* Correspondi

1876-1399/$ - se

doi:10.1016/j.ec

Clinical Simulation in Nursing (2012) 8, e469-e475

www.elsevier.com/locate/ecsn

Featured Article

Second Life�: A New Strategy in Educating NursingStudents

Michelle Aebersold, PhD*, Dana Tschannen, PhD, Marc Stephens, MAED,Patricia Anderson, MILS, Xuefeng Lei, MD, MSUniversity of Michigan School of Nursing, Ann Arbor, MI 48109, USA

KEYWORDSeducation;patient safety;virtual worlds

ng author: mabersol@um

e front matter � 2012 Int

ns.2011.05.002

designed and implemented a virtual hospital unit in Second Life� to run virtual simulations. Three sce-narios were developed about topics that represent areas that contribute to patient safety, as well as key

Abstract: The purpose of this article is to discuss how the University of Michigan School of Nursing

student learning challenges. Fifteen students completed a 6-question survey evaluating their experi-ence. Comments indicated students did identify the potential benefits of the Second Life� simulation.The Second Life� platform may also provide avenues for learning in the clinical arena for a multitudeof health care professionals. The opportunity to simulate emergent, complex situations in a nonthreat-ening, safe environment allows all members of the team to develop critical communication skills nec-essary to provide safe patient care.

Cite this article:Aebersold, M., Tschannen, D., Stephens, M., Anderson, P., & Lei, X. (2012, November). Second life�: Anew strategy in educating nursing students. Clinical Simulation in Nursing, 8(9), e469-e475.doi:10.1016/j.ecns.2011.05.002.

� 2012 International Nursing Association for Clinical Simulation and Learning. Published by ElsevierInc. All rights reserved.

Introduction

Human patient simulators are becoming well integrated intomany nursing school curricula and provide an excellent wayfor students to learn in a safe environment. However, thereare other learning technologies that can be used, takingadvantage of the advanced technical skills of many of thenext generation of learners (who have grown up withcomputers and the Internet). The purpose of this article isto provide an overview of one advanced learning technology,the virtual environment of Second Life� (SL), and to sharehow the University of Michigan School of Nursing designedand implemented a virtual hospital unit in SL to run

ich.edu (M. Aebersold).

ernational Nursing Association for Clinica

simulations in a virtual space. The process used to selectand develop virtual simulation scenarios is also discussed.

Background

Emerging technologies in education focus primarily onthose technologies that allow collaboration with teachersand students and engagement with course-related content.Emerging technologies in health care make use of Web 2.0technologies. Web 2.0 is not a new version of the Web butrefers to the ways designers have used the Web platformand also to the changing behaviors of those using theWeb (Burrows, 2007). Web 2.0 generally refers to suchWeb programs as YouTube, Facebook, MySpace, blogs,

l Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Second Life�: A New Strategy in Educating Nursing Students e470

wikis, Twitter, and Flickr. These programs are also referredto as social media or social networking programs. Web 2.0also refers to such technologies as online gaming and three-dimensional virtual environments. These are spaces whereusers can interact with others in a synchronous, or real-

Key Points� Three virtual simula-tions were develoepdto seu with seniorlevel students.

� Students thought theexperience was betterthan or as good asSimMan�.

� Students struggledwithtext chatting.

time, fashion. Many nursingschools currently use learn-ing management systemsor course management sys-tems such as Blackboard orWebCT�. Additionally, fac-ulty use Webcasts or pod-casts to deliver content tostudents. Students may usemobile devices such assmartphones, PDAs, orother mobile applicationsto look up informationsuch as drug references dur-

ing a clinical experience.Use of these newWeb 2.0 technologies is coming at a time

in nursing education when many courses are moving onlineand many of our students are considered the net generation,or digital natives: children who were born into and raised inthe digital world (Palfrey & Gasser, 2008). It is also comingat a time when educators are challenged with rethinking thepedagogical approaches to teaching and learning. The recentpublication from the Carnegie Foundation, EducatingNurses: A Call for Radical Transformation, discusses theneed for students to engage in activities in the learning envi-ronment that enables them to bridge the gap from theory topractice (Benner, Sutphen, Leonard, & Day, 2009). Thiscan be done through simulation. Many nursing schoolshave active simulation programs in which they use humanpatient simulators as part of the overall student educationprocess. Human patient simulation has proven to be a suc-cessful educational strategy to improve knowledge acquisi-tion, the recognition of deteriorating patients, and criticalthinking (Lapkin, Levett-Jones, Bellchambers, & Fernandez,2010). The success of human patient simulation provides uswith an opportunity to venture into the use of simulation ina virtual environment such as SL.

Second Life�

SL is an online three-dimensional virtual world developedby Linden Lab. It launched in 2003. It is a free, open accessprogram that can be downloaded on most computers.Virtual worlds are three-dimensional, multiplayer environ-ments with a social context (Aldridge, 2009). They are dif-ferent from games as they generally do not focus ona specific goal. Participants in virtual worlds use an avatar,an online graphical representation of themselves, to interactwith others and travel throughout the virtual environment.SL is similar to social networking sites such as Facebook

pp e469-

and MySpace. In SL you can join user groups based onyour interests (social or educational). You can travel to dif-ferent areas (called islands) to meet other people (i.e., theiravatars); engage in social activities (e.g., dancing); or par-ticipate in meetings, support groups, or educational oppor-tunities (e.g., genome island). Many universities andcorporations have islands in SL where they conduct busi-ness or hold staff meetings or educational sessions. SLhas its own currency, called Linden dollars, which allowsusers to buy items such as clothing for their avatar or fur-niture for their office. Avatars (users) can communicatewith each other by using a text chatting method or a voicechat method that requires computer headphones. Avatarsare moved around the virtual space or island by means ofthe computer keyboard or pull-down menus in SL. An av-atar can walk or fly to travel around an island. To go to dif-ferent islands, avatars teleport, using a map in SL thatallows them to go from one island to another. Avatars canalso build objects in SL and animate those objects by usinga scripting code. This allows the user to build a chair andanimate it so that an avatar can sit on the chair. Avatarscome with a standard set of clothes. More clothing canthen be made or purchased from vendors in SL.

Interest in SL as a platform for education has beengrowing in many areas, including health care. The firsteducators in SL taught courses on art, architecture, business,instructional technology, urban planning, humanecomputerinterface, communities, sociology, education, game design,health care and disaster response, and simulation develop-ment (Linden, 2005). SL is currently used for role-playing,collaboration, real-time interaction between students andfaculty, and an alternative environment to create simulationsfor nursing students (Skiba, 2009).

One of the strongest uses of SL educationally is the roleof supporting simulation. SL is an excellent tool forsupporting a broad approach to simulation, especiallysimulation involving interaction among multiple partici-pants. SL provides the learner with the ability to beintimately involved in the story of an immersive scenarioand the ability to simultaneously step back and get a moredetached and broader view. This broad-view approach wasused at the University of Michigan Medical School in thedesign of The Virtual First Responder, an elective coursefor 2nd-year medical students that explores the use ofvirtual reality (SL and immersive Cave Automatic VirtualEnvironment technology) to simulate mass-casualty di-saster triage (Stephens & Chapman, 2009). Virtual realitycan be an excellent platform for exploring ‘‘learning by do-ing’’ scenarios that are potentially dangerous or difficult tosimulate in real life.

An important aspect that makes SL’s multiuser onlinenature stand out over single-user computer programs is theability for a community of people to meet over a topic ofinterest within the virtual world. There is a broad publichealth community within SL that is engaged in topicsranging from H1N1 pandemic preparation to cancer and

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Figure 1 An outside view of wolverine hospital.

Second Life�: A New Strategy in Educating Nursing Students e471

other chronic disease survivor networks. Health careworkers can use SL to network with others in their field.For example, surgeons have held a conference within SL(Leong, Kinross, Taylor, & Purkayastha, 2008) to discusssurgical technology. SL has been used to model compo-nents of human anatomy and body processes for health sci-ences education. SL’s level of graphics is sufficient to allowfor simulations in which precise modeling of the humanbody is not required. This use has included heart murmursimulators, mental health simulators, nutrition simulators,and some modeling of body structures such as skeletonsand internal organ systems (University of Michigan HealthSciences Libraries, 2008). While the physical models cre-ated within SL are slowly gaining enough fidelity to beused in realistic simulation, the resolution of objects inSL is not yet to the point that they can be used for hyper-realistic and smoothly animated simulation of the humanbody. This is mainly because of network signal delay (SLcontent is delivered to the user on an as-needed basis),and the need for SL’s rendering engine to allow less thanstate-of-the-art computers to interact with the virtual worldsystem. Although SL is not yet developed for high-endgraphics and gaming, it does make an acceptable environ-ment for role play and simulations involving interpersonalinteractions.

Virtual Hospital Development

In 2008 the University of Michigan School of Nursingundertook a project to establish a nursing acute care unit onthe University of Michiganeowned Wolverine Island in SL.This project was supported by an internal grant from theCenter for Research on Learning and Teaching. The Univer-sity ofMichiganMedical School maintainsWolverine Island

pp e469-

in SL (Anderson & Stephens, 2008) as a place for use bymembers of the University of Michigan community fromany discipline who wish to explore the use of SL in theircourses. Features of Wolverine Island include a library withinformation and items to help University of Michigan new-bies get started using SL, a large sandbox area to allow usersto learn how to build objects, an assortment of both lectureand small-group meeting spaces spread over the island, anda medical building structure that is not fully developed.

An eight-bed virtual hospital unit was built in theunfinished medical building on the fifth floor (Figure 1).This hospital unit was developed to resemble an acutecare unit found in any hospital setting. It includes foursemiprivate clinical rooms, a conference room, and a nurs-ing station. Each clinical room has two beds and is equip-ped with wall-mounted blood pressure gauges, bedsidecardiac monitors, medical supply cabinets, a sink, a com-puter desk, and chairs (Figure 2). The conference roomhas an oval table with chairs around it that avatars can sitin (Figure 3). The nurse station is equipped with a centraldesk and computer workspace, crash cart, medication dis-pensing unit, x-ray view boxes, and wheelchairs(Figure 4). Most of the equipment was purchased throughan online shopping Web site, now called Second Life�

Marketplace (https://marketplace.secondlife.com). Grantmoney was exchanged for Linden dollars, which wereused for the purchases. Nursing scrubs and badges werealso developed and given to the nursing students for theiravatars to wear.

SL Simulations

Once the eight-bed virtual unit was established, simulationscenarios were developed, and beta testing was conducted

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Figure 3 Virtual team conference room.

Figure 4 Virtual nursing station.

Table 1 Virtual Simulations at the University of MichiganSchool of Nursing

Scenario Description Roles

1. Safety issueswith medicationadverse events

This scenario involvedan IV antibiotic infusedon the wrong patient.The nurse (student) hasto problem solve how tohandle the situation,including ensuring thatthe patient is OK,notifying the physician,and completing anincident report.

BedsidenurseChargenurse

2. Difficultinterprofessionalcommunications

This scenario involved analtercation with aphysician over a patientwho was NPO but wasfed prior to a scheduledprocedure. The nurse(student) had to managethe difficultconversationand follow up with theassistive personnel whogave the patient themeal.

BedsidenurseChargenursePhysicianNurseassistant

3. Priority setting This scenario involvedassessing a group offour patients,prioritizingwhat their needs were,and delegatingappropriate tasks toassistive personnel.

BedsidenurseNurseassistant

Figure 2 Virtual unit patient care room.

Second Life�: A New Strategy in Educating Nursing Students e472

to determine the feasibility of virtual simulations. Institu-tional review board approval was obtained, and the projectwas given exempt status. Simulation scenarios were chosenas the teaching methodology because human patientsimulation is a proven technique in the education of healthcare students (Jeffries, 2007) and virtual simulations havebeen shown to be as effective as human patient simulation(Youngblood et al., 2008).

Three virtual simulation scenarios (Table 1) were devel-oped to use with senior-level students: (a) safety issues withmedication adverse events, (b) difficult interprofessional

pp e469-

communications, and (c) priority setting. The scenarioswere developed through a five-step process: (a) key conceptidentification, (b) competency and standard mapping, (c)scenario building, (d) debriefing development, and (e)beta testing and refinement of the scenario as needed(Aebersold & Tschannen, in press). The key concepts iden-tified were medication safety, interprofessional communi-cation, and priority setting. These concepts were chosenbecause they represent areas that contribute to overall pa-tient safety as well as key student learning challenges.The concepts were mapped to the Quality and Safety Edu-cation for Nurses recommendations (Cronenwett et al.,2007) and the 2009 Joint Commission’s National PatientSafety Goals, in addition to course objectives for thesenior-level courses. Once this mapping was done, the sim-ulation scenario was developed. Each scenario was scriptedand included an introduction phase (where directions weregiven), an action/interaction phase, and a nursing-teamfeedback phase. The development included cue cards de-scribing the roles participants were playing or actions

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Figure 5 Results of student survey.Note. Scale, 1 (strongly disagree) to 5 (strongly agree).

Second Life�: A New Strategy in Educating Nursing Students e473

they needed to take and what objects would be needed inSL. These objects might include a movable bed or an inter-active assessment module that displays information aboutthe patient. After a scenario was written, debriefing ques-tions were identified for use after the scenario wascompleted.

Two of the three scenarios (communication and medi-cation safety) were beta tested by a group of senior-levelsecond-career BSN students who were in their last nursingcourse. The students who played a role in the scenario wentto the school computer lab and logged into SL, and theremaining students remained in another classroom andwatched the simulation via LCD projector through one ofthe facilitator’s avatars. A total of 15 students participated.The students were all given information on the scenario(e.g., students playing roles in the simulation were givencue cards if a certain response was required during thesimulation), and then the scenario was started. Thecommunication was done using the text chat function inSL so that all students could see the communicationinteraction. One of the facilitators ran the scenarios in SLby giving the students their instructions via text chat andpassing notecards (written information that can be passedin-world between avatars) when appropriate. The simula-tion scenario ran for 10 to 15 minutes, in which the studentsinteracted with the other avatars and worked towardachieving the scenario objectives. At the conclusion ofthe scenario, all 15 students returned to the classroom.Students went through the debriefing process as a group toreflect on their interactions in the scenario. Students wereasked to rate their experience in terms of course objectives,preparation for clinical, realistic environment, effectivelearning, improved decision-making skills, and overallpositive experience. The purpose of the questionnaire wasto evaluate the experience in SL and to determine whethera virtual environment such as SL is a feasible way toconduct simulation scenarios.

Feedback

The 15 students completed a six-question survey evaluat-ing their experience (Figure 5). Responses were rated ona 5-point Likert-type scale, with 1 ¼ strongly disagreeand 5 ¼ strongly agree. ‘‘SL helped prepare me for clin-ical’’ was rated overall a 2.5, with the range of 1 to 4.‘‘SL was realistic’’ had a mean score of 2.8 and a rangeof 1 to 4. ‘‘SL reinforced learning objectives’’ hada mean score of 3, with a range of 2 to 4. The mean scorefor the question stating, ‘‘SL is an effective learning expe-rience’’ was 2.8, with a range of 1 to 4. ‘‘SL improveddecision-making skills’’ had a mean score of 2.7 anda range of 1 to 4. Overall, students rated the experienceas 3.1, with a range of 1 to 5.

Comments written by students identified the potentialbenefits of the SL simulation, and some thought the

pp e469-

experience was better than or as good as SimMan� (high-fidelity simulation). ‘‘It is a real good practice system andsince it resembled real life scenarios, it gives almost thesame experience one would have received in ordinary sim-ulations.’’ Students were able to navigate their avatarsaround the unit without much difficulty despite it beingtheir first time in SL. Students did become immersed intheir roles, and one student wanted ‘‘more of an abilityto have groups participate . . . have students set up theirown avatars.’’ The most common problems students iden-tified were technical difficulties. Students had a tendencyto want to talk to each other while they were role-playing because they were sitting in the same room.The text chat function was slow, particularly for studentswith poor typing skills. Student also had a difficult timekeeping track of which role the avatars were playing(e.g., nurse, family member, charge nurse). It shouldalso be noted that the actual running of the simulationswas delayed 45 minutes because of unforeseen technicalissues, which may have resulted in some preconceivednegative attitudes.

Our findings are similar to the experience of other studentsin which negative perceptions were caused by technicaldifficulties and student concerns about learning in a ‘‘game-like’’ environment (Cheal, 2009). Although students at theUniversity ofMichiganSchool ofNursing have been exposedto manikin-based simulation, this was their first virtual expe-rience, and some student comments implied that it was‘‘game-like.’’ Based on the results of the beta-testing, modi-fications were made before the program was rolled out tosenior-level traditional undergraduate students. Studentswere givenmore background information on SL. A chart out-lining the characters in the simulation and their respectiveroles was developed for each scenario to help students easilyidentifywhowas playing thevarious simulation roles (chargenurse, bedside nurse, family member). Scenario directionswere also refined as needed to ensure clarity and understand-ing. For example, the person playing the role of the family

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Second Life�: A New Strategy in Educating Nursing Students e474

member was given cue cards on how to act and whatquestions to ask the nurse. Although every effort was madeto minimize technical difficulties, students still struggledwith text chatting to someone they were sitting with in thesame room. Future modifications will include using voiceover Internet protocol rather than text chat and havingstudents who are playing roles link in remotely.

Discussion

Use of simulation in education has demonstrated improve-ment in performance in many areas, including anesthesiacrisis management training (Gaba, Howard, Fish, Smith, &Sowb, 2001) and cardiac arrest team responses (Wayneet al., 2008). In a systematic review of the effectivenessof simulation in health science education, Harder (2010)found that the majority of studies reviewed demonstratedsimulation is effective in increasing students’ skills. Simu-lations using human patient simulators can be costly, and insome centers the high demand for use of the simulatorsmakes it difficult to get access. Virtual simulations in SLcan be another strategy for delivering scenarios that focuson nursing skills such as inter-professional communication,priority setting, or patient safety.

For these reasons, the purpose of this project was to createa virtual hospital unit in SL to determine the feasibility ofusing it to conduct simulation scenarios to facilitate learningamong nursing students. The long-term goal of this project isto incorporate simulated virtual experiences using the‘‘virtual hospital’’ in SL into all levels of the nursingcurriculum, including collaborative learning experienceswith students in other health disciplines. Currently ourvirtual simulations are being incorporated into two senior-level nursing capstone courses. Student performances duringthose simulations will be evaluated with a standardizedevaluation tool, and the student experience will again besurveyed. The rich environment offered by SL may also beused to create virtual simulations that incorporate studentsfrom other disciplines. Currently, the faculty membersassociated with the project play the role of other disciplines(e.g., doctors, respiratory therapists). Because of the abilityto participate from anywhere, it is possible to involve otherprofessionals in the simulations, creating an opportunity forcollaborative learning through joint problem solving anddecision making.

Recommendations

The SL platform may also provide avenues for learning inthe clinical arena for a multitude of health care pro-fessionals. Communication among the interdisciplinaryteam members remains one of the most prominent rootcauses of medical errors (Institute of Medicine, 2000). Theopportunity to simulate emergent, complex situations in

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a nonthreatening, safe environment will allow all membersof the team to develop critical communication skills neces-sary to provide safe patient care. For example, nurses, phy-sicians, and respiratory therapists could be required torevive a patient found down in the emergency waitingroom. Such an experience (i.e., simulation in a safe envi-ronment such as SL) will help facilitate team members’preparedness for such situations in real life. Although thisis currently being done with manikin-based simulators,SL can facilitate this type of training without requiring ev-eryone to be on site in the simulation lab. Success of similarsimulations has been identified in mass casualty and bioter-rorism preparedness (Idaho State University, 2007). SL pro-vides a platform for a wide variety of simulations andexperiential learning opportunities for all health disciplines.Opportunities for the future use of SL are vast. They arelimited only by the failure of faculty to think outside thetraditional boundaries of the classroom.

Acknowledgments

The authors gratefully acknowledge the Center for Re-search on Learning and Teaching at the University ofMichigan for its generous financial support of the project.

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