Clinical Nursing, LGBTQI+, Nursing Education, Virtual Reality



  1. Hannans, Jaime


Abstract: Teaching nursing students to understand LGBTQI+ health care perspectives is critical in providing safe and effective care. Nursing curricula often have limited LGBTQI+ content to prepare students, with clinical experiences too varied to ensure exposure to specific gender diversity learning opportunities. Immersive virtual reality is a promising strategy to offer rich learning experiences from the perspective of the LGBTQI+ community.


Article Content

Despite a focus on health care inequities intended to address gaps toward diversity, equity, and inclusion, nursing textbooks and program curricula remain limited in content focused on lesbian, gay, bisexual, transgender, queer, and intersex individuals (LGBTQI+). Historically, nursing curricula were developed from a Eurocentric, often female, lens (Durocher & Caxaj, 2022; Morris et al., 2019), with health care systems structured toward gender binary selections, male or female. Additional constraints for LGBTQI+-focused practice opportunities include the unpredictable nature of clinical settings, lack of gender identity-inclusive training within facilities, clinical site limitations, faculty preparation to deliver content, and decades of systematic biases existing.


Although the 2021 Gallup Poll indicates the LGBTQI+ population has doubled (7.1%) since 2012, there continue to be known health disparities, fears, and limited access to unbiased health care providers and support (Deguzman et al., 2018). In addition, baby boomers, currently the highest predictable age group requiring health care interventions, are potentially the first generation in the United States living openly as LGBTQI+ individuals (Henriquez et al., 2019). As the population grows, there is urgency for nursing education to integrate gender-inclusive curricula (Durocher & Caxaj, 2022).



A review of the literature found two challenges to nursing education preparation to care for the LGBTQI+ community: 1) lack of content available to facilitate teaching and 2) a shortage of educational strategies that provide opportunities for application to practice. Deguzman et al. (2018) conducted a content analysis of two commonly used health assessment nursing textbooks, finding less than 15 pages of content included in either textbook about the care of LGBTQI+ individuals and families. Also identified was a lack of case study examples for application to practice-some publishers have realized the gap in published content, recently creating additions to content, and the National League for Nursing (2022) has introduced ACE+, teaching resources and cases on individuals who identify as LGBTQ+.


Studies have investigated nursing students' attitudes toward LGBTQI+ persons and strategies to reduce provider/student bias. The consensus is that educational opportunities are needed to develop the skills required to care for this high-risk population (Deguzman et al., 2018; Henriquez et al., 2019; Morris et al., 2019; Sherman et al., 2021). Some strategies have been shown to improve nursing student awareness, knowledge, or preparation to care for LGBTQI+ individuals. In studies by Henriquez et al. (2019) and Sherman et al. (2021), students demonstrated greater knowledge, awareness, and confidence in preparation for care.


Identifying a lack of available content and educational strategies, Saini et al. (2022) scaffolded LGBTQI+ health content across an undergraduate baccalaureate program in New Zealand; a team of faculty designed case studies, exam questions, and other learning materials. Similarly, Morris et al. (2019) focused on evaluating research that aimed to reduce health care provider or student bias. In a systematic review of 60 interventional studies from 2005 to 2017, 13 articles reported on the integration of educational interventions focused on the LGBTQI+ community. Strategies included case studies, conferences, lectures, and small-group discussion. Most studies assessed knowledge and attitudes/awareness; some evaluated student comfort levels in caring for individuals, finding positive outcomes. However, none of the articles evaluated for a change to implicit bias scores, nor did they address the use of innovative technologies for learning, such as immersive virtual reality (VR).


The use of VR experiences in nursing has grown exponentially, with many campuses turning to remote delivery. VR uses computer-based technology to create a three-dimensional interactive environment (Agency for Healthcare Research and Quality, 2022). The 2020 Horizon Report (EDUCAUSE, 2020) defines immersive VR as 'typically a more immersive experience, involving manipulations of and interactions with virtual objects within an entirely virtual environment" (p. 29). IVR has been found to be of significant value in health care provider education, with self-reported gains in understanding and the demonstration of increased empathy from the first-person individual perspective (Elzie & Shaia, 2020).



There is a need for curriculum design to support the inclusion of implicit bias training and LGBTQ+ content in preparation for practice. Since January 2023, all nursing programs in California are required to have one hour of direct training on implicit bias, further demonstrating the need to discuss health disparities and discrimination across high-risk populations (California Assembly Bill 1407; LegiScan, 2021). One solution to ensure exposure to LGBTQI+ patient-centered health care education is through the use of IVR.


Clinical experiences cannot guarantee examples of professional behaviors and skill practices to care for LGBTQI+ individuals and families. Using an IVR platform, Embodied Labs (, undergraduate baccalaureate senior nursing students experience situations from the perspective of the individual, essentially walking in another's shoes. The initial pilot was planned as a one-on-one experience in which students would wear a 360-degree VR headset embodying Eden, a 72-year-old transgender woman (see Supplemental Content for a photograph showing student donning the VR headset, available at Because of the pandemic, the simulated experience was modified using remote delivery facilitated by faculty in groups of 8 to 12. Through the use of storytelling, aligned to INACSL best practices in simulation, the IVR provided an innovative experiential teaching and learning opportunity (INACSL Standards Committee et al., 2021).


In the two-part IVR lab, Eden shares her story across decades as she transitioned from Edward to Eden (see Supplemental Content for photograph showing the user view during the Eden Lab VR session, available at The second lab provides a journey with Eden to the LGBTQI+-affirming community center, with glimpses of experiences from five other individuals. The IVR activity aligned to clinical course objectives, requiring attendance and postactivity reflection for credit/no-credit participation. There was no requirement to respond during the live session. Ground rules were set at the beginning of the 90-minute simulated experience to maintain a safe learning environment. Throughout the IVR, pause points, following a facilitation guide with open-ended prompts, allowed students to share perceptions, feelings, and reflections within the peer group.



Although the initial concern was that the remote delivery mode could be less immersive, an unexpected benefit was identified. The pause points allowed for peer-to-peer in-session debriefing, resulting in highly active participation and rich, detailed responses. Students shared personal experiences and knowledge or asked clarifying questions about the LGBTQI+ community. One student acknowledged a lack of understanding about the difference between gender identity and sexual preference. Emotional perspectives were evident, with students demonstrating empathy, In some cases, students made statements about advocacy for, affirmation for, or intent to change future nursing care practices for LGBTQI+ individuals and families.


Additional benefits were identified from the strategic integration of LGBTQI+ content. Remote delivery expands the use of VR for teaching and learning in both face-to-face and online programs. It allows for use during transitions to remote learning and in situations limiting access to clinical facilities. In curricular development, programs can align to content, course, and program learning outcomes to meet the level of the learner while providing diverse perspectives of individuals often faced with inequities in health care.



The VR experience provided students an opportunity to discuss a variety of topics related to LGBTQI+ health care, including clarifying terminology, understanding the difference between gender identity and sexual orientation, using affirming language, identifying historical-societal discrimination practices, and considering challenges to seeking health care. Although research is needed to determine the short- and long-term impact of the IVR experience, this innovative practice is promising as a flexible way to engage peer-to-peer learning while promoting safe learning environments. The known lack of content in nursing textbooks and curricula, along with the growing population, demonstrates the need for consistent approaches to provide innovative, memorable experiences to develop skills to care for the LGBTQI+ community.


Future research could identify VR labs best suited for individual versus remote group mode delivery. Additional study to address best practices for facilitation of IVR, faculty preparation to teach LGBTQI+ content, and impact to student learning would be valuable.




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