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Development of an online educational toolkit for sexual orientation and gender identity minority nursing care

Objective: to develop and implement an online education resources to address a gap in nursing education regarding the concept of cultural humility and its application to healthcare encounters with persons who identify as lesbian, gay, bisexual, transgender, queer, intersex (LGBTQI) or Two-Spirit. Improved understanding of LGBTQI and Two-Spirit community health issues is essential to reducing the healthcare access barriers they currently face. Method: an online educational toolkit was developed that included virtual simulation games and curated resources. The development process included community involvement, a team-building meeting, development of learning outcomes, decision-point maps and scriptwriting for filming. A website and learning management system was designed to present learning objectives, curated resources, and the virtual games. Results: the Sexual Orientation and Gender Identity Nursing Toolkit was created to advance cultural humility in nursing practice. The learning toolkit focuses on encounters using cultural humility to meet the unique needs of LGBTQI and Two-Spirit communities. Conclusion: our innovative online educational toolkit can be used to provide professional development of nurses and other healthcare practitioners to care for LGBTQI and Two-Spirit individuals.


Team Building
At the onset, we brought the team of simulation design experts and LGBTQI2S content experts together with four community stakeholders in a face-to-face visioning meeting. We reviewed the objectives and discussed how a framework of cultural humility would guide the educational toolkit's content and development. Together the group determined that four virtual simulation games (VSG) and two to three mini-games would be created for the toolkit.
The priority scenario topics identified were: 1) an older gay man experiencing grief following the loss of his partner; 2) a transgender youth experiencing significant anxiety; 3) a lesbian women experiencing pregnancy assumption; and 4) a transgender man experiencing misnaming. There were many topics that were identified and could be addressed with additional time and resources.  While the primary website is entirely in English, a second complete French mirror is currently in translation.
This will enable the team to capture and store French language resources, which can be linked to a French version of the VSG course within the repository.

Usability and Evaluation Testing
The website and virtual simulation games have undergone formal usability testing by a group of nursing students and faculty members from three sites to evaluate ease of use, engagement, and usefulness of the toolkit.
Additionally, informal feedback has been received from users following the launch of the open-access website. Obtained feedback will inform further changes to the tools prior to implementation of a larger evaluation study with a larger multi-site sample of nursing students and nurse practitioner students. Ethics approval has been obtained, and further funding has been secured to support this evaluation phase.

Results
Our objective was to address an identified gap in nursing education through the development of a cultural humility toolkit and its application to healthcare encounters with the LGBTQI2S community. We generated an easy-to- The value of using authentic gender minority individuals as standardized patients has been recognized in medical education, however there are challenges to recruitment and ensuring psychological safety (42) . Cultural humility principals were used to ensure the psychological safety of actors, which included self-awareness of our own strengths and limitations, openness to exploring new ideas, being egoless, providing supportive interactions, and engaging in self-reflection and critique (43) .
One of the biggest challenges was our inability to integrate bisexual, intersex, and two-spirit content into the online educational toolkit. Despite wanting to ensure that we captured the patient experiences of all LGBTQI2S identities, we were unable to network with appropriate community members and organizations to ensure cultural safety. In Rev. Latino-Am. Enfermagem 2021;29:e3470.
an attempt to ensure an authentic patient experience, we wanted to approach these topics more thoughtfully. LGBTQ patients when conducting a sexual health history and screening for intimate partner violence (48) .

Next Steps
A multi-phase, multi-site, mixed-methods study of the feasibility, usability and learning outcomes associated with completing the SOGI-Nursing eLearning toolkit is currently underway. Phase 1 involves usability testing of the website; participants will be undergraduate and graduate nursing students as well as nursing faculty.
We will also recruit 5-10 LGBTQI2S content experts to review the website and the VSGs to provide feedback about the content. Phase 2 of the study will explore the implementation and evaluation of the SOGI-Nursing online educational toolkit. Further plans may include evaluating the learning outcomes and their usefulness in knowledge, attitude, and behaviour change.
Plans for additional VSGs are in development and include 1) a bisexual woman engaging in risky health behaviours and 2) parents of an intersex child engaging with a nurse, 3) contact tracing of a man who has sex with men who has a reportable sexually transmitted infection.
We acknowledge the need to include an appropriate Two-Spirit perspective and therefore continue to search for collaborative opportunities with the Two-Spirit community.

Conclusion
Despite increased awareness surrounding LGBTQI2S populations and the unique health disparities affecting these individuals, nurses continue to lack educational preparedness regarding caring for this population. The development of the SOGI Nursing website is the first step