The importance of culture and diversity are addressed during traditional nursing education. However, little literature exists about how virtual communities like Second Life might influence cultural competence. The Ecology of Culturally Competent Educational Design will be introduced as starting point for development and evaluation of cultural competence in virtual worlds.

1. Teaching Cultural Competence
in Web-Based Communities
Eric Bauman, PhD, RN
Alex Games , PhD
© Copyright by Eric B. Bauman 2009
All Rights Reserved

2. Author Information and COI Statement
Eric Bauman, PhD, RN
Faculty Associate
University of Wisconsin School of Medicine &
Public Health
Department of Anesthesiology
COI: Consultant -Vernon M emorial Healthcare and TM FD
Investments: Pfizer, SHSAX
Alex Games, PhD
Assistant Professor
Michigan State University
Department of Telecommunications, Information
Studies &Media
COI: None

3. Identity and Consequence
• Virtual communities encourage
participants to “try on” different
identities and reflect on the
consequences of their decisions while
“wearing” these identities.
(Gee, 2003; Turkle, 1995)

4. Why is Identity and Consequence
Important in Clinical Education?
• Acculturation and Indoctrination of a
professional
• Cultural Competence
• Learning as Behavioral Change
Popkewitz, 2007

5. Acculturation - Indoctrination
• Part of the educational experience focuses on learning how to
become part of a cohort
• Beyond the required professional knowledge base, novice
clinicians must come to understand the conduct and
expectations of the rank and profession they hope to join
How to: Look - Act - React
Gee, 2003; Popkewitz, 2007

6. From Novice to Expert: Transition from
the virtual world to the real world
• Avatars and virtual worlds can be designed
to evoke students preconceived notions of
culture and identity
– In terms of cohort social norms and cues
– In terms of professional expectations and cues
Benner, 1984

7. Ulrike (Rica) Dieterle
Librarian
Ebling Health Sciences Library
University of Wisconsin - Madison
IDENTITY
Chris Holden, PhD
Asst. Professor
University of New Mexico
University College

8. Gerald Stapleton
University of Illinois at Chicago
College of Medicine
IDENTITY
Allan Barclay
Librarian and Information Architect
Ebling Health Sciences Library
University of Wisconsin - Madison

9. Moses Wolfenstein, MS
Doctoral Student
Department of Curriculum & Instruction
University of Wisconsin-Madison
School of Education
So what about Identity?
Identity is fluid and malleable - How can we use this fluidity to enhance learning experiences?
As instructors should we or do we need to impose restrictions on in-world identity

10. Cultural Competence
• Published literature readily discusses the importance of integrating
cultural competence into health sciences curricula
• There is little literature to indicate that simulation and standardized
patient education has readily integrated culture and diversity into
health sciences curricula.
• Both obvious and subtle cues related to culture, gender, and race can
often have profound social-cultural implications and biological
consequences related to diagnosis and treatment
• Cues derived during observational and behavioral encounters may
drive important decisions related to diagnosis and patient care.
(Culhane-Pera, Reif, Egli, Baker, and Kassekert, 1997; Tervalon and Murray Garcia, 1998;
Smedley, Stith, and Nelson, 2003; Steele and Aronson, 1995)

11. Learning as Behavioral Change
• Through in-world interaction and during post experience
debriefing instructors can facilitate behavioral responses from
students that represent either cultural competence or cultural
cliché and stereotypes
• Educators bear the responsibility for providing environments
that provide a safe medium to facilitate the transfer of
knowledge and facilitate behavioral change
• Web-based and virtual worlds can provide a translational
platform for behavioral change related to culture and diversity
Thiagarajan, 1992; Games and Bauman 2009

12. The Ecology of Culturally Competent
Educational Design
• Context(s)
• Character(s)
• Narrative
• Activity

13. Context
• Virtual simulated spaces can be designed in ways that
authentically capture environmental fidelity
– Replicate in virtual form aspects of the real world that
students occupy in actual practice
• Safer environments where students could afford to learn from
mistakes with no risk to patients
– virtual worlds provide opportunities for learning and
professional development without the consequences
associated with actual therapeutic misadventure
• Virtual simulation overcomes some of the barriers associated
with fixed or physically created environments
– Money, Location, Space allocation
Games and Bauman, 2008; Squire 2006; Bauman, 2007

14. Character
• The fluidity and malleability of virtual environments applies not
only to the look and feel of virtual teaching spaces, but also
learners identities
• The ability to try on multiple identities may be of great value for
the construction of learning experiences involving culture and
diversity
• Players shape and design their avatars (characters), which
become their in-world identities
• Identity expectation related to ones future professional affinity
group is an important tenet of learning
(Gee, 2003; Squire, 2006)

15. Narrative
• Narratives provide peoples memories with a collection of
patterns that help them recognize and make sense of the world
• Narratives assist players in the negotiation of their identities,
particularly projective identities. Projective identities place
learners in the shoes of the virtual identities they are playing
• Narratives also provide spaces for reflection on the
consequences of student action or inaction. Learners can be
encouraged to see the consequences of their decisions from
multiple perspectives and deliberate practice
(Bruner, 1991; Gee, 1991, 2003)

16. Activity
• Interactivity is one of the most important defining characteristics of
successful learning in games and virtual worlds.
• Participation in virtual worlds is only meaningful when players are
actively engaged in their environment rather than passively observing it
• The game and its environment define identity and developing affinity
groups
• In the health sciences, virtual spaces include familiar settings where
learners can practice many of the activities germane to the professions
they hope to join
(Gee, 2003; Taekman, Segall, Hobbs and Wright 2007)

17. Conclusion
• Virtual or web- based communities that authentically replicate real-
world clinical experiences can provide translational educational and
research experiences for both students and educators
• virtual platforms facilitate access to learning experiences that would
otherwise be difficult or impossible to recreate in traditional educational
environments
• Virtual or web-based experiences may provide consistent exposure to
diverse cultural content across curricula that are NOT available in
actual clinical or traditional mannikin-based simulation environments
• Virtual and web-based educational platforms should take advantage
the malleable nature of their environment to further develop student
experiences related to culture and diversity
• Evaluation of virtual worlds in the context of health sciences
education is important because the potential for understanding
the role of cultural sensitivity in virtual and designed
environments may provide a useful lens for assessment of
cultural competence

18. References
Bauman, E. (2007). High fidelity simulation in healthcare. Ph.D. dissertation, The University of Wisconsin-
Madison, United States. Dissertations & Thesis @ CIC Institutions database. (Publication no. AAT
3294196)
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA:
Addison-Wesley.
Bruner, J. (1991). The narrative construction of reality. Critical Inquiry 18 (Autumn), 1-20.
Culhane-Pera, K.A., Reif, C., Egli, E., Baker, N.J., and Kassekert (1997). A curriculum for multicultural
education in family medicine. Family Medicine, 29(10), 719-723.
Games, I. and Bauman, E. (In Press). Virtual worlds: An environment for cultural sensitivity education in the
health sciences. International Journal of Web Based Communities.
Gee, J. P. (1991). Memory and myth: A perspective on narrative. In A. McCabe & C. Peterson (Eds.), Developing
narrative structure (pp. 1 - 26). Mahwah, NJ: Erlbaum.
Gee, J.P. (2003) What Videogames Have to Teach Us Ab out Learning and Literacy. New York, NY: Palgrave-
McMillan.
Popkewitz, T. (2007). Cosmopolitianism and the age of school reform: science, education and making a
society by making the child. Routledge.
Smedley, B. D, Stith, A. Y, and Nelson, A. R. (Eds.). (2003) Unequal treatment: Confronting racial and ethnic
disparities in health care. Washington, D.C.: National Academies Press.
Steele, C.M. & Aronson, J. (1995) Stereotype Threat and the Intellectual Test Performance of African
Americans. Journal of Personality and Social Psychology. 69(5), 797-811.
Squire, K. (2006). From content to context: Videogames as designed experience. Educational Researcher.
35(8), 19-29.
Taekman J.M., Segall N., Hobbs G., and Wright, M.C. (2007). 3DiTeams: Healthcare team training in a virtual
environment. Anesthesiology. 2007: 107: A2145.
Tervalon, M. and Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in
defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and
Underserved, 9(2), 117-125.
Turkle, S. (1995) Life on the screen. Identity in the age of the Internet. New York: Touchstone.

19. Special Thanks
• Eric Graves: American Research Institute
• Gerald Stapleton: University of Illinois at Chicago
College of Medicine
• Jerry Heneghan: Virtual Heroes
• Jeff Taekman: Duke University - Human Simulation
and Patient Safety Center
• Bob Waddington: SimQuest
• Allan Barklay: University of Wisconsin - Madison,
Ebling Library

20. Contact Information
Eric Bauman, PhD, RN
B6/319 CSC
Department of Anesthesiology
600 Highland Avenue
Madison, WI 53792-3272
Email: ebauman@wisc.edu
Office: 608-263-5911
Linkedin: http://www.linkedin.com/in/ericbbauman