Simulation for teaching is documented within the writings and ruminations of the early philosophers (Topor, 2002). Although contemporary education has moved beyond the puppets of Aristotle, the use of simulation to inspire learning still remains. Simulated learning environments (SLEs) offer forms and levels of realism and can include, among other strategies, role-play, task trainers, manikins, and virtual environments. As a methodology, simulation is consistently used in aviation and the armed forces—two areas that are often credited as the founders of modern simulation (Rosen, 2008).
Aligned with the pedagogical paradigm of learner centeredness, higher education in particular, is now utilizing simulation for the teaching of health workers (Health Workforce Australia, 2010b). In addition to this, nurse educators generally accept that SLEs contribute to the provision of learning opportunities that ultimately enhance clinical experience (Bland, Topping, & Wood, 2011), despite a lack of robust research to support these views (Health Workforce Australia, 2010a).
Workforce training research supports the notion that a current and continuing shortfall in the health workforce can cause a lack of valuable clinical placement opportunities for undergraduate nursing students (Andre & Barnes, 2010; Health Workforce Australia, 2014). In lieu of this changing public health profile, a concomitant need for curriculum reform exists (Nancarrow, Moran, & Graham, 2014).
In addition, the expectations of a graduate nurse have changed, as health workforce needs dictate that graduate training, along with the capacity for collaborative patient care, must include skills in management, leadership, and critical thinking (Benner, Sutphen, Leonard, & Day, 2010). Educators report that SLEs can potentiate student learning, and, with technological innovations, some are now considering the possibility of alternate forms of simulation, such as those using a virtual environment.
In the higher education sector, despite being in an exploratory phase of application, the use of virtual simulated learning environments (VSLEs) offers a diversity of application in educational practice (Gregory et al., 2013). Enabled through a virtual world, this learning environment occurs when a computer generates a three-dimensional realm where users are represented by an avatar, which is a self-nominated digital representation of themselves (Boulos, Hetherington, & Wheeler, 2007). Capabilities of the avatar include purposeful movement, gesturing, speech, and text chatting. Those features, coupled with the synchronous nature of a virtual world, can potentiate a rich social environment (Dalgarno, Lee, Carlson, Gregory, & Tynan, 2011). The potential of this market has been seized with enthusiasm by Linden Labs, the creators of a virtual world known as Second Life®.
A diversification in the undergraduate student profile (Ahmad, Wan, & Jiang, 2011; Yoder & Terhorst, 2012) continues to promote a need for flexible delivery of content—a demand that can be met by the ever-increasing affordances of technology. The adoption of virtual worlds as a platform to deliver simulated learning experiences has come at a time when changes and needs in education are parallel and responsive to technological social advances. Through broadband network rollouts, increased bandwidth, and improvements in technological infrastructure, the use of virtual worlds has moved from a clunky slow technology to now offering an interactive synchronous learning opportunity (Chau et al., 2013). There is a breadth of contemporary educational opportunity, such that students can experience scenarios and have experiences that otherwise are not possible in a standard classroom (Stewart et al., 2010).
When Clark (1983) posited that technologies were “mere vehicles” (p. 445) to deliver content, it may have been because the potential of technology was not entirely realized. In fairness, contextually, that comment perhaps reflects the didactic nature of pedagogy at the time. Technology has also been likened to “a lever and an enabler of teaching approaches,” taking care to stress that as a mode, it is not the driver (Southern Cross University, 2011, p. 12). Furthermore, a synchronous capability is suggested as being able to enhance contemporary higher education in a space where, regardless of time and geographical constraint, learners are able to divide time between life and learning commitments.
When recounting Heidegger’s notions about technology, McCullough (2002) stated that “technology is the epistemology of the age” (p. 22). According to Kiili (2005), technology has the ability to encourage active learning opportunities, rather than being a substitute teacher, delivering content en masse to a passive audience. Warlick (2006, para. 5) also added that technology “is the pen and paper of our time, and it is the lens through which we experience much of our world.” Furthering these notions is the view that technology is not just an object void of presence or the power to sway thinking. It can also influence pedagogy, extending well beyond the chalk-and-talk teaching styles of a bygone era (Martin et al., 2011; Yoder & Terhorst, 2012). Moreover, it potentiates a learner’s capabilities (Satterfeild, 2015).
Nurse educators have the onerous task of ensuring that their teaching not only includes contemporary educational and disciplinary theory but also that it is linked to disciplinary practices that acknowledge and are responsive to the changing demands of health education. A persistent and foundational argument in ongoing nursing education discourse focuses on the quality and readiness of the graduate nurse to take on the role of the RN (Grealish & Smale, 2011; Scully, 2011)—a focus that drives the educational quality of the developmental experience of nursing students.
A concurrent argument focuses on a rigid outdated curricula that is now considered inept in its ability to tackle the health needs of the 21st century (Andre & Barnes, 2010; Julio et al., 2010). This, together with reports such as Vital Signs 2013: The State of Safety and Quality in Australian Health Care (Australian Commission on Safety and Quality in Health Care, 2013), highlights the imminent need to change to a contemporary curriculum that responds to the health workforce demand and is delivered in a way that best meets the needs of consumers.
This systematic review seeks to present and interpret the current applications of the virtual world of Second Life in the education of undergraduate nursing students.
Search Engines and Limits
As valuable contributors to evidence-based knowledge (Whitmore & Knafl, 2005), both experimental and nonexperimental research on the use of Second Life was considered. An extensive literature review was conducted. Searches included electronic databases, manual searches of reference lists, and Google™ Scholar. Databases searched included CINAHL®, Medline®, Education Research Complete™, ERIC™, Computers and Applied Sciences Complete™, and Library, Information Sciences and Technology™. Prior to 2008, particularly in health education practice, limited evidence exists regarding the use of Second Life. Therefore, peer-reviewed manuscripts published between 2008 and 2014 was a limiter on all conducted searches.
The primary focus was to review the use of Second Life in undergraduate nursing education. Inclusion criteria consisted of articles presenting primary research that used Second Life with undergraduate nursing students in the higher education sector. Research focusing on the perspectives of both educators and learners was included.
The current review, although tangential, builds and extends on the work of De Gagne, Oh, Kang, Vorderstrasse, and Johnson (2013), who presented a synthesis of literature that reported on virtual multidisciplinary health education perspectives between 2000 and 2012. Despite taking a similar approach, the current aim was to review research using Second Life solely in undergraduate nursing education. Therefore, excluded from the current review were research articles that focused on postgraduate nursing education, research that reported on the use of Second Life in multidisciplinary education, and publications that presented the findings of research already included.
Search Terms and Articles Retrieved
The search terms were nurse* and (know* OR learn* OR educat*) and (virtual and world OR reality). Six database searches with limiters elicited 285 articles after the removal of duplicates.
As the first phase of quality assessment, the abstract of each article was reviewed. Research that focused on interprofessional or postgraduate education was excluded in this phase. Full texts were then retrieved for a final quality assessment. Articles were excluded that did not report on primary research. Those that presented the same research results from a previous study (i.e., same authors) were also excluded. Small research studies, including pilot research, remain in this review due to their phenomenological significance. Fourteen articles remained after quality assessment.
All studies were based within the higher education sector, with a global representation of the United States, the United Kingdom, Finland, Australia, and Asia. Of the 14 research articles reviewed, students as the sole research participants were the focus of 12 articles, with educators as sole participants in two. Three publications utilized qualitative methods, such as interviews, and six relied on quantitative methods, such as a survey and performance assessment tools. Five publications applied mixed methodological approaches.
To develop an understanding of the perception of using Second Life as an educational tool, 10 studies used participant response via open questioning. To determine the learning value of the use of Second Life, four relied on objective performance measures. Thematic analysis of the articles revealed the following emerging concepts: transferability, learner-centered approach using Second Life, and the evaluation of Second Life as a new emerging educational methodology.
Findings and Discussion
Narrowing the gap between theory and practice in nursing education is an ongoing challenge for nurse educators. Therefore, it is not surprising that it was a dominant theme in this review. The global priorities of patient safety, decision making, and assessment skills were evident. In particular, seven of the studies examined the ability of the student to link theory that was previously delivered in face-to-face or didactic modalities to practice in the virtual world of Second Life.
McCallum, Ness, and Price (2011) demonstrated competent decision-making skills in a group of Bachelor of Nursing students who completed an assessment in Second Life. Those students (n = 5) were presented with a ward simulation, in which they were instructed to prioritize their decisions based on a nursing assessment of patient need. The authors concluded that the students were able to link previous theory to clinical practice, despite the absence of many of the usual visual cues.
Kidd, Knisley, and Morgan (2012) conducted one of the first studies of assessment using Second Life in mental health nursing. Students (n = 126) were given basic avatar training and then completed an assessment that required them to review a mental health client in the virtual community setting in Second Life. The basic training required of the students was estimated to take between 6 and 8 hours. Other course work was removed due to this increased workload. Student participation in the virtual simulation was compulsory; however, responding to an evaluation survey was optional. Conclusions drawn from that study suggest that Second Life provides the opportunity for students to interact with mental health scenarios in a physically safe environment. Students reported that as an educational tool, Second Life was moderately effective (Kidd et al., 2012).
In another study, to learn about patient safety, students (n = 15) were presented with three scenarios (Aebersold, Tschannen, Stephens, Anderson, & Lei, 2012). Evaluation by educators of this Second Life experience was positive, where they reported an alignment with the learning objectives and a link to real clinical situations. Extending on these findings, Aebersold, Tschannen, and Bathish (2012) demonstrated that virtual simulation does improve student performance in both leadership and communication. It is worth noting that in both of these studies, students participated in either role-playing or observer positions.
Evans and Curtis (2011) used observer and active roles. After initial on-campus tuition, students participated in simulations focusing on lateral violence, where the learning objective was to enact conflict resolution. Seventy-five percent of respondents stated that they felt more comfortable learning this content in Second Life in preference to real life, and that they were able to easily transfer previously learned information into the virtual practice.
Extending this concept of scenario-based observations in Second Life, Tao, Lim, and Watkins (2010), using avatars, presented a birthing scenario to students (n = 35). Educators acted as both nurse and patient. A data projector was used to synchronously show the scenario to students who, while in the classroom setting, were able to generate discussion during the scenario. Student self-report following this activity suggests that learning the content using this modality led to an improved understanding and higher engagement with the content and facilitated a link between theory and practice.
Research by Tschannen, Aebersold, McLaughlin, Bowen, and Fairchild (2012) utilized an experimental approach to determine the effectiveness of Second Life for learning. A group of students participated in three activities in Second Life, during which they rehearsed theoretical concepts about patient safety and communication. A second group (control) rehearsed the theoretical concepts during three laboratory-based simulations. All students were then individually assessed using a Capacity to Rescue Instrument in a clinical simulation facility. The Second Life group scored higher overall (F[1,113] = 5.84, p < .02). This demonstrated that the virtual simulation rehearsal resulted in a greater ability to transfer knowledge from didactic theory to real clinical situations. Tschannen et al. (2012) suggested that this was due to the increased realism that can be enacted in a virtual learning environment. Also considered was that the anonymity afforded in Second Life may have enhanced the learning experience.
Three studies focused on the concept of transferability, directly observed as student capability to display learned behavior in Second Life, similar to practical capabilities in real life. The measurement of the effectiveness of decision making and collaborative practice was the focus of research by Rogers (2011), where clinical decisions were required to progress the virtual simulation. For example, nursing students were intentionally geographically separated, were required to work as a team, and also were required to agree on the clinical interventions in order for the simulation to progress. The work by Rogers concluded that the setting of Second Life can provide an environment that is conducive to the construction of knowledge. Other significant findings were the reported heightened engagement of students who were presented with the real-life scenarios in Second Life and the way they reacted positively to the teamwork.
The transferability of newly constructed virtual knowledge was examined in two studies. Sweigart and Hodson-Carlton (2013) and Sweigart, Burden, Hodson-Carlton, and Fillwalk (2014) focused on the educational effectiveness of Second Life as a learning platform by observing undergraduate nursing students’ ability in the performance of a client interview. Results from both research projects indicated that those participants who had not rehearsed interviewing skills in Second Life did not interview as effectively in a real-life assessment interview. This was measured by the number of questions and follow-up questions asked by the participant during the interview, which demonstrates the effective transference of virtual knowledge to real-life practice.
Perhaps the most notable testament to the transferability of learning in Second Life is the research by Schmidt and Stewart (2010), in which the use of virtual clinical hours replaced real-life clinical practice time. Although the number of actual hours are not specified in that study, a limited and comparable number of clinical hours were offered in addition to the submission of a brief written assignment. Schmidt and Stewart “feel the virtual world offers a creative, consistent, and verifiable way for selected clinical experiences” (p. 75). Despite the appreciation that simulation in general offers an authentic learning experience, there continues to be debate and reservation about the trading of simulation hours with clinical time (Hanberg & Baraki, 2009; Health Workforce Australia, 2010a).
Learner-Centered Approach Using Second Life
Student-centered learning is a contemporary pedagogical approach that places the student at the center of a cycle where learning is meaningful and interactive and challenges the learner to identify his or her own learning needs (Billings & Halstead, 2012). According to Southern Cross University (2011):
A learning centred [sic] approach directs teaching and curricula towards the complete learning process acknowledging the attributes and active roles of learners alongside those of teachers, the discipline, and the community. Such an approach means that students and teachers are partners in learning and that disciplinary ways of knowing and doing are valued. (p. 4)
The current review revealed that a heightened student engagement can be provided by interactions in the Second Life environment (Chow, Herold, Choo, & Chan, 2012; Rogers, 2011; Tschannen et al., 2012). Further, adjunctive notions of a learner-centered approach include learner fun (Evans & Curtis, 2011) and collaborative learning opportunities (Kidd et al., 2012; Rogers, 2011). In research where students were not actually driving an avatar (i.e., watching others in a Second Life simulation), the results were equally positive (Tao et al., 2010). This echoes findings from research about teaching and learning using high-fidelity simulation in which students reported high levels of engagement and learning outcomes when watching peers participate in a simulation (Jeffries, 2007).
Sweigart et al. (2014) described a multiyear evolution of the use of Second Life across the curriculum. Students were able to engage with virtual case studies that depicted various ages, gender, and multicultural community members. Sophomore students interviewed the same avatar client for a range of assessments across the curriculum, including a general health assessment that led to the development of a nutritional plan and a urogenital-sexual assessment. Conducting these interviews on the same avatar client was seen to further enhance the realism of the experience by simulating ideal nursing practice methods, as is recommended in a learner-centered approach (Southern Cross University, 2011).
Skiba (2009) and Teräs, Myllylä, Kaihua, and Svärd (2011) explored the unique perspectives of student-centered learning from the educator’s perspective. During interviews, 10 Finnish teachers who use Second Life demonstrated that creating collaborative practice among students and teachers is a feature of using Second Life. The virtual platform is seen to reduce the hierarchal relationship between student and teacher (Teräs et al., 2011). Supporting the findings in e-learning–related literature, Teräs et al. described educators who use Second Life as being facilitators of knowledge, whereas student learning is largely self-driven. In that environment, the presentation of authentic content allows the student to create knowledge.
Learner centeredness was a key theme in the study conducted by Chow et al. (2012), where enthused students initiated and guided their own learning based on their identified needs during the simulation of a rapid-sequence intubation. The content of that teaching module was outside of the course syllabus, and completion of the simulation was a testament to the students’ motivation. The study by Chow et al. adds to the paucity of information about content delivery using Second Life. Perhaps this acknowledges authentic teaching practices, as discussed by Teräs et al. (2011), where the more traditional content-driven didactic methods are aligned to learning by knowing, rather than by doing. It would seem that Second Life may be considered as learning with technology more so than learning from technology.
Evaluation of Second Life as a New and Emerging Education Technology
To investigate learning in the virtual environment of Second Life, researchers either used a validated instrument or developed an evaluation methodology. The lack of an instrument that fit the unique needs of the research was cited as to why the authors developed their own research tool. Those studies mainly relied on the perceptions of learning as gauged by the student and, in fewer cases (three), by the educator. Six studies used a researcher-developed survey to gather data in combination with the use of open-ended questions. Other techniques used as an adjunct to surveys were thematic analysis of student written reflections and a review of text chat communications. Small sample size was identified as a limitation in many of the studies (Aebersold, Tschannen, & Bathish, 2012; Kidd et al., 2012); however, this would be expected given the novel subject matter.
Contrastingly, Chow et al. (2012) reported findings via the technology acceptance model, and, as the name suggests, this tool seeks to understand the reasons why a technology—in this instance Second Life—is either accepted or rejected. That study showed that the perceived ease of use is the most “influential construct to directly affect perceived usefulness and behavioural intention” (p. 1140). This result highlights the importance of student and staff preparedness when introducing Second Life as a teaching and learning modality. Aebersold et al. (2012) used the Emergency Medicine Crisis Resource Management tool to show that student performance improved significantly in the areas of team communication and professional behavior. The Capacity to Rescue Instrument was adapted for use in the study by Tschannen et al. (2012) to determine individual student performance in nursing competencies. The results of that study demonstrate clear evidence that the transference of learning from didactic methods to the clinical setting is enhanced via virtual rehearsal. Review of the research beyond data collection and analysis has implications for future research also.
Skiba (2009), in a narrative retrospective account from three pioneers of Second Life, discussed local issues that either helped or hindered the successful use of Second Life in education. All three pioneers recounted that initial support from enthusiastic virtual groups, such as Virtual Ability and Wisconsin Technology Enhanced Collaborative Nursing Education, as well as their local university’s teaching and learning departments, was invaluable to their adoption of Second Life. Students who resisted the use of Second Life were comparably anxious and hesitant to adopt other learning platforms, such as blogs and wikis. The three pioneers interviewed agreed that both staff and students had a large learning curve to master the basic skills required to operate in Second Life and that technical support was of benefit.
Evans and Curtis (2011) reported the impact of initial poor faculty readiness, where, as a result, the simulation project did not commence without incident, causing frustration for students. Faculty attitudes, such as a lack of self-confidence and the ability to use the technology, were also shown to potentially influencing student attitude toward interacting within Second Life (Kidd et al., 2012). Less engaged staff, such as those who are part time and under contract, were not as comfortable with the use of the technology, and their fearful attitude was considered as an influence on the negative student response.
Maximum fidelity, such as realism, or the full potential of Second Life, was not utilized in some of the reviewed studies. Communicating in Second Life can be achieved through multiple modes, including live speech (voice chat). In other words, when the individual operating an avatar speaks through this mode, it is audible in the virtual world immediately. Many of the studies chose to use text chat (where users type communication) exclusively so that a printed record of the dialogue could be used as an adjunct learning tool—for example, during debriefing sessions (Evans & Curtis, 2011; Kidd et al., 2012). However, McCallum et al. (2011) noted the use of this slower form of communication as a reason for missed student actions during their simulation study. Although positively reviewed by the students in the study by Rogers (2011), the enforced collaboration required in this simulation, although not reflective of practice behavior, was applied as a learning strategy.
A review of the current research on the use of Second Life as a platform in teaching and learning within undergraduate nursing curriculum is presented. Education is demonstrated in a learner-centered environment, where Second Life is shown to promote dimensional collaboration and a heightened student engagement. This review also provides evidence that research focusing on the use of Second Life in undergraduate nursing is in an early stage. Although further development and understanding is required, positive outcomes have demonstrated the need for ongoing evaluation. It is important to ascertain whether the learning in Second Life is unique or can be further validated with larger cohorts of students.
The future for this type of interactive technology within nursing curriculum is positive. Second Life as a teaching and learning platform may indeed provide the opportunities for learning that are lacking in the current clinical setting and serve as a valuable adjunct in the education of the future health workforce.
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