Technological advances are providing nurse educators with innovative ways to deliver nursing education content. One of these advances, virtual reality software such as Second Life® can be used to depict real-life clinical situations (McCallum, Ness, & Price, 2011; Stanley & Rojas, 2014; Tiffany & Hoglund, 2014). This emerging technology allows for the collaboration of students and teachers outside of the traditional classroom environment and provides an alternative when public health nursing clinical placements are limited (Foronda & Bauman, 2014). According to Hayden, Smiley, Alexander, Kardong-Edgren, and Jeffries (2014), the evidence shows that 50% of simulation can be substituted for traditional clinical experiences in core prelicensure nursing courses. Second Life simulation may also be used as a platform for online learners (Kidd, Knisley, & Morgan, 2012). Simulated learning provides a safe environment for nursing students to learn without the risk of harm to patients (Baker & Brusco, 2011; Kidd et al., 2012).
This article describes the educational innovation of integrating Second Life virtual learning experiences into clinical learning for traditional baccalaureate senior students in a public health nursing course. The public health curriculum was reviewed and some changes were made to incorporate virtual simulated experiences so all students had an opportunity to participate in standardized learning activities such as a disaster. In addition, the virtual simulation experiences enabled the faculty to rotate one or more students off the clinical site to control the size of the clinical groups.
Second Life is a virtual software platform owned by Linden Labs (Ahern & Wink, 2010). Second Life participants develop avatars that are used to participate in virtual activities, that may not be experiences available in real-world situations. Educators can use this platform to develop opportunities for collaborative learning experiences. Participants must have access to graphics-capable computers and educators may be responsible for costly fees to purchase an island (i.e., a virtual learning environment) and for the annual renewal of Second Life (Menzel, Willson, & Doolen, 2014). A systematic review of the Second Life literature in undergraduate education demonstrated that although participation promotes student engagement and positive learning outcomes, further research is needed to validate learning effectiveness (Irwin & Coutts, 2015).
Although many examples of using Second Life in nursing education are described in the literature, fewer examples exist in public health nursing education. Innovative teaching examples using Second Life include a virtual hospital unit in which students address safety issues, interprofessional communication, and priority setting (Aebersold, Tschannen, Stephens, Anderson, & Lei, 2011); decision-making skills for patients receiving surgery (McCallum et al., 2011); postpartum hemorrhage management (Honey, Connor, Veltman, Bodily, & Diener, 2012); assessment and skills training (Baker & Brusco, 2011); and conducting mental health assessment in the home setting (Kidd et al., 2012).
Faculty at University of Wisconsin-Oshkosh integrated community-based Second Life scenarios into learning options in their online accelerated nursing program. Scenarios included nutritional assessment at a WIC clinic, protecting public safety through restaurant inspection, disaster preparedness, and visits to a homeless shelter and refugee camp (Schmidt & Stewart, 2010). In another community-based Second Life learning opportunity, educators developed a poverty simulation with a homeless family and an immigrant family who experienced the consequences of living in poverty in various locations on “Wald Island” (Menzel et al., 2014). Authors suggested that a greater learning curve exists for faculty in comparison with students, and although Second Life can be an effective learning platform for online programs, the associated expenses need to be considered.
The constructivism framework, used to guide thinking about how students learn, emphasizes the active role played by learners. Social interaction is the mechanism for obtaining knowledge. When students are exposed to new information in the scenario, they experience a cognitive imbalance. Students construct new knowledge in their interactions and responses to the Second Life scenarios. Their reflection on their learning leads to the integration of new knowledge, which students can then apply to real-life nursing practice. The educator sets up questions to encourage reflective thinking, facilitates student problem solving, and provides additional sources of information as needed to respond to the scenario (Parker & Myrik, 2009; Yilmaz, 2008).
Second Life Scenarios
Nursing faculty modified the Second Life scenarios originally developed for an RN degree completion program at the same school. Faculty who developed the original Second Life scenarios were involved in doctoral projects that focused on scenario development. All students had previous experience with Second Life in a junior-level nursing course and were provided with an orientation on how to use the virtual reality program. Students accessed the scenarios on Moodle™, the online learning system used by the university. Faculty designated two of the three scenarios for students to complete, which were selected to supplement learning experiences available at the clinical site. The three options were:
- Airplane Crash Disaster. A plane has crashed into a chemical plant, resulting in chemical release and fire. Students triage victims using the emergency services algorithm and develop a message explaining the accident to the general public.
- Family Health. Students assess five family scenarios in the public health clinic (Women's and Children's Clinic, WIC Clinic, Adolescent Health Clinic, Family Health Clinic, and Interprofessional Care Conference). The focus of assessment is on the family and the impact of social conditions on the family.
- Home Safety Assessment. Students perform a home safety assessment for an older woman, who has multiple chronic health conditions and has sustained a hip fracture. Prior to her return home from the hospital, a plan is developed. The home was determined to be unsafe by emergency medical services when they responded to the injury call. In addition, safety issues for children need to be addressed as the patient has young grandchildren that visit frequently.
Students were given one clinical day to complete each scenario and respond to questions. Clinical faculty debriefed students in small groups or for some groups, processed the scenario as an entire clinical group. The students were each charged a $10.00 laboratory fee to cover the cost of renting an educational space in Second Life.
Evaluation of Student Learning and Satisfaction
A survey and a focus group with senior nursing students who completed the Second Life learning activities were conducted to evaluate student experiences with the Second Life learning platform. Institutional review board approval for the study was obtained from Bethel University. All students enrolled in the undergraduate public health nursing course (N = 77) were invited to complete a postactivity survey following the completion of at least two Public Health Nursing Second Life scenarios. In addition, one student from each of the seven clinical groups was randomly selected to participate in a focus group.
Survey items were developed based on the focus of the public health nursing course, which organized content based on the Henry Street Consortium Entry-Level Population-Based Public Health Nursing Competencies (Garcia, Schaffer, & Schoon, 2014) and Public Health Intervention Wheel concepts (Keller, Strohschein, Lia-Hoagberg, & Schaffer, 2004). The survey was administered through the Qualtrics management system. Students indicated which Second Life scenarios they had completed and answered questions (Table 1) related to their perception of competencies they accomplished in public health nursing (11 items), public health nursing knowledge gained (9 items), and satisfaction with the virtual learning experiences (5 items). For knowledge and satisfaction items, students selected item responses on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree).
A total of 48 students responded to the survey; 47 students indicated they completed both the Home Safety Assessment and the Airplane Crash Simulation, and six students completed the Family Health Simulation. When home visits were not available in the student's clinical setting, the Family Health Simulation provided an alternative experience. The total number of responses to survey items varied because not all students responded to all of the survey questions. Students (N = 43) ranked the entry-level population-based public health nursing competencies (Garcia et al. 2014) that they perceived they had accomplished from 1 to 5; Table 1 identifies the competency percentages based on students' choice of the top five competencies from high to low.
For development of public health nursing knowledge (Table 2), the means were highest for assessing the impact of environmental factors (mean = 2.98) and prioritizing nursing interventions based on safety concerns (mean = 2.98). These means are consistent with scenario content, which all addressed environment and safety issues. The highest satisfaction mean (Table 3) occurred for the item on “the onsite public health clinical experiences were valuable learning experiences” (mean = 2.90) and the lowest mean occurred for the item, “Second Life modules were as effective for learning about public health nursing as my onsite clinical experience” (mean = 2.07).
Development of Public Health Nursing Knowledge
Satisfaction with Virtual Learning Experiences
Focus group questions addressed how the scenarios helped students think about public health nursing, what they liked about participating in Second Life, what they found to be challenging, and the perceived benefits. The focus group session was audio taped, transcribed, and analyzed by identifying common themes, using clustering as a content analysis strategy to group similar responses to open-ended questions (Krippendorff, 2005).Three common themes for learning emerged from analysis of focus group data: benefits of Second Life, strategies to promote learning, and challenges encountered in completing Second Life scenarios. Benefits included an increased awareness of the public health nursing role and available resources and exposure to situations they might not experience in clinical. For learning strategies, students especially liked processing the scenario in a group. Some students expressed they wanted more feedback on whether they were making the right decisions. Challenges included technology issues and wanting a greater level of interactivity. Some students expressed that some of the scenarios were not realistic enough.
Recommendations for Using Second Life as a Clinical Learning Activity
Because there were no data on student's baseline knowledge of public health nursing knowledge prior to the virtual learning experiences, learning outcomes were evaluated based on student self-report. Survey findings show that students agreed they achieved public health nursing competencies and grew in public health nursing knowledge, consistent with the simulation scenarios. Although students reported having a higher level of satisfaction with onsite clinical experiences in comparison to learning through Second Life modules, this finding is not surprising given that real-life learning experiences are valued by students.
To improve the student learning experience with Second Life, software enhancements should be added to improve the technological aspects of the program (Menzel et al., 2014). Chow, Herold, Choo, and Chan (2012) stated that it is critical to have technology-specific training and support when implementing virtual worlds in health care education. It is also important to standardize the hardware students are using by mandating specific hardware requirements (Schmidt & Stewart, 2010).
After reviewing the results from the Qualtrics survey and focus groups, public health nursing faculty made several modifications to the Second Life modules. The plane crash scenario was changed to a more robust, interactive train or bus crash, with the addition of several more victims. Faculty integrated additional disaster preparedness content throughout the module and included a flood from a tornado that caused the crash. In addition, the students had access to an enhanced story line for each victim. In the second year of Second Life simulations, all students completed the disaster preparedness module. Students had the opportunity to apply the theoretical concepts of disaster preparedness within their simulation experience. Clinical faculty were given the option of debriefing the disaster preparedness module with students in a clinical conference or in an online discussion. Students were required to complete the Second Life activity and come to the conference with answers prepared to the questions in the module. Most of the faculty chose to have students debrief in a face-to-face discussion format, noting the enhanced group learning that occurred.
The hoarder or safety house and family health modules were used for the options of assigning clinical make-up for students, or as a learning enhancement if similar experiences were not available in the clinical setting. Faculty determined that the Second Life simulations were a meaningful learning experience as a convenient and reasonable alternative to making up a clinical day, which can be very difficult to organize given the complex schedules of students, faculty, and agency public health nurses.
Another change made was communication of the technology requirements to students in the letter sent out during the summer between the junior and senior years. Students were reminded that they needed to comply with the university's technology requirements, which would enable them to navigate the requirements for Second Life simulation. In the second year of including the Second Life simulations in the curriculum, no difficulties or technological challenges with Second Life were reported.
Because variability exists in learning opportunities across public health nursing clinical sites, it is important to give faculty flexibility in choosing whether to include additional Second Life simulations, in addition to disaster preparedness, and how to debrief the learning experience. Nursing clinical faculty were able to choose the options that enhanced student learning based on the unique opportunities in the clinical setting.
Second Life is a safe method to learn about public health nursing without the risk of harm to clients or students. In undergraduate nursing education, Second Life simulation can enhance clinical learning and provide an alternative to making up a missed clinical day. In addition, Second Life simulation can provide a convenient and reasonable alternative for experiencing immersion in a public health nursing activity that is difficult to create, such as disaster preparedness. Nurse educators have the ability to strengthen the virtual learning experiences by providing a thorough orientation, as well as by working with developers to enhance realism and interactivity to promote optimal learning. Virtual learning experiences are viewed as a reasonable alternative for learning when clinical sites are not available.
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|Competency Item (n = 43)||Frequency in Top Fivea||%|
|1. Applies the public health nursing process to communities, systems, individuals, and families.||28||65|
|2. Shows evidence of commitment to social justice, the greater good, and the public health principles.||23||53|
|3. Incorporates mental, physical, emotional, social, spiritual, and environmental aspects of health into assessment, planning, implementation, and evaluation.||22||51|
|4. Works within the responsibility and authority of the governmental public health system.||22||51|
|5. Practices public health nursing within the auspices of the Nurse Practice Act.||19||44|
|6. Demonstrates leadership.||18||42|
|7. Demonstrates nonjudgmental and unconditional acceptance of people different from self.||18||42|
|8. Uses basic epidemiological principles.||16||37|
|9. Uses collaboration to achieve public health goals.||15||35|
|10. Effectively communicates with communities, systems, individuals, families, and colleagues.||14||33|
|11. Establishes and maintains caring relationships with communities, systems, individuals, and families.||12||28|
Development of Public Health Nursing Knowledge
|Knowledge Item (n = 42)||Mean|
|1. How to assess the impact of environmental factors (family home, neighborhood, community) on planning for interventions.||2.98|
|2. How to prioritize nursing interventions based on safety concerns.||2.98|
|3. How to determine relevant individual level interventions.||2.81|
|4. How to determine relevant community level interventions.||2.69|
|5. How to determine relevant family level interventions.||2.69|
|6. How to use systems-level strategies to promote the health of the population.||2.64|
|7. How to apply the Public Health Intervention Wheel to a clinical setting.||2.57|
|8. How to identify and collaborate with community partners and resources to accomplish public health goal(s).||2.50|
|9. How to determine relevant community resources for referral.||2.50|
Satisfaction with Virtual Learning Experiences
|Satisfaction Item (n = 42)||Mean|
|1. The onsite public health clinical experiences were valuable learning experiences.||2.90|
|2. I received the support I needed to complete the Virtual Reality Simulation Modules.||2.76|
|3. The learning expectations for the Second Life modules were clear.||2.71|
|4. Virtual reality clinical experiences were valuable learning experiences.||2.43|
|5. Second Life modules were as effective for learning about public health nursing as my onsite clinical experience.||2.07|