Ms. Wood is Senior Manager, KPMG Canada’s Business School, Toronto, Ontario, Canada. Ms. McPhee is Professional Development Leader in Nursing, University Health Network, Toronto, Ontario, Canada.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
The authors thank all of the nursing stakeholders at University Health Network who have been part of this initiative.
Address correspondence to Carolyn McPhee, BN, MSN, Professional Development Leader, University Health Network, Eaton North 1–812, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4. E-mail: Carolyn.firstname.lastname@example.org.
Lilianna, a staff nurse, breathed a sigh of relief as she glanced into Mrs. B’s room and found her resting quietly, holding her daughter’s hand. Mrs. B is an elderly patient with a serious cardiac problem. She spent a tearful morning after the team discussed her wishes not to be resuscitated in the event of a cardiac arrest. Shortly afterward, Lilianna looked up from the computer chart to see Mrs. B’s daughter approaching her, calling her name in an aggressive tone, and saying, “I need to talk to you right now. I just found out that my mother doesn’t wish to be resuscitated. You can’t allow this to happen!”
This scenario probably sounds familiar to most nurses, but finding the best response can be difficult. Fortunately, in this situation, Lilianna is an avatar and will now have an opportunity to rehearse this situation in the virtual world of Second Life®.
Second Life® is a web-based, three-dimensional environment that replicates the real world. Developed by Linden Lab (San Francisco, CA), this popular virtual presence started out as an environment for hard-core gamers but has evolved into a social environment and a place to disseminate information. Participants in Second Life® begin by developing an avatar that serves as a representation of them in the virtual world. This avatar can mimic an individual’s real-life appearance or may be completely different. Once an avatar is established, the participant can use it to visit different environments, called “islands,” and learn, explore, shop, play, and have many experiences that may or may not be possible in real life. Today, many major organizations have a virtual presence in Second Life® and use it for entertainment, learning, and business.
This article outlines one organization’s experience with establishing a virtual presence, describes some of the challenges that were encountered, and offers suggestions as to how they can be resolved. The authors also offer suggestions for other organizations embarking on their own virtual adventure.
The Organization: Getting Started
University Health Network (UHN) has always been interested in innovative learning practices, so using Second Life® for education seemed like a natural fit. UHN is a tertiary-care academic teaching hospital with three sites in downtown Toronto, Ontario, Canada.
In 2008, the nursing department began to explore the learning opportunities presented by virtual worlds. The possibilities seemed endless, and education leaders were eager to get started. To begin to use the virtual world productively, the authors undertook the following activities:
- Installation of Second Life® software.
- Selection of a vendor.
- Development of the environment.
- Preparation of the participants.
- Preparation of the facilitators.
- Development of the educational role-play.
Installation of Second Life® Software
The first step toward using Second Life® is installing the Second Life® software. Unfortunately, technical issues prevented a quick start. Most social networking and gaming sites, including Second Life®, are restricted by information technology teams to control leisure use of the Internet. Eventually, after many discussions with the network security team, access was granted for select computers. As a result, only the Second Life® project team could access the software, download it, and install it on their computers ( http://wiki.secondlife.com/wiki/Firewall_Configuration).
Gaining access to Second Life® was only the first technical hurdle. Second Life® requires a high-speed Internet connection, a good microprocessor, a specialized graphics card, a great deal of memory, and a recent operating system. Although many of these requirements are easily met with a new computer, older computers may need to be upgraded or replaced. In this case, Second Life® worked on some machines, but others had to be upgraded. By far the most challenging upgrade was the graphic cards. Graphic cards appropriate for use in Second Life® were not standard at the institution and had to be tested by the information technology team before they could be installed. Eventually, the right upgrades were obtained and the project team could begin to experiment with the functionality of Second Life®.
The process of gaining access to the right technology can be frustrating but has proven to be a valuable learning experience that can be applied to other technology-based projects. Because it can be difficult to predict what challenges will occur with technology projects, it is best to start sooner rather than later. The technological problems associated with this project lasted for more than 6 months. Getting an early start on the technology pieces can lead to fewer problems later, during development of the learning component.
Selection of a Vendor
Developing a virtual world requires a specialized skill set that no one in the institution possessed. Instead of developing the skill set in-house, the authors decided to outsource the work to a vendor to ensure that the project would be developed professionally and in a timely manner. A request for proposal was released, and within a few weeks the vendor was selected.
The following considerations were important in the vendor selection process:
- Experience creating Second Life® environments, especially educational environments that included role-play and immersive experiences.
- Interest in research and experimentation in Second Life®.
- Price point.
The vendor that was selected had extensive experience building in Second Life®. The vendor was also very familiar with using Second Life® for educational role-plays. This experience allowed the vendor to provide valuable assistance as the authors began using the site and deciding on first scenarios.
Development of the Environment
With a vendor in place, the development of a virtual world, or “build,” as it is called by professionals, could begin. The first step was to purchase an island. An island is a unique, self-contained area that an organization can use to develop a virtual presence in Second Life®. Islands are purchased online and come in many shapes and sizes ( www.secondlife.ca).
Next the project team, which included leaders on the corporate nursing education team, identified which components of the hospital to re-create on the island. The team decided to include the main entrance; the lobby; two patient care units (a general medical unit and a surgical unit), each containing two nursing stations; a medication room; and eight patient rooms. The team also identified a number of standard, hospital-specific items, such as beds, mobile computers, and vital signs carts, as well as bedside equipment, such as oxygen monitors and cardiac monitors, to include in the build. The process of determining which objects to include was challenging. To assist other organizations, a list of questions to consider was established:
Will you replicate the existing organization or develop a fictional environment? If you are replicating an existing environment, keep in mind that most organizations only re-create portions of their real-world environment as opposed to the entire location.
What will the participants/learners do in the environment? Talk to the education team to determine what type of scenarios would benefit the nursing staff. This will help you decide what rooms and spaces need to be created. Think about whether participants will be reading or reviewing information. If this is the case, you will want to include areas that incorporate text documents (called “notecards” in Second Life®), PowerPoint presentations, or videos. If participants will be role-playing, you will need to include areas that mimic the real-world environment.
Which areas will you want accessible to the general public? In Second Life®, it is possible to limit access to Second Life® participants. Some organizations allow everyone access to their entire site, whereas others limit public access to the front entrance and provide their employees with restricted access to other areas.
Which objects are required in the virtual site? Is furniture or specialized equipment required? Consider what objects are routinely used in the real world.
Which objects require programming so that they can be manipulated during a scenario? Think about the specific tasks or types of information the participants will have to obtain while on the island. How will the participants interact with objects in the virtual world? Will they need to sit on chairs, lie on beds, or select settings on equipment?
Once these questions were answered, the next step was to prepare for the development of the site. The vendor began this process with a thorough photography shoot. The vendor visited the hospital and took photographs of everything that would be re-created. The focus was not only on the way the object or area looked but also on details such as textures and shadows. In this way, the vendor could ensure that the virtual world would look as close as possible to the real-life environment.
Preparation of the Participants
As the vendor began development, internal considerations shifted to how the virtual world would be introduced to the learners. An informal assessment showed that the target audience was new to Second Life®. Many had never heard of a virtual world, and those who had heard of it knew of it only as an environment for social networking and not for education. Before the initiative could begin, participants would have to become familiar with how to use the environment.
The authors wanted to provide enough training so that the participants could use the environment in a meaningful way, but time available for training was limited. Based on their experiences, the authors developed a list of questions that could be used to define an orientation to Second Life® for beginners.
Will time be allotted in the training session for the learner to create a customized avatar? Providing time for learners to create their own avatar is ideal; however, it might not be practical in all situations. If it is not possible, a catalog of avatars will need to be created so that they can be preassigned before the education session begins.
Will a virtual world dress code be required? If so, will a uniform or an inventory of acceptable outfits, such as scrubs, patient gowns, or business attire, be provided to participants, or will they need to locate their own clothing? If participants need to dress their own avatar, then training must be provided.
What type of activity will participants be required to perform? Will avatars need to walk, sit, ride, or fly? The answer to this question will determine the types of movements that must be covered in the orientation.
To what extent will participants need to manipulate objects? If they will be required to use equipment such as wheelchairs, oxygen masks, or paging systems, then training needs to be provided.
How will the participants communicate? Second Life® communication can occur through voice chat using a microphone or through a text feature. Participants may need to learn how to use these features.
If the goal is to provide a minimal amount of training for participants, then it might be helpful to consider some of the following shortcuts:
- Create a selection of avatars in advance of the training session. Let the participants choose an avatar, or preassign avatars.
- Preselect the avatars’ clothing and have them dressed and ready (e.g., in scrubs or street clothes).
- Use simple scenarios to start. Scenarios that use audio communication and require minimal movement are the easiest.
- Log the participants on to Second Life® ahead of time and position the avatars in the environment where the scenario will take place. Please note that this will work only if the facilitators are physically located in the same area as the participants.
This level of simplicity will not work for everyone. However, these shortcuts will allow participants to get started very quickly. When the authors used these shortcuts, new participants were up and running in less than 5 minutes.
To take advantage of some of the more complex features in Second Life®, participants will need a longer orientation. Key questions to discuss with the project team before implementing more complex scenarios are as follows:
Will you provide learners with an orientation to Second Life®, or will you require that staff learn Second Life® on their own time?
If you plan to provide an orientation, will it be conducted in-person with a training manual or as an online tutorial?
An in-person orientation session is usually the quickest way for learners to get started. Ideally, the orientation includes setting up an account; customizing an avatar; practicing navigation skills; visiting a Second Life® location; exploring Second Life®, including the virtual site; and spending some time practicing the new skills.
Preparation of the Facilitators
In addition to preparing the participants, it is important that facilitators be familiar with the basic features of Second Life®, including:
- Creation of an avatar.
- Navigation throughout the environment.
- Operation of custom objects.
- Preparation of the scenario environment.
It is also recommended that facilitators conduct at least one practice session using the scenario before the live training session.
The educational process used to establish and deliver this initiative consisted of four key stages:
Provide background information about Second Life®. The first objective in the educational process was to provide the participants with information about Second Life®, including what it is and how it is used for learning; a brief tutorial on how to use it; and general information about the process of using Second Life® to role-play scenarios.
Introduce the learning scenario. Once the participants had a clear understanding of Second Life®, the authors introduced the learning scenario and reviewed it so that they clearly understood their role and the learning objectives.
Complete the learning activity. The learning activity took place in one of two ways: (1) Participants logged on to Second Life® and role-played the learning scenario. (2) Participants observed the live scenario and considered the behaviors and responses that took place during the role-play.
Debrief the activity. When the scenario was complete, the role-play participants and observers discussed the role-play scenario as a group. The debriefing activity was guided by a facilitator. This activity provided an opportunity to reinforce the learning experience. The participants reflected on what went well and what could have been improved. They also considered other responses that the Second Life® participants did not try and discussed why the scenario did or did not resolve positively.
Development of the Educational Role-Play
Initially, three scenarios were used to introduce Second Life® to the nursing staff at UHN. Each scenario began with an overview of what to expect in Second Life® and finished with a debriefing session and a written or verbal evaluation of the nursing staff’s experiences with Second Life®. Several best practices were learned through this experience.
In this scenario, a new graduate nurse received a report from an experienced nurse who had just completed the night shift. The scenario took place at the nursing station on a patient unit. The experienced nurse stood over the new nurse and her preceptor, giving the impression that she was “not to be messed with.” As the experienced nurse delivered her report, she appeared rushed and had an abrupt manner. She left as soon as she finished giving the report. After she left, the new nurse attempted to prioritize the care of her patients. She identified her priorities and discussed them, along with her rationale, with her preceptor. The preceptor provided feedback along the way.
This scenario was selected because new graduate nurses have expressed that they frequently feel overwhelmed when organizing care for a group of patients. The scenario provided them with an opportunity to practice prioritizing in a realistic but nonjudgmental environment.
Three Second Life® participants were required for this scenario: an experienced nurse who worked the night shift, a new graduate nurse who received the report, and a preceptor who discussed the prioritization of the assignment. A group of six to eight learners participated in this session. One learner volunteered to play the role of the new graduate nurse in Second Life®, and the others observed the scenario from a different location. Nurse educators played the roles of the experienced nurse and the preceptor.
At the end of the scenario, the nurse educators met with the learners to debrief. They discussed the skill of prioritization, reviewed and debated the rationale for the choices made during this role-play, and identified helpful strategies that could be applied to real-life situations.
Feedback from both the Second Life® participant and the observers was positive. All participants commented that the scenario was realistic and indicated that they had reviewed and consolidated the skill of prioritizing.
In the second scenario, the family member of a patient approached a staff nurse. She appeared distraught because she had just been informed that her mother, the patient, had requested that a do not resuscitate order be placed in her chart in the event that her condition should deteriorate. The family member insisted that the order be removed from the patient’s chart. The nurse’s role was to respond to the family member while considering the ethics framework described by the College of Nurses of Ontario (2009) and incorporating principles of patient-centered care. This topic was selected as part of an annual professional development day for staff nurses working in the cardiac program. Approximately 130 nurses participated in this experience.
Two Second Life® participants were required for this scenario, the family member and the nurse. A staff nurse assumed the role of the nurse, and a nurse educator assumed the role of the family member. A group of 10 to 15 learners participated in the session. The nurse and the family member worked in Second Life®, and the others observed the scenario from a different location.
At the conclusion of the role-play, the cardiac educators facilitated a debriefing session to discuss patient-centered communication strategies when dealing with ethical issues. Overall, staff feedback was positive. Many of the participants indicated that Second Life® provided a positive experience and was realistic and less threatening than a traditional role-play. Constructive feedback included a request for more practice time and a suggestion to build in an orientation to Second Life® so that participants could become more familiar with its interactive features.
The third scenario was part of a research study on horizontal violence, a term used to describe peer-to-peer bullying between members of the nursing staff. Nurses who consented to being part of the research study were randomized into different groups, two of which involved role-playing in Second Life®. One of the scenarios is described here.
A research participant was approached by a bully nurse, who berated her for the care she provided. The bully nurse said, “Every time I take over your patients, I end up cleaning up your mess. I’m surprised the patients don’t complain more about the care you give them.” The research participant was instructed to respond to her colleague. Two Second Life® participants were required for this scenario, a nurse facilitator, who played the role of the bully, and a research participant, who played the role of the staff member.
The scenarios were not observed by others. When the role-play was complete, the study participant and the facilitator met face-to-face to debrief and discuss ways to de-escalate bullying behaviors.
The feedback was similar to feedback received for other scenarios. Nurses enjoyed the experience, but wanted more time to learn how to interact in the environment and practice the scenarios.
Best Practices and Lessons Learned
The experience of developing and implementing this Second Life® educational initiative generated a number of best practices and lessons learned. These include:
- Ensure that the facilitators and learners can access Second Life®. At UHN, access to Second Life® was blocked. The authors were unable to move this initiative forward until this issue was resolved.
- Verify that the computers meet or exceed the requirements noted by Second Life®. They will require a good microprocessor, a specialized graphics card, and a great deal of memory. Most of the computers used for this initiative had to be upgraded or replaced to meet these requirements.
- Consider choosing a vendor who has used Second Life® to deliver educational role-plays. The vendor used for this project was very experienced in this area and was able to provide guidance on how to deliver the role-play scenarios.
- When identifying what to include in the build, consider using a checklist or speak with others who have developed a Second Life® environment. The original build captured all of the main elements, but the authors could have saved a lot of time by consulting a checklist (see the suggested checklist earlier in the article).
- Consider using Second Life® as a component of a blended learning session. Basic theory could be provided in a classroom setting or through an e-Learning course, and then the participants could participate in a Second Life® role-play to practice a skill or consolidate the learning.
- Plan the scenario. Second Life® role-play scenarios should be general and not overly scripted. Participants should be given an overview of the scenario, but not too much detail. This allows the role-play to feel real and in the moment. Unless training is provided ahead of time, the scenarios developed for new users should be simple and require little interaction with the Second Life® objects. However, participants will definitely want more interaction in subsequent Second Life® scenarios.
- Determine the location. Ideally, participants in Second Life® will be in different physical locations so that they cannot see or hear each other. In the first scenario, described earlier, the authors made the mistake of placing the participants side-by-side in cubicles. This made the scenario feel less realistic and was distracting to the participants and others working around them. Although participants may be physically separate, it is easier if they are located near each other to allow troubleshooting of technical issues and an opportunity to meet for a debriefing session.
- Define the method of communication. Instead of the text feature, audio can be used to communicate. Audio is more true to life, and typing skills can vary. Despite the benefits of audio, it sometimes faded or stopped completely, usually because someone inadvertently changed or muted the volume. Usually, the issue could be corrected quickly, but audio problems were disruptive to the learning experience.
- Ensure that technical support is available during the educational session to troubleshoot minor issues that arise.
- Decide whether avatars will be assigned or whether learners will choose an avatar. It is easier to preassign participants an avatar than to provide training on how to create one. However, participants may prefer to create their own avatar, so it is important to consider providing them with this option, especially if they are able to create them ahead of time.
- Plan a trial run of the role-play to ensure that the facilitators are comfortable with the scenario and the learning objectives of the session.
- Conduct the educational session. Role-playing a scenario to one participant at a time can be time consuming. Consider allowing others to observe in another location and learn through the debriefing session. More complex scenarios, such as those that require multiple participants, are resource intensive and challenging to deliver. It is important to clearly identify the desired objective of the scenario and the role of each participant ahead of time to ensure that the educational experience is smooth.
- Debrief the educational session. Leave time at the end of the session to reinforce key messages.
As a result of these initial educational sessions, several nurse educators have made plans to introduce role-play in the virtual world as part of their professional development days for nursing staff. For the authors, the next steps include spending time increasing their expertise as well as that of the nurse educators and then to expose more nurses to this exciting learning modality. After that, the authors will begin to create more complicated scenarios that will include patients who have a variety of health concerns, such as pain and cardiac arrhythmias.
Other steps include working with the build team to optimize the environment by closing off rooms that are not being used. Second Life® allows a maximum number of objects on each island. Eliminating areas that are not used will allow the addition of more equipment and furniture to increase the realism of the virtual unit. Another goal is to secure physical space to provide a permanent location for Second Life® educational sessions.
Although it has taken more than 1 year to establish and use the virtual learning environment, the senior leadership team in nursing at UHN supports and encourages innovation. This support provided the motivation to overcome obstacles and explore the learning opportunities presented by virtual worlds. This experience provided knowledge that will assist with other technology-related educational projects. Feedback from both the nursing staff and nurse educators has been positive.