‘Asian’) and include only specific and salient information where evidence exists for their relevance to clinical decision making and patient outcomes. If racial, ethnic, social or other information is included, ensure that the case studies used for teaching represent the diversity in the current Australian population (including any names used).

Consider…

• Robert is undergoing STI screening following multiple unprotected sexual encounters with men.’

Why is this important? What can I do?

• Recognise that patient centred care requires challenging stereotypes and categorisation. Social or behavioural risk factors should not be implied by race, culture, sexuality or gender, and should not reinforce stereotypes.

Consider…

• ‘She has attended the ED 6 times for concerns relating to…’

Why is this important? What can I do?

• Ensure you are not attributing blame for poor health to individuals based on their attributes, condition or circumstances.
• Avoid biased or pejorative language which frames the individual in an adversarial manner. Consider whether the difficulty lies with the patient or in the interaction, and why that might have been the case.

Consider…

• ‘Patient is confused/distressed/concerned…’

Why is this important? What can I do?

• Ensure you are not attributing blame for poor health to individuals based on their attributes, condition or circumstances.
• Avoid biased or pejorative language which frames the individual in an adversarial manner. Consider whether the difficulty lies with the patient or in the interaction, and why that might have been the case.

Consider…

• ‘Has difficulty recalling the details of her prior management plan’

Why is this important? What can I do?

• Ensure you are not attributing blame for poor health to individuals based on their attributes, condition or circumstances.
• Avoid biased or pejorative language which frames the individual in an adversarial manner. Consider whether the difficulty lies with the patient or in the interaction, and why that might have been the case.

Consider…

• ‘He does not report drug use’.

Why is this important? What can I do?

• Ensure you are not attributing blame for poor health to individuals based on their attributes, condition or circumstances.
• Avoid biased or pejorative language which frames the individual in an adversarial manner. Consider whether the difficulty lies with the patient or in the interaction, and why that might have been the case.

Consider…

• ‘He has discontinued the medication due to the cost/accessibility/side effects/poor therapeutic alliance with the relevant clinician…’

Why is this important? What can I do?

• Explore the root causes of health behaviour rather than attributing them to patient factors (e.g. social group) or choice.
• Deficit narratives are prevalent in health professions education and perpetuate inequity and marginalisation. Such narratives describe people or groups in terms of what they lack or how they fail, without considering broader social and historical factors. How has historic or current marginalisation or lack of cultural competence in healthcare providers contributed to disconnection from health systems?

Consider…

• ‘Ida’s long working hours in a sedentary office setting, as well as her caring responsibilities, contribute to her BMI in the morbidly obese weight range’.

Why is this important? What can I do?

• Explore the root causes of health behaviour rather than attributing them to patient factors (e.g. social group) or choice.
• Deficit narratives are prevalent in health professions education and perpetuate inequity and marginalisation. Such narratives describe people or groups in terms of what they lack or how they fail, without considering broader social and historical factors. How has historic or current marginalisation or lack of cultural competence in healthcare providers contributed to disconnection from health systems?

Consider…

• ‘A 55-year-old with a 40 pack year history of smoking’

Why is this important? What can I do?

• Avoid using a behaviour as an adjectival noun and instead provide specific and relevant information.

Why is this important?

• Understand the profile of the local population(s) and their particular social and health needs, and integrate this into teaching.

What can I do?

For example:

• Start meetings or gatherings (even online) with an Acknowledgement of Country, and consider how to make this meaningful for you and the others present, rather than a recitation. Coordinate a Welcome to Country for formal gatherings. Familiarise yourself with the difference between a Welcome and an Acknowledgement.
• Situate patient cases used for teaching in a genuine local context. For example if a patient lived in a particular rural area, how would that impact their access to healthcare and their management planning?

Why is this important?

• Case studies used for teaching should be representative of the diversity in the Australian population, including names and images. However it is important to consider how representation occurs; does it inform practice or illustrate health inequity, or does it perpetuate stereotypes? (see Principle 2).
• Where possible, consider how representation occurs in educators, other staff, assessors and simulated patients. Making diversity visible to students can help them develop a sense of themselves as belonging to a community of learners and future health professionals. (see Principle 4)

What can I do?

Engage with quality resources to understand the diversity in the Australian population, as well as health inequities.

Images used for teaching should include people of colour as well as diversity in body types.

• Mind the Gap (a clinical handbook of dermatology in black and brown skin).
• Skin Deep (a free, open access database of paediatric dermatology in a range of skin tones).
• Reframing Revolution (a free image gallery of women’s healthcare, with a diversity of skin tones and body types).

Consider inclusive practices in engaging with simulated patients, noting that the benefits to learning which come with engaging with diverse simulated patients and scenarios must be balanced with the need for safety for the volunteers or actors.

Why is this important?

Othering’ creates boundaries between individuals or groups that is based on negative preconceptions, and contributes to marginalisation. It assumes a homogenous norm and positions others as external to that group. This has implications for both healthcare outcomes and the way that students build a sense of themselves as future healthcare professionals.

What can I do?

• Avoid ‘othering’ particular groups in teaching. For example, can communication skills and strategies that are helpful for different patient populations be integrated into regular teaching (perhaps using contextual examples which cover the breadth present in our communities) rather than taught as a stand-alone session only given for certain populations?
• Language use is also important. For example, when educators discuss how ‘we can work with LGBTQIA+ people’, they may position themselves and those in the conversation as outside that community. This may exclude LGBTQIA+ students from the conversation and contribute to marginalisation.

Why is this important?

• Teach and model the selection and use of contemporary best-practice models of patient-centred care, which are strengths-based, trauma-informed, focused on preventive care, and multidisciplinary.

What can I do?

For example:

• First Nations maternity care programs which provide continuity of care through a multidisciplinary team
• RACGP Guidelines on trauma-informed care
• RACGP Guidelines on preventive care
• RACGP position on models of shared care for chronic conditions

Why is this important?

• Consider the roles students can play as health advocates during their training and as professionals.

What can I do?

• How can bystander training or similar modules be incorporated into curriculum, and relevant skills built across the program?

This involves recognising that students each bring their own history, culture, context and individual circumstances. Educators have a responsibility to recognise that the richness of student experience and context may necessitate flexibility and predictability in the approach to learning and support, for example students with caring responsibilities or work commitments may need advance notice of any timetable changes. However, it is important to avoid framing student factors in a deficit-focussed manner. Many aspects of students’ experiences and circumstances outside their studies provide strengths, knowledge and capabilities they can draw on as learners and as professionals (for example the time management developed as a working parent, or the consumer perspective of the health care system developed as a carer).

Bias and marginalisation can impact on academic outcomes, progression, wellbeing and rates of burnout. Students from marginalised groups carry an additional load which may not be visible to educators. This is often particularly relevant for students who represent more than one marginalised group, who may be exposed to overlapping or intersectional forms of discrimination.

Power dynamics in work and learning environments may make it challenging to report these experiences if they do occur. A framework to actively check on student wellbeing and discuss behaviours of concern should be in place. It should not be expected that a student will independently identify and report inappropriate behaviour, particularly when exhibited by those in senior roles.

All students should be able to feel like they are safe and welcomed.

Central to belonging and inclusion is building relationships between peers and between educators and students.  Accumulating evidence supports a key role for relationships of trust and psychological safety in both the learning process and in the way that feedback is received and acted on by students.

Points of transition are particularly important for establishing expectations and building inclusion; for example the commencement of the course, or the transition to learning in a clinical environment or on placement). In addition, particular groups may benefit from a more tailored approach, including culturally or linguistically diverse or International students, Indigenous or First Nations students, students with a disability, neurodiverse students or LGBTQIA+ students. Where a tailored approach is taken, the expected benefits need to be weighed against the risks of perpetuating ‘othering’ of (a) particular group(s).

However many of the principles of inclusive teaching are applicable to all learners and may encompass steps as simple as using students names and pronouns correctly, collectively committing to standards of behaviour, and framing questions in a way that makes it safer to make mistakes or be uncertain.

Professional identity formation is the process of developing a sense of who you are as a professional, what values and principles guide your work, and how you can contribute to improving the health of the communities you serve. Educators can actively consider how to bring an equity and inclusion perspective to the way they support students to develop their own professional identity. 

• Is there diversity in the visible professional role models? Can mentoring or focussed placements play a role?  Does the imagery and text used allow students to see themselves in the learning space?
• How can explicit discussions of norms and values in the profession incorporate equity and inclusion? Is there exploration of how these translate to the learning environment?  For example, can students collectively develop a set of standards or behavioural expectations for learning which draw on guidelines for health professionals?
• Programs designed to teach professionalism or respond to lapses in professional behaviour need to be mindful of student diversity and have a constructive, educational approach.
• Self management, self-reflection and self-regulation skills should be integral components of the health professional curriculum.
• Students can be supported to build a toolkit for how to respond when observed practice of peers, supervisors or other health professionals does not meet the ideals of the profession. In early years this may focus on students establishing their own safety and support systems but can build towards more advanced skills in calling out non-inclusive behaviour.
• Students can be empowered to be drivers of positive change in professional environments, recognising the challenges of personal safety and hierarchical structures.

Using Universal Design for Learning (UDL) to remove barriers to access for all students.  This approach recognises that making learning accessible benefits all students.  There are many ways that you can engage with UDL, starting with small ways to modify your teaching practice:

• Consider how digital materials and platforms used for teaching can be more accessible.
• Explore how to make online and blended learning work best for all students.
• Consider how to make learning experiences more conducive for neurodiverse.
• Explore how authentic assessments can be inclusive, and feedback can be effective for all learners.
• Consider how placements or clinical learning experiences can be more inclusive.
• Undertake an online module on Universal Design for Learning.

Reasonable accommodations are required by law for students who are impacted by a disability, health or mental health condition.  At Deakin, the Disability Resource Centre provides support for students and may coordinate an Access Plan to document what accommodations are necessary. 

Access Plans and accommodations are an important way for students to ensure that they receive the support they require.  However they do not replace the need for inclusive teaching practices.  In fact, applying UDL principles across a course may mean that students with a disability or other circumstances which affect their learning do not have to disclose their status or seek additional support or accommodations.  It is important to recognise that disclosing personal circumstances such as disability can be a significant barrier to some students, whilst others do not identify with the term ‘disability’.  Educators can emphasise that the Disability Resource Centre provides confidential support to students with a wide range of conditions.

For example, are discussions regarding Indigenous Health safe and respectful for First Nations students in the cohort?  Do transgender students feel comfortable participating in sessions on sex and gender? It can be problematic to lean on students as experts, or to invite them to provide feedback or insight specifically because of their identity or experience. Some students from marginalised groups may want to be active in such discussions but others may not wish to take on this cultural load.  

Consider how the topics which are covered in teaching sessions are made available to students ahead of time, and how they can be empowered to engage in learning in a way that is safe and flexible for their individual needs. If learning or discussion occurs opportunistically, (for example in a clinical setting), ensure that it is appropriate and respectful for all participants, accommodate students’ needs to step away where needed, and consider checking in afterwards.

Reflecting on and evaluating your own teaching helps to ensure you are embedding inclusivity in your work. You can ask for feedback from those around you, or make it clear that you are open to discussing the content, curriculum or culture of the learning environment.

Recognise that language use changes over time. You may need to periodically update or modify your use of terminology.

• Deakin Inclusive language guide
• LGBTQIA+ terminology
• First nations/Aboriginal and Torres Strait Islander
• Cultural and linguistic diversity
• Disability inclusion (see video)
• Neurodiversity terminology

Practice asking people about their identity and preferences for communication (e.g. ‘If you’re comfortable with sharing…’, ‘What pronouns would you like me to use?’), so that you can do this confidently when it is necessary and appropriate. Sharing your own identity may help to normalise this. Courses involving structured communication skills training may incorporate skills in adapting the approach to the individual and their circumstances.

Many people are hesitant to change their practice or take further steps as they are concerned they will make mistakes or say/do the wrong thing. However, the potential harm you might cause through a well-intentioned mistake is far outweighed by the cumulative impact of many years of marginalisation or discrimination. Change often requires discomfort and uncertainty. Educators preparing their students to practice in an uncertain and rapidly changing environment can also foster their own capacity for managing failure. If you do make a mistake:

• Listen and reflect on the impact of your error.
• Apologise without reservation or caveat.
• Learn about what you could do differently.
• Adjust your practice for next time.

Educators have a responsibility to act or speak up if they observe inappropriate language use or behaviour by staff or students. You can build your confidence in appropriately and safely intervening by undertaking active bystander training or similar activities. Deakin’s Diversity, Equity and Inclusion team regularly provides training and workshops for staff and students.

All Higher Degree by Research students are required to complete the Respect at Deakin module. Students in other programs could be encouraged to undertake this module at the commencement of their course, or students could be prompted to review this module if it appears that they need a reminder of the University’s expectations. Students can also explicitly establish collective standards for behaviour in learning environments, with clear steps to follow when issues occur.

More serious incidents may need further action: see below.

Know what to do should an incident occur or should a student or staff member need additional support.

• Student Heath Wellbeing Services provide free and confidential support for students including counselling, medical, disability support and spiritual wellbeing.
• Safer Community is a free and confidential support service for staff and students who are experiencing threatening or inappropriate behaviour.
• Student Complaints provide an avenue to report all student concerns in accordance with the Student Complaints Resolution policy and procedure.
• Student Conduct provides an avenue to report allegations of student misconduct.
• Deakin University Student Association DUSA Advocates provide qualified, experienced and confidential advice and support regarding academic matters
• Harassment and Discrimination Contact Officers (HDCOs) are volunteers, trained to provide confidential information and support to staff and students with concerns relating to discrimination, harassment, bullying, vilification, and victimisation.
• Multifaith Chaplaincy includes provision of spiritual and personal advice, counsel, support and referrals. Multi-faith Chaplains are volunteer positions within the University and are accredited by the Council for Chaplaincies in Tertiary Institutions (CCTI).