Healthcare simulation has become a central modality within health professions education, providing structured opportunities for experiential learning, deliberate practice and reflective debriefing [1–4]. The effectiveness of simulation-based education depends heavily on learners’ willingness to engage, take interpersonal risks and openly examine their performance during debriefing. These processes rely on psychological safety and equitable participation within the learning environment [5,6].

Despite growing attention to diversity, equity and inclusion in simulation, learners from minoritized backgrounds frequently report experiencing simulation environments differently than their peers [7–10]. Concerns related to stereotype threat, belonging and evaluation bias may shape how learners participate in scenarios and debriefings [11–14]. These dynamics can influence engagement, help-seeking behaviour and learning outcomes [15,16]. Recent conceptual work has applied Minority Stress Theory to healthcare simulation, proposing that core features of simulation-based education, including observable performance, social evaluation and structured debriefing, may activate minority stress processes among learners [17]. The theory itself originates from psychological research examining how stigma-related stress affects the health and functioning of marginalized populations [18–20].

While this conceptual framework helps explain how minority stress processes may arise in simulation environments, educators require practical guidance for translating these insights into educational practice. Despite growing attention to equity and inclusion in simulation-based education, there remains limited conceptual guidance for understanding how simulation environments themselves may activate identity-related stress processes. The purpose of this article is therefore to translate Minority Stress Theory into practical recommendations for simulation educators. This work builds on prior conceptual scholarship applying Minority Stress Theory to simulation-based education [17], including the author’s prior work, as well as broader theoretical and empirical literature on minority stress.

Minority Stress Theory describes how individuals occupying stigmatized social positions experience chronic stress arising from both external conditions and internalized expectations of bias [18–20]. Prior conceptual work has applied this framework to healthcare simulation, identifying how simulation’s performance-based, socially intensive and evaluative characteristics may activate minority stress processes [17]. Distal stressors refer to external, objective conditions such as experiences of discrimination, exclusion or structural inequities, whereas proximal stressors involve internal psychological processes, including expectations of bias, heightened vigilance, identity concealment and internalized stigma [18–20].

Simulation environments possess characteristics that may intensify these processes. Simulation activities require observable performance, occur in socially intensive settings and frequently involve explicit or implicit evaluation by peers and faculty [1–5]. For learners who already anticipate bias or exclusion, these conditions may heighten vigilance and increase cognitive load. These identity-related stress processes may also reduce learners’ willingness to engage fully in simulation activities, potentially limiting the reflective and experiential learning processes central to simulation-based education. Research across educational and psychological contexts suggests that stereotype threat, belonging uncertainty and identity management can consume cognitive resources and reduce performance even among highly capable learners [11–13].

Educational research also demonstrates that learners from historically marginalized groups often experience training and learning environments differently due to social and structural dynamics [9]. In simulation settings, these dynamics may manifest as reduced willingness to volunteer for leadership roles, reluctance to ask questions, diminished engagement during debriefing or heightened anxiety during performance.

Because minority stress processes are shaped by environmental cues, simulation educators can influence their activation through thoughtful design and facilitation choices [7,8]. Drawing on Minority Stress Theory and related educational psychology literature, these processes provide a useful framework for identifying aspects of simulation design, facilitation and assessment that may unintentionally activate identity-related stressors. Translating these insights into educator practices can help reduce barriers to participation and support more equitable learning environments.

Many established simulation practices, including structured prebriefing, facilitated debriefing and attention to psychological safety, already align with principles that may mitigate minority stress. However, these approaches are not typically framed through an explicitly equity- or identity-informed lens. Applying Minority Stress Theory provides a framework for understanding how these practices may be adapted or refined to better address identity-related stressors in simulation environments.

Table 1 summarizes common minority stress processes that may arise in simulation environments and corresponding strategies educators can use to mitigate these dynamics. The following guidelines outline practical strategies for reducing minority stressors and promoting identity-safe simulation environments.

Drawing on Minority Stress Theory and related educational psychology literature, the following strategies outline practical approaches that simulation educators can use to reduce minority stressors and promote identity-safe learning environments.

Effective implementation of equity-informed simulation practices requires attention at both the faculty and programme levels. Faculty development initiatives should integrate training on inclusive facilitation alongside existing instruction on debriefing and simulation pedagogy [5]. Programme leaders can support these efforts by establishing formal processes for reviewing scenario design, assessment practices and learning environments [7,8].

Implementation of these practices may vary across simulation programmes depending on available resources, faculty development infrastructure and institutional priorities. Programmes may therefore need to adapt these strategies to local contexts while maintaining the underlying principles of inclusive facilitation and equitable learning environments.

Importantly, responsibility for addressing minority stress should not fall solely on individual educators. Organizational commitment is necessary to ensure sustained attention to equity in simulation [7]. This may include allocating resources for faculty development, incorporating inclusivity metrics into programme evaluation and supporting diversity among simulation faculty and leadership.

These efforts should be understood not only as equity initiatives but also as quality improvements in simulation-based education. Learning environments that reduce unnecessary psychological burdens allow all learners to engage more fully in experiential learning and reflective practice [6,18–20]. Collectively, these strategies highlight how simulation programmes can translate conceptual insights from Minority Stress Theory into practical actions that promote more inclusive and equitable learning environments. While this framework is grounded in Minority Stress Theory and highlights the experiences of learners from minoritized backgrounds, many of the strategies described may benefit all learners by promoting psychological safety, inclusive facilitation and equitable participation across a range of visible and invisible identities including those that may not be immediately apparent to facilitators.

Simulation-based education offers powerful opportunities for experiential learning, yet its performance-based and socially evaluative nature can inadvertently reproduce inequities experienced in broader educational and clinical environments [9,11–13]. Building on prior conceptual work applying Minority Stress Theory to simulation-based education, this article translates that framework into practical strategies for simulation educators [17]. Thoughtful attention to scenario design, facilitation strategies, assessment practices and programme structures can reduce minority stressors and promote equitable participation in simulation-based education.

Future research should evaluate how minority stress processes operate within simulation-based learning environments and whether targeted educator practices mitigate their effects. Empirical studies could examine relationships between simulation design, facilitation practices and learners’ perceptions of psychological safety, belonging and evaluation fairness. Mixed-methods research incorporating learner surveys, performance metrics and qualitative reflections may be particularly useful for identifying how identity-related stressors influence participation, cognitive load and learning outcomes in simulation [6,11–13,18–20]. Such work would help refine implementation strategies and support the development of evidence-based guidelines for inclusive simulation practice. Continued research is needed to evaluate these approaches and further refine strategies for fostering inclusive simulation environments.