Journal of Nursing Education

Major Article 

Virtual Worlds in Nursing Education: A Synthesis of the Literature

Jennie C. De Gagne, PhD, RN-BC, CNE; Jina Oh, PhD, RN; Jeongae Kang, MS; Allison A. Vorderstrasse, DNSc, APRN, CNE; Constance M. Johnson, PhD, RN

Abstract

Although the literature has highlighted the use of virtual worlds in teaching–learning, little is known about the concepts associated with this technology in nursing education. Moreover, the application of virtual worlds to education has been underdeveloped theoretically, with much of the work being exploratory. Thus, the aim of this integrative review was to identify the current evidence on the use of virtual worlds in the education of nursing and other health professional students and to describe emerging themes surrounding this phenomenon. We searched seven electronic databases for relevant articles and used Whittemore’s and Knafl’s integrative review method to synthesize the literature. Twelve articles met the selection criteria for this review, from which three overarching themes emerged: (a) critical reasoning skills, (b) student-centered learning, and (c) instructional design considerations. This integrative review extends our understanding of virtual worlds in nursing education and the potential barriers and facilitators of their use. [J Nurs Educ. 2013;52(7):391–396.]

Dr. De Gagne is Assistant Professor, School of Nursing, Georgia State University, Atlanta, Georgia; Dr. Oh is Associate Professor, Department of Nursing, Institute of Health Science, Inje University, Busan, South Korea; Ms. Kang is doctoral student, School of Education, University of North Carolina, Greensboro; Dr. Vorderstrasse is Assistant Professor, and Dr. Johnson is Associate Professor, School of Nursing, Duke University, Durham, North Carolina.

This work was supported by the Korea Meteorological Administration Research and Development Program under the Center for Atmospheric and Earthquake Research (CATER 2009-3310) Foundation and the Inje University Research and Scholarship Foundation in 2011–2012. The authors thank Marilyn M. Lombardi, PhD, Director of Academic and Strategic Technology, Duke University School of Nursing, for her initial critique of the manuscript, and Ms. Elizabeth Tornquist, Expert Technical Editor, for her assistance in proofreading and editing the manuscript. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jina Oh, PhD, RN, Associate Professor, Department of Nursing, Institute of Health Science, Inje University, Bokjiro 75, Busanjin gu, Busan, 614-735, Korea; e-mail: ohjina@inje.ac.kr.

Received: December 13, 2012
Accepted: February 27, 2013
Posted Online: June 10, 2013

Abstract

Although the literature has highlighted the use of virtual worlds in teaching–learning, little is known about the concepts associated with this technology in nursing education. Moreover, the application of virtual worlds to education has been underdeveloped theoretically, with much of the work being exploratory. Thus, the aim of this integrative review was to identify the current evidence on the use of virtual worlds in the education of nursing and other health professional students and to describe emerging themes surrounding this phenomenon. We searched seven electronic databases for relevant articles and used Whittemore’s and Knafl’s integrative review method to synthesize the literature. Twelve articles met the selection criteria for this review, from which three overarching themes emerged: (a) critical reasoning skills, (b) student-centered learning, and (c) instructional design considerations. This integrative review extends our understanding of virtual worlds in nursing education and the potential barriers and facilitators of their use. [J Nurs Educ. 2013;52(7):391–396.]

Dr. De Gagne is Assistant Professor, School of Nursing, Georgia State University, Atlanta, Georgia; Dr. Oh is Associate Professor, Department of Nursing, Institute of Health Science, Inje University, Busan, South Korea; Ms. Kang is doctoral student, School of Education, University of North Carolina, Greensboro; Dr. Vorderstrasse is Assistant Professor, and Dr. Johnson is Associate Professor, School of Nursing, Duke University, Durham, North Carolina.

This work was supported by the Korea Meteorological Administration Research and Development Program under the Center for Atmospheric and Earthquake Research (CATER 2009-3310) Foundation and the Inje University Research and Scholarship Foundation in 2011–2012. The authors thank Marilyn M. Lombardi, PhD, Director of Academic and Strategic Technology, Duke University School of Nursing, for her initial critique of the manuscript, and Ms. Elizabeth Tornquist, Expert Technical Editor, for her assistance in proofreading and editing the manuscript. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jina Oh, PhD, RN, Associate Professor, Department of Nursing, Institute of Health Science, Inje University, Bokjiro 75, Busanjin gu, Busan, 614-735, Korea; e-mail: ohjina@inje.ac.kr.

Received: December 13, 2012
Accepted: February 27, 2013
Posted Online: June 10, 2013

In recent years, virtual worlds have been making their mark in patient education (Demiris, 2006 ), in the delivery of health care services (Tourigny, Clendinneng, Chartrand, & Gaboury, 2011 ), and in consultation with experts (Baker, Parks-Savage, & Rehfuss, 2009 ). Virtual worlds have also been adopted by faculty for educating medical and other health care students (Cowdery, Kindred, Michalakis, & Adams, 2009 ). The great advantage of virtual worlds is that they can bring together geographically dispersed participants in a single, unified context for convenient, synchronous collaboration. The format also allows students to be more active participants while learning (Kirriemuir, 2008 ). A virtual world can reshape the learning, communications, and social interactions for distance education students as well (Sibbett, 2007 ). Yet, although the literature has reported the use of virtual world platforms in teaching–learning processes and outcomes (Ahmad, Wana, & Jiang, 2010 ; Broom, Lynch, & Preece, 2009 ; Dev, Youngblood, Heinrichs, & Kusumoto, 2007 ; Schmidt & Stewart, 2009 ; Tao, Lim, & Watkins, 2010 ; Wiecha, Heyden, Sternthal, & Merialdi, 2010 ), little is known about the use of this technology in nursing education. Indeed, the application of virtual worlds to the field of education has been undertheorized, with much of the work being exploratory, descriptive, and technologically focused (Savin-Baden et al., 2010 ).

What Is A Virtual World?

Defined as “a synchronous, persistent network of people, represented by avatars, facilitated by computers” (Bell, 2008 , p. 2), a virtual world is a computer-based multimedia environment in which people interact with other users or objects via their personal graphic representation known as an avatar (Boulos, Hetherington, & Wheeler, 2007 ). The term virtual world sometimes is used interchangeably with virtual reality (Ahmad et al., 2010 ; Baker, Parks-Savage, & Rehfuss, 2009 ), which can be misleading. Typically, virtual reality is experienced by an individual wearing a head-mounted simulation unit or in a high-cost simulation theater or a “cave” in which high-resolution projectors are directed to three, four, five, or six of the walls that form the cave’s room-sized cube. In contrast, the virtual world experience, particularly in the age of lightweight and networked laptop computers and gaming systems, is portable. The virtual world community may be seen as a subset of the larger virtual community phenomenon that is supported via two-dimensional, browser-based environments, such as Facebook®. Ultimately, the term virtual world combines the collaborative properties of the virtual community with the “synchronous, graphically intense environment of the online game” (Kozinets, 2010 , p. 193) to form a type of play space that can be particularly hospitable for teaching and learning activities. Examples of virtual world platforms are Second Life ( http://www.secondlife.com), There ( http://www.there.com), ActiveWorlds ( http://www.activeworlds.com), and Twinity ( http://www.twinity.com), all of which are currently used for teaching–learning, exhibitions, entertainment, or public meetings.

This integrative review was designed to (a) identify the current evidence on the use of virtual worlds in the education of nursing and other health professions students and (b) provide new perspectives on the topic and identify gaps or need for future studies.

Method

An integrative review can include both experimental and nonexperimental research and presents varied perspectives on a phenomenon of concern, thereby contributing to theory development and evidence-based practice (Whittemore & Knafl, 2005 ). With this in mind, we used Whittemore’s and Knafl’s (2005 ) integrative review method to provide theoretical grounding for anticipated future trends, and we discuss the implications for the use of virtual worlds in nursing education.

An extensive literature review was conducted to locate published material related to the use of virtual worlds in the education of students in nursing, medicine, and allied health. Initially, we searched the CINAHL®, ERIC, Education Research Complete, OVID®, ProQuest®, PubMed®, and Scopus® databases using the search terms = (nurs* OR health* OR medic*) AND (virtual OR 3D OR 3-D OR Second Life) AND (world* OR environment* OR set* OR communit*) AND (educa* OR instruct*), and we matched the search terms to the titles, abstracts, keywords, and subject headings (truncated search terms with wildcard symbols were used to extend the search). Hand searches of journals and ancestry searches were also conducted.

Studies in nursing and health care education domains were included in the review. Only peer-reviewed articles written in the English language and published between January 2000 and March 2012 were considered for inclusion. Articles were excluded if they were review articles, proceedings, or dissertations; if they focused primarily on patient–client education, rather than student learning or education of health professionals; if they focused primarily on the effectiveness of virtual reality in a laboratory; or if they focused primarily on evaluation of the technology itself.

A secondary review was conducted on the initially returned 585 articles led to the elimination of 335 duplicates, yielding 250 potentially relevant citations. We reviewed all titles and abstracts for possible inclusion; 102 articles that did not meet the inclusion criteria were eliminated. After reviewing the full text of the 148 remaining studies, we excluded 136 because of the aforementioned exclusion criteria. The appraisal was conducted collaboratively by the primary author and co-authors. Finally, we organized the 12 remaining articles in a Microsoft® Excel spreadsheet on a shared network drive to synthesize analytical factors found in these empirical studies (Figure ).

Flowchart of the article selection process for this integrative review of the virtual worlds literature in the education of nursing, medicine, and allied health students.

Figure. Flowchart of the article selection process for this integrative review of the virtual worlds literature in the education of nursing, medicine, and allied health students.

Thematic analysis was used to synthesize the main findings from the studies. This involved (a) becoming familiar with these data, (b) generating initial codes, (c) searching for themes, (d) reviewing themes, (e) defining and naming themes, and (f) producing the report (Braun & Clarke, 2006 ). While synthesizing the important elements of each theme in an integrative summary of the phenomenon, we created a table to summarize the data (Table A ; available in the online version of this article).

Findings and Discussion

The 12 reviewed studies on the use of virtual worlds in the education of nursing and other health professionals students included 504 participants in various health-related disciplines, such as nursing, medicine, forensic science, and sports science (Table A ). Articles that met the inclusion criteria were published between 2007 and 2012, which notably reflects the inception of virtual worlds technology. Of the 12 studies, nine were conducted in the United States, whereas the remaining three were conducted in Australia, Malaysia, and the United Kingdom. The most frequently used research method was case study (n = 5), followed by mixed-methods (n = 4), survey (n = 2), and focus group (n = 1). Various topics (e.g., trauma training, patient transfers and safety training, community nursing, pediatric nursing, and insulin therapy for type 2 diabetes) were studied. Among the different types of virtual world platforms, Second Life was the most frequently used (Table A ). From critical reading and the analysis of the studies, three themes emerged: (a) clinical reasoning skills, (b) student-centered learning, and (c) instructional design considerations.

Clinical Reasoning Skills

Multiple clients have similar health issues, yet their responses to care are different, requiring nurses to use critical thinking and clinical reasoning. Critical thinking in nursing is the use of cognitive processes to analyze knowledge or evidence (Benner, 1984 ). This is related to, yet different from, clinical reasoning, which is defined as the cognitive and metacognitive processes that are used to analyze the evidence relative to a particular situation or patient (Banning, 2008 ) and then is applied to nursing care, demonstrating clinical nursing judgment (Victor-Chmil, 2013 ). Clinical reasoning requires that a nurse can identify vital questions and problems, can gather relevant information, and can communicate effectively with others to solve complex problems. Thus, nursing faculty must continuously reassess the way in which they teach clinical reasoning strategies to determine best practice (Banning, 2008 ; Rowles & Russo, 2009 ).

Several of the studies revealed that courseware or training materials developed in a virtual world platform enhanced students’ clinical reasoning. For example, the study by Ahmad et al. (2010 ) showed that 71% of students performed proficiently on quizzes after viewing tutorials conducted in a virtual world. Using a game-like virtual world also assisted nursing students in developing knowledge and in augmenting clinical skills, as reported by students who participated in a focus group on the use of a virtual hospital ward for teaching (Broom et al., 2009 ). However, a case study by Dev et al. (2007 ) did not reveal differences between the use of a virtual world and a human patient simulator in teaching mass-casualty response; the students showed significant improvements in performance with both methods. Tao et al. (2010 ), who explored how a virtual world could be incorporated into classroom teaching in a survey study, reported that 91% of the students surveyed improved their understanding of theory content and their ability to apply that theory in clinical settings. The pilot study by Wiecha et al. (2010 ) explored the potential of using a virtual world to teach primary care physicians the proper procedures for prescribing insulin for patients with type 2 diabetes; participants showed a significant increase in confidence in the management of insulin therapy. Also, a mixed-methods study on the effectiveness of mass casualty incident training for nurses and physicians created in a virtual world found that most (86%) participants improved in competence and confidence (Heinrichs, Youngblood, Harter, Kusumoto, & Dev, 2010 ). In a study by Sweigart, Hodson-Carlton, Campbell, and Lutz (2010 ), students in a virtual world were able to self-critique their patient interview skills and reflect on how they asked questions through the captured interview scripts. Multidisciplinary mass-casualty education in a virtual emergency department enhanced the development of collaborative or team learning, along with effective communication skills (Heinrichs et al., 2010 ).

Improvement of clinical reasoning through experiential learning in a virtual world and improvement in the application of theories to real-life situations were suggested in several studies (Dev et al., 2007 ; Heinrichs et al., 2010 ; Jensen et al., 2012 ; Jensen, Korsager, Ong, Magrabi, & Coiera, 2010 ; Schmidt & Stewart, 2010 ; Stewart, Pope, & Duncan, 2009 ; Tao et al., 2010 ). However, the findings on the effects of virtual world use on clinical reasoning were from small studies with nonrandomized samples. In addition, one study found no difference in effectiveness when compared with simulation (Dev et al., 2007 ), suggesting that the integration of a virtual world into the curriculum does not alone improve students’ learning outcomes. Nevertheless, the findings as a whole suggest that using a virtual world in nursing education is feasible and acceptable in teaching clinical reasoning, and it enhances the level of knowledge, skills, and competence. It is noteworthy that several studies (Heinrichs et al., 2010 ; Schmidt & Stewart, 2010 ; Sweigart et al., 2010 ; Tao et al., 2010 ; Wiecha et al., 2010 ) also reported that the virtual world platform was the learning method preferred by students for grasping new concepts and practicing difficult skills without risk.

Student-Centered Learning

Another theme that emerged in the literature was student-centered learning in a virtual world simulation. In a student-centered learning environment, students have safe, meaningful, and interactive exercises that enable them to identify their unique learning needs (Billings & Halstead, 2009 ). Several concepts associated with student-centered learning, such as fun, interaction, immediacy, autonomy, relevancy, and social presence, were identified in the literature.

The activities created in a virtual world were considered purposeful and meaningful by many students. For example, participants in a study that taught students about improving inpatient transfers and hand washing via a virtual hospital believed the intervention was realistic and fit the purpose (Jensen et al., 2012 ). Generally, virtual world experiences were perceived as helpful, enjoyable, and useful (Broom et al., 2009 ; Schmidt & Stewart, 2010 ; Stewart et al., 2009 ; Tao et al., 2010 ; Wiecha et al., 2010 ). Most of the participants in one study (Heinrichs et al., 2010 ) reported that they felt immersed in the virtual classroom throughout the learning session. Immediate feedback via an on-screen message in response to an action required in a scenario seemed to enhance students’ interest and motivation (Jensen et al., 2012 ; Stewart et al., 2009 ; Weiner, McNew, Trangenstein, & Gordon, 2010 ; Wiecha et al., 2010 ). However, some participants reported that the learning was distracting at times (Wiecha et al., 2010 ) and that mandatory online live chats were not helpful to their learning (Schmidt & Stewart, 2010 ).

Although many studies identified technical difficulties as barriers to using a virtual world for teaching and learning, some studies found that the learning curve for the environment was not steep (Heinrichs et al., 2010 ; Jensen et al., 2010 ). Use of a virtual world as a safe learning environment was especially appreciated when students had to achieve critical clinical skills that required repeated practice (Ahmad et al., 2010 ; Broom et al., 2009 ; Dev et al., 2007 ; Stewart et al., 2009 ).

Swan and Shih (2005 ) found that increased social presence was directly correlated with higher levels of student attention, motivation, and satisfaction, which are critical components of active learning. Although social presence has been defined in various ways, the most often cited definition comes from the seminal work of Short, Williams, and Christie (1976 ), who defined social presence as the “degree of salience of the other person in the interaction and the consequent salience of the interpersonal relationship” (p. 65). Garrison, Anderson, and Archer (2001 ) defined social relevance as the students’ ability to present their personal characteristics as real people in an online community. Studies by Jensen et al. (2012 ) and Stewart et al. (2009 ) found that participants experienced a sense of social presence that was important to the creation of a successful virtual community. For instance, all participants in one study reported that a virtual world had advantages over other online methods because of the connection to the helpful and supportive learning community (Jensen et al., 2012 ). The participants also expressed a sense of connectivity from being able to meet with faculty and student-service staff in a virtual world (Stewart et al. 2009 ). Aragon (2003 ) emphasized that increasing social presence in online learning is a way to enhance interactions between students and the instructor and to dispel feelings of isolation. Therefore, educators using a virtual world as a teaching platform are encouraged to facilitate a sense of belonging and to create a safe environment, as these contribute to the overall success of the educational experience.

Instructional Design Considerations

Instructional development strategies are particularly important in online learning given the possibility of more options compared with traditional classroom instruction. Educators must constantly think about the need for particular technologies in their teaching. Given that virtual worlds are still new to many nursing faculty, it is important to ensure that teaching strategies take advantage of the technology without sacrificing educational quality.

Many concerns exist about using a virtual world platform in the curriculum. Technical issues include slow Internet connection (Ahmad et al., 2010 ), poor audio–video quality (Dev et al., 2007 ), difficult navigation (Jensen et al., 2012 ), computer crashes (Heinrichs et al., 2010 ), low fidelity (Wiecha et al., 2010 ), and design flaws in the scenarios (Schmidt & Stewart, 2010 ). In two studies, marginal Internet connection was perceived as one of the biggest limitations, perhaps reflecting prerequisite technological specifications for effective use of a virtual world platform (Ahmad et al., 2010 ; Schmidt & Stewart, 2010 ). Some students who participated in the study by Broom et al. (2009 ) felt that their time was wasted and that a real clinical experience would have served them better; however, this was a small sample.

Comfort level in using the technology has varied greatly between studies (Broom et al., 2009 ; Heinrichs et al., 2010 ). In some studies, feelings of stress and frustration were related to inadequate video and sound quality, and computer failures and crashes interfered with effective communication among students, instructors, or both (Heinrichs et al., 2010 ; Stewart et al., 2009 ; Wiecha et al., 2010 ). Some students made negative comments about low fidelity and the unrealistic movements related to incomplete or sketchy prototype scripts run in the program (Ahmad et al., 2010 ; Broom et al., 2009 ). In many studies, a moderate level of satisfaction with the technology was observed (Heinrichs et al., 2010 ; Jensen et al., 2012 ; Sweigart et al., 2010 ; Tao et al., 2010 ). Although the instruction must be interactive and interesting for students, educators must bear in mind that students may connect to an online course through a variety of bandwidths. Several studies have pointed out the importance of including orientation sessions and technical support or resources for both students and faculty before the learning process begins (Dev et al., 2007 ; Schmidt & Stewart, 2010 ) so that preparation for the virtual world platform experience does not need to be provided while the technology is in use.

Although a virtual world can provide students with opportunities to practice real-world learning experiences without restriction, the time and money that need to be invested in building compelling and effective scenarios in this platform must be taken into consideration (Sweigart et al., 2010 ; Tao et al., 2010 ; Wiecha et al., 2010 ). Disparities in technology access have been identified as a growing concern in the education of students in health-related disciplines, thus challenging the uniformity of the curriculum (De Gagne, Bisanar, Makowski, & Neumann, 2011 ). Such difficulties are compounded by the challenges and development needs in the use of virtual worlds. The issues surrounding cost, accessibility, increased development time, and technology disparities have been well documented in the literature.

Implications and Conclusion

This integrative review examined the existing work on using a virtual world in nursing education. We used Whittemore’s and Knafl’s (2005 ) approach in an ongoing dynamic process to identify certain concepts that should be considered in assessing the outcomes of using a virtual world in nursing education. This study suggests that using a virtual world platform for teaching nursing concepts or health-related topics may be effective in enhancing clinical reasoning by exploring issues and ideas through interactive and immersive learning experiences. However, the use of virtual worlds has been reported to include both positive and negative perceptions and outcomes.

Nurse educators are faced with many challenges, one of which is selection of the most effective ways to support learners in achieving their goals, including using the most appropriate technology in particular contexts. A number of studies indicate that virtual worlds have the potential to support teaching and learning across the curriculum (Ahern & Wink, 2010 ). For example, virtual sites in Second Life are owned or rented by more than 100 universities in the United States and other countries for holding classes or meetings with students, displaying artwork or audiovisual presentations, and sponsoring conferences (Baker, Wentz, & Woods, 2009 ). In 2013, a total of 11 sites were retrieved in Second Life through the search term nursing education. The group Virtual Nurse Educator (Second Life, 2012c ) engages in creating and sharing educational activities to enhance nursing education in Second Life, and the Medical Virtual Education Society (Second Life, 2012b ) is a virtual community in which medical and nurse educators network to search for innovative teaching methods and positive learning outcomes in Second Life. Members of nurses at Eastern University (Second Life, 2012a ) are investigating the use of Second Life and other virtual worlds for education and for developing a place for nurses and other allied health professionals to meet and expand professional contacts. Further, 1,300 relevant movie clips were retrieved using the search term Second Life and nursing in the video-sharing Web site, YouTube. Most of these videos were created by educators in universities and medical centers highlighting innovative programs, such as a simulation laboratory, clinical community, journal club, gerontology activity, or mental health activity. These Second Life sites highlight the use of virtual worlds as a way of expanding the face-to-face campus classes, online courses, or clinical experiences to enhance teaching–learning experiences.

One limitation of this integrative review is the possibility that we did not locate all sources. Another limitation relates to the subjectivity of our interpretation, despite use of a well-documented integrative process (Whittemore & Knafl, 2005 ). Applications of this study’s findings may be geographically limited, given that the studies reviewed were conducted primarily in the United States and Western countries. In addition, the review was limited to studies that focused on virtual worlds used in health-related disciplines within narrow topical parameters.

Despite the limitations, this study extends our understanding of virtual worlds and the potential barriers and facilitators to their use. The study may help anticipate future trends in the use of virtual worlds in the education of students in nursing and other health professions. The next step could be the development of an evaluation tool to facilitate the implementation and evaluation of effects on the instructional outcomes. Larger, more rigorous studies are needed to further examine the effectiveness of virtual worlds as a platform for nursing education.

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  • Wiecha, J., Heyden, R., Sternthal, E. & Merialdi, M. (2010). Learning in a virtual world: Experience with using Second Life for medical education. Journal of Medical Internet Research, 12(1), e1. doi:10.2196/jmir.1337 [CrossRef]
Table A.  Characteristics and Summary of Studies Reviewed on the Use of Virtual Worlds in Nursing Education.

Table A. Characteristics and Summary of Studies Reviewed on the Use of Virtual Worlds in Nursing Education.

Table A.  Characteristics and Summary of Studies Reviewed on the Use of Virtual Worlds in Nursing Education.

Table A.  Characteristics and Summary of Studies Reviewed on the Use of Virtual Worlds in Nursing Education.

Table A.  Characteristics and Summary of Studies Reviewed on the Use of Virtual Worlds in Nursing Education.

10.3928/01484834-20130610-03

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