Reflecting US Diversity Through Shadow Health’s® Virtual Patient Population

Shadow Health has a wide range of simulation characters, or Digital Standardized Patients™, that allow students to practice clinical skills in nursing disciplines from Fundamentals to Advanced Primary Care. Because of the patented natural language Conversation Engine within Shadow Health’s Digital Clinical Experiences™ (DCEs), students can practice authentic conversations with patients with diverse representation that students may not see in the clinical setting.

Shadow Health understands the importance of allowing students the opportunity to interact with patients in a respectful, meaningful, and accurate way. It takes a large team of collaborators to create screen-based simulation offerings—including a cross-functional team of Nurse Educators, Developers, Artists, Technical Sound Designers, Learning Designers, Narrative Designers, Product Managers, and Scrum Managers. They make it their priority to incorporate optimal learning opportunities with realistic conversation and empathy to each of the simulated patients to truly make them virtual human beings who breathe, blink, and have rich and complex histories.

Additionally, Shadow Health partners with external experts and agencies to ensure diverse personas are presented respectfully. Creating virtual patients that represent a variety of backgrounds and cultures allows students to practice conversation skills and empathy on patients, as well as therapeutic communication.  Screen-based simulation guarantees that students can interact with patients from a wide range of backgrounds and experiences and can consider patient needs along with social determinants of health.

Here are some examples of patients in Shadow Health representing diverse backgrounds and ensuring students can practice therapeutic communication.

Anita Douglas

Anita Douglas is a 72-year-old Black woman who appears in both graduate and undergraduate DCEs. Anita appears in Advanced Pharmacology and Advanced Diagnostics DCEs for graduate students. In the Advanced Diagnostics DCE, Anita has been experiencing fatigue and weakness that has impaired her activities of daily living for a few months and has had her symptoms dismissed as ‘old age’.

Anita Douglas

As an older patient, students should be mindful of how they interact with Anita to avoid implicit ageism. Ageism in the healthcare setting can impact adequate care, prevalence of health conditions, and healthcare costs (Levy et al, 2018). Additionally, discrimination is even more prevalent among older minority individuals particularly as it relates to delayed care and poor communication (Rhee et al, 2019). In these simulations, students must remain aware of how implicit bias toward race, gender, and age may impact interpretation of a patient’s signs and symptoms throughout the diagnostic process. They must also take potential risk factors into consideration when determining their working medical diagnosis.

In the Undergraduate Leadership DCE, Anita is one of five patients that students manage care for over three consecutive days at Shadow General hospital. Students must apply several leadership concepts, including prioritization, delegation, ethics, change management, and patient advocacy. For Anita, this means evaluating her condition to ensure positive outcomes for patient care. Anita suffers a hip injury and has already been in the hospital for three days. During the morning of the third day, Anita wants to ambulate by herself and maintain her independence. She also requests education on physical therapy and how to avoid future falls. When she asks for an expedited discharge even though her goals have not been met, students will need to consider the best course of action utilizing leadership skills.

Daanis LaFontaine

Daanis LaFontaine, 18, is a member of the Turtle Mountain Band of Chippewa Indians, an Ojibwe people. Assignments featuring Daanis and our other Native American characters were developed in partnership with Dr. Misty Wilkie, an enrolled member of the Turtle Mountain Band of Chippewa Indians and a nurse who grew up on the Turtle Mountain Indian Reservation in Belcourt, North Dakota.

Daanis LaFontaine and her mother, Rebecca LaFontaine

Dr. Wilkie is a nurse educator who teaches at Bemidji State University and has now served as a consultant on three different products for Shadow Health. When developing Daanis, Dr. Wilkie and the development teams were able to exchange questions and ideas which resulted in whole, authentic, and accurate representations of these patients.

For example, Daanis’s name was chosen with special care and consideration. “Daanis” means “daughter” in the Ojibwe language. “LaFontaine” captures the Metis French influence on the Turtle Mountain people.

Daanis appeared first in the Maternal Health DCE. She is in labor with her son Zachary and her mother, Rebecca LaFontaine, is in the room with her. Students will learn about Daanis’s birth plan preferences and transcultural considerations such as allowing additional family members into the room, restricting and respecting considerations around touch, and honoring her request to take the placenta home.

The Shadow Health development team also partnered with a local artist from the Turtle Mountain Band of Chippewa Indians to create the initial concept art for Daanis LaFontaine and her mother, Rebecca. For example, in the simulation, Rebecca is wearing a traditional ribbon skirt, a symbol of womanhood and pride among many Ojibwe communities.

Fatima Khan

In a Medical-Surgical DCE, students meet Fatima Khan, a 44-year-old type 1 diabetic who is pre-operative and awaiting a laparoscopic cholecystectomy. As part of this simulation, students practice healthcare considerations that may be important to Muslim patients, including diet, modesty and privacy, touch restriction and consent, and substance use restriction.

Fatima Khan

To develop Fatima’s character, the Shadow Health team drew upon published research and best practices for South Asian/Muslim patients in hospital settings. Muslim women in particular report provider bias, and a lack of sensitivity or understanding around concepts of modesty and dress. To accommodate Fatima’s needs and because the hijab does not obstruct or interfere with the surgery site, Fatima wears her hijab during the operation.

Students interview the patient and are challenged with recognizing a change in patient status. In this simulation, Preceptor Diana remains present in the room during the patient assessment to fulfill the patient’s request of having a same-gender provider present.  Using clinical reasoning to implement safe, effective, patient-centered care, the students create a culturally appropriate care plan for Fatima.

Felipe Barbosa

Felipe Barbosa is a 48-year-old Brazilian American man who presents with a rash in a primary care setting in the Advanced Primary Care – Adult Management DCE. Felipe is in a healthy, happy marriage and has been married to his husband, Marvin, for three years. He is proud of his work as a firefighter, but a recent traumatic episode caused resulting grief.

Felipe Barbosa

The Shadow Health team leaned on published research and evidence when creating the transcultural learning objectives for this case. Due to implicit provider bias against Latino and gay communities, Felipe is more likely to experience discrimination. Before they begin the simulation, students receive guidance on why patient demographics matter and how visible and invisible biases can contribute to healthcare disparities and shape an individual’s perception of and reaction to healthcare. Specifically, students receive a reminder that because members of the LGBTQ+ community face discrimination that impairs healthcare and could impact patients seeking care, it is important to practice respectful, empathetic interaction with gender and sexual minorities.

Lupe Sosa 

Lupe Sosa, 21, is a college student who balances a full academic schedule as a philosophy and music double major, along with a work/study job at the library, DJ gigs in local nightclubs, club fencing, and vibrant relationships with their friends and family. Lupe is gender non-binary and uses they/them pronouns. Non-binary people do not identify with the binary gender identities of man or woman. Students can meet Lupe in the Advanced Primary Care: Mental Health* DCE. In the scenario, students help Lupe consider the possible cause of their sleep disturbances. 

Lupe Sosa

For Lupe’s character, Shadow Health worked with Trans Equity Consulting, an organization with experience in medical simulation and deep ties to LGBTQ+ communities.

Lupe’s simulation includes a Rapport Building activity where students practice invaluable communication skills. This includes students introducing themselves with their pronouns and establishing how Lupe would like to be referred to. Examples of microaggressions against non-binary patients that could appear in the healthcare setting, including misgendering or refusing to use a patient’s name, are addressed in the Rapport Building activity (National LGBTQ Health Education Center). While these are small steps towards building rapport with patients from vulnerable populations, they have the potential to make a big impact on building rapport with a population that experiences high levels of discrimination and microaggression in healthcare settings.  

Quan Van Tran

When students first meet Quan Van Tran, 50, they encounter him in a clinical setting shortly after he has received a positive diagnosis of HIV. Quan is a Vietnamese American who immigrated to the United States. In previous years, research shows the number of HIV diagnoses among Asians in the U.S. increased, and 1 in 5 Asians living with HIV in the U.S. did not know they had it. Quan also does not think of himself in terms of sexual orientation. His assignment is imbued with a need for students to demonstrate cultural humility. HIV is a sensitive topic and the depth of history required for contact tracing may also be challenging for new nurses. He is featured in Community Health DCE.

When obtaining a patient’s sexual history, it would be inappropriate for students to ask Quan to think of himself in terms of his sexual orientation and will push back if students continuously ask inappropriate questions about his identity instead of appropriate questions about his sexual history. This is a feature in Shadow Health that makes students think carefully about obtaining patient history and obtaining medically relevant behavior.

Quan Van Tran

Studies show nurses often lack the proper education to adequately provide safe and competent care to the LGBTQ+ community (Kroning et al., 2018). It was important to the Shadow Health team to call attention to a specific vulnerable and underrepresented population. This character was developed with a nursing expert from the Vietnamese American Nurses Association. His demographics as an older Asian American man represent a growing population for new HIV infections, which is underrepresented in healthcare education.

Additionally, Shadow Health recently conducted research, published in Clinical Simulation in Nursing, to determine if virtual patient simulations can effectively teach nursing students about patient care issues they may not encounter as part of their clinical education. The team focused specifically on a patient living with HIV, recognizing that people living with HIV face stigma and discrimination in society at large and in the healthcare system itself. Findings suggest that participation in a virtual simulation of a patient living with HIV can positively impact nursing students’ attitudes.

Tanner Bailey

Tanner Bailey is a 30-year-old transgender man who works as a theatre director at a queer theatre company. In his spare time, he loves working out and watching old movies. He is proactive about his health and happiness. Tanner appears in two different simulations in Advanced Pharmacology and Community Health DCEs, where cases highlight the difficulties trans people face on a daily basis due to unjust bias including regular discrimination in health care and the job sector. Bias against transgender and gender diverse (TGD) people in healthcare can lead to significant health disparities and limited access to appropriate care (Sherman et al., 2021). He also appears in the Advanced Diagnostics DCE where students collaborate with Preceptor Diana to determine a working medical diagnosis from his visit to the clinic. By featuring Tanner in three different simulation experiences, students across nursing education have a higher chance of interacting with a transgender patient, which they may not have the opportunity to in traditional clinicals.  

Tanner Bailey

For Tanner’s appearance in the Community Health DCE, Shadow Health worked with Trans Equity Consulting, the same consulting agency referenced for Lupe’s case. With their guidance, Shadow Health’s development teams crafted a whole, authentic representation of Tanner and his experiences in Shadowville. 

Similar to Lupe, Tanner’s simulation also includes a Rapport Building activity. According to consultant input, establishing rapport with a trans client is extremely important during a visit. This population has often had negative experiences in the healthcare system—research shows that 25% of trans patients report delaying healthcare-seeking out of fear of mistreatment and discrimination. In addition to asking about pronouns and his preferred name, students will also determine what terms Tanner prefers for referencing his anatomy (he prefers “chest” instead of “breast”); and discussing Tanner’s preferences for physical examination prior to beginning the exam. 

Additionally, Shadow Health recently conducted research, published in Nurse Educator, to determine the effect of a virtual patient simulation scenario of caring for a transgender adult on nursing students’ attitudes and beliefs about transgender people. Study findings support experiential learning in nursing as an effective tool in teaching cultural competence and sensitivity when caring for transgender patients.

Xavier Daniels

Xavier Daniels is a 54-year-old Black man who has come to the clinical for an establishing care visit during the Advanced Primary Care: Adult DCE. He was laid off three years ago and did not have health insurance until beginning his current job as an electrician two months prior to this visit. Xavier last saw a provider three and a half years ago, at which point he was diagnosed with high blood pressure. He felt dismissed by this provider, who did not offer education about high blood pressure management and insinuated Xavier would not be able to afford future visits.

Xavier Daniels

Xavier felt his last provider was “rude and dismissive” – potentially due to his race. This type of racial bias by healthcare providers impacts patient’s ability to receive proper care. Students in this DCE practice building trust and rapport as a new primary care provider, exploring barriers to care including experienced racial bias that have resulted in unmet health needs. Students will also assess Xavier’s health concerns and engage in therapeutic communication to create a treatment plan for him.

Zachary LaFontaine

In the Advanced Primary Care – Pediatrics DCE, students have the opportunity to interact with Daanis and her son Zachary. Students care for Zachary as an infant at his 2-month well visit and then in a later assignment when Zachary is a toddler for a sick visit.

Zachary LaFontaine with Daanis’s mom, Rebecca

Students learn that baby Zachary sometimes sleeps on a cradleboard, a traditional carrier used historically and still today by indigenous families. While this assignment creates a space for learning and awareness of cultural specificities unique to Daanis’s background, it also is focused on an often-encountered infant care topics across all demographics. With Daanis, students will need to dig deeper to uncover information about Zachary and discover how Daanis and Zachary are doing.

This assignment also includes learning moments for students about inequities in healthcare. Daanis supports herself, attends school, and works a job at the university bookstore to provide for her family. Part of the student’s role in this simulation is to not only provide their patients with education around infant care but also learn more about inequities in healthcare, with Daanis supporting herself and Zachary while continuing to further her education.

Students see Zachary again when he is 30 months old and experiencing gastrointestinal issues. His grandmother, Rebecca, calls in for a telehealth visit. To further showcase the cultural specificities in this simulation, the background also includes artwork from a Turtle Mountain artist in the assignment. This was an important feature to include because it is a telehealth visit case and it gives students a realistic preview of the LaFontaine home. Since we are seeing the LaFontaine home for the first time, Dr. Wilkie recommended one of her favorite artists from the Turtle Mountains, Bill Brien of Bountiful REIs, to provide authentic artwork for the walls of their home.

What this means for nursing students

Research indicates that change is necessary for healthcare to eliminate bias, reduce health disparities, and consider the impact of social determinants of health for patient care (Carter, 2020). While preceptors can guide students on social context or special considerations to keep in mind during a patient interaction in the clinical setting, students can practice interacting with virtual human beings from different backgrounds and engage in thoughtful, empathetic communication through means like screen-based virtual simulations. This not only streamlines student learning but guarantees they have the opportunity to practice respectful interactions with a diverse range of patients.

Contributions and revisions of this piece were done in part with Watson Nelson Consulting, a partner with Shadow Health to ensure matters of diversity, equity, and inclusion are accurately represented with simulation characters. Learn more about Watson Nelson Consulting.


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