We developed an educational toolbox that includes VSGs of varying lengths (i.e., short vignettes to full games) and curated educational resources. We relied heavily on consultation with LGBTQI2S researchers and communities to determine the priorities to be addressed. Each VSG included embedded self-assessments, learning outcomes, and targeted resources. The toolbox will be disseminated through an awareness campaign and will be hosted on a website for a minimum of 5 years. The project consists of three sequential phases (design, development, and implementation). This article describes the first two phases that have been completed. Evaluation of the implementation phase will be reported in a future article.
Phase 1: Designing the Online Educational Toolkit
Visioning Meeting. The overarching goal of the project is to advance nursing and other HCPs' cultural humility in practice. Specific objectives proposed for the educational toolkit are outlined in Table 1. We convened a 1-day workshop with the three CIHR Award recipients and four community stakeholders from the LGBTQI2S community, during which we planned the process for developing the educational toolkit and VSGs. Our first priority was to gain a deeper understand of the objectives of the project and to collaborate with stakeholders and content experts to determine the following:
- issues of LGBTQI2S individuals seeking and receiving health care
- learning the needs of HCPs
- priority scenario topics
- the number and type of VSGs to be developed
- key content to be included in the educational material
Proposed Toolkit Learning Objectives
Cultural Humility. The development team and content experts shared their perspectives of the project and the theoretical underpinnings for the project. Globally, there is a call for HCPs' initial and continuing education to incorporate cultural humility practice into clinical skills (Brennan et al., 2012; Clark et al., 2011; Wylie et al., 2016). Cultural humility was developed in response to the nonintersectionality of the more common health care practice of cultural competence (Kirmayer, 2012; Tervalon & Murray Garcia, 1998). It differs most notably in that cultural competence is an end-state achievement, whereas cultural humility is ongoing and requires continued critical self-reflection as a foundational principle, seeks to understand individual and systemic power imbalances, and is grounded in health equity (Foronda et al., 2016; Johnson & Munch, 2009; Kirmayer, 2012; Tervalon & Murray Garcia). The results of practicing cultural humility are lifelong learning composed of mutual benefit, empowerment, partnerships, respect, and optimal care (Foronda et al., 2016). A cultural humility framework adapted to graduate nursing education outlines specific concerns, issues, skills, and education strategies using cultural humility at the graduate level and in subsequent practice (Clark et al., 2011). Most research describes the application of cultural humility practice on an ad hoc basis to individual courses or activities in health care postsecondary and continuing education (Carabez et al., 2015; Dao et al., 2017; Jernigan et al., 2016; Kumagai & Lypson, 2009; Ontario Public Health Association, 2017; Yingling et al., 2017). There is also a call to include cultural humility in international standards for clinical simulation education (Foronda et al., 2016).
Priority Topics. As a large group, we discussed and agreed on priority topic areas to be addressed, such as specific patient populations, their issues, and their needs, and we linked them to relevant learning needs of HCPs. Breaking into small groups, we outlined four main clinical scenarios to be the focus of the VSGs (Table 2) and four rapid-fire focused VSGs to be developed (Table 3). Further, we identified four writing teams to work on the scenarios. Each writing team comprised at least one of the development team members and one of the CIHR Award recipients in alignment with their particular content expertise. Teams met via Zoom meetings to work on the individual scenarios. Development team members led content experts through the design process. We also consulted individuals with lived experience to ensure authenticity of the scripts. The process followed the Canadian Alliance of Nurse Educators using Simulation VSG design process (Tyerman et al., 2018). The VSGs consist of video clips of interactions between HCPs and patients filmed from the viewpoint of the HCP, which places the learner “in the HCP's shoes.” As a game progresses, the video stops at key points in the scenario and requires the learner to use critical thinking to select the best response to a clinical decision-making question.
Summary of Video Simulation Game Topics
Rapid Fire Topics
Phase 2: Development of VSGs and Sexual Orientation and Gender Identity Nursing Website
When developing a new simulation or VSG, we employ the principle of backward design in which the learning outcomes are identified first (Egan et al., 2014; Luctkar-Flude et al., 2017). The process consisted of writing learning outcomes, rubrics, and decision point maps (Table 3).
Learning Outcomes and Assessment Rubrics. Following identification of two to three learning outcomes for each VSG, we created assessment rubrics for each scenario (Table 4). Indicators for each learning outcome were leveled to the competent, intermediate, and novice learner, based on the first three stages outlined in Benner's novice-to-expert model, which is frequently applied to simulation education (Thomas & Kellgren, 2017).
Sample Learning Outcomes with Levelled Indicators
Decision Point Map. Next, we determined clinical decision-making points for the games that aligned directly with each learning outcome based on the assessment findings encountered in the scenario. We created a grid or decision point map that outlined the assessment findings, decision point questions, and three potential responses that may be selected by the learner (Table 5). We also provided a rationale for why each response was correct or incorrect.
Sample Decision Point Map
Script Writing. After the decision points were finalized and reviewed by the entire team, we wrote the scripts that guided the filming of the game videos. The scripts included descriptions of the setting, as well as instructions for actors' movements, behaviors, and dialogue. The VSG scripts were reviewed by our simulation and content experts and consultants prior to filming the VSG clips.
Filming. Although the game videos can be filmed with any video equipment, we used a GoPro camera. Thus, the games were filmed from the perspective of the nurse to promote immersion in the scenario. A short video clip was filmed leading into each decision point and for each response.
Game Assembly. We employed a user-friendly VSG template using Articulate Storyline software that allows us to quickly drop the film clips into the game flow and to add text for the decision points and rationale (Keys et al., 2020) (Figure 1).
Sample video simulation game screen capture.
Usability Testing. Prior to implementation, the development team reviewed the flow of scenes and wording of responses in each VSG. Further testing by faculty and learners will evaluate usability of the games and website. Feedback provided will be used to guide any needed modifications.
Debriefing Design. Based on the level of the learners, learning outcomes, and other contexts, we selected a debriefing method deemed appropriate for online delivery. We elected to use a self-debriefing format involving self-assessment with the rubric and self-reflection guided by a series of questions designed to elicit reflection upon personal biases, learning, and practice changes.
Website Development Process. A key requirement of the project was the ability for the games, resources, and content to be widely accessible through a dedicated online presence. The resulting website incorporates a database of independently searchable resources that are also integrated within the learning modules. We followed traditional learning strategies to ensure that modules were consistent with current best practices for the autonomous online learning.
Pedagogical Considerations. Online modules were structured to incorporate best practices in online pedagogy, including learning outcomes, scaffolding, and debriefing. Modules and scenarios were developed around learning outcomes directly related to the learning needs (Marsh, 2007), which were determined in the first meeting. Rubrics, quizzes, and the scenarios provide immediate feedback to learners based on their selections, which has been shown to improve learner performance (Leibold & Schwarz, 2015). Each module has a debrief and opportunities for reflection, which assists learners in making real-world connections to content within online learning systems (Guthrie, 2010).