Empowering suitable, safe, and confidential patient-nurse interactions via technology requires tools that support social environments and foster experiences similar to face-to-face communication. The current and ongoing shortage of healthcare practitioners, coupled with increase in access to healthcare insurance and an aging population in the United States, is straining the traditional healthcare delivery system to meet the demand for services. The Bureau of Labor Statistics (2013) projects a need for an additional 1.05 million Registered Nurses (RN) and 20,400 physicians by 2022 (Health Resources and Services Administration Bureau of Health Professions, 2013). Thus, there is a clear need for technological tools to supplement the existing healthcare delivery systems to enhance patient access, care outcomes, and the patient experience. This is especially true for rural and/or geographically remote patients.

New technologies such as blogs, podcasts, portals, social media, and telemedicine based platforms have become prevalent; many are experiments using technologies to assist physicians, nurses, caregivers, and patients to meet their needs and to augment the traditional healthcare services delivery model (Barry & Hardiker, 2012, Buckley, Tran, Prandoni, 2004). While individuals (especially patients) and healthcare institutions are embracing such technologies, there are concerns that include the quality and credibility of information available on such media. Because of the unregulated and open architecture of the Internet, it is difficult to separate harmful, incomplete, unsubstantiated, or amateurish information from information created by credible sources (Diaz et al., 2002). Furthermore, the ability of technology driven tools to navigate the ambiguities of ethical and moral issues in hospital setting is still uncertain (Abbott & Shaw, 2016).

...technologies need to provide a richer communication experience, as close as possible to real life patient and nurse interaction, while protecting privacy and confidentiality for patients. Use of technology can also include breaches of privacy and confidentiality (often unintentional) that can have serious implications for providers, patients, and hospitals (National Council of State Boards of Nursing, 2011). In nursing, such breaches in confidentiality may result in discipline or sanctions against a nurse’s license to practice, but most importantly risk the well-established trust between patient and nurse (Canadian Nurse Protective Society, 2010). Suitable, safe, and confidential patient-nurse interactions via technology requires tools that support social environments and foster experiences similar to face-to-face communication. Such technologies need to provide a richer communication experience, as close as possible to real life patient and nurse interaction, while protecting patients' privacy and the confidentiality of their medical information.

Virtual worlds (VWs) are an example of a promising technology that can provide immersive media richness and bring social activities closer to real-life experience. This technology has developed to the point that nursing providers and patients may benefit by taking advantage of this emerging platform. With continued and growing demand for out-of-hospital care models, nurses will need to manage patient connections while still maintaining quality and efficiency. Internet-based technologies such as VWs can play a critical role to enable nursing providers to accomplish this goal.

The role of nurses in delivering healthcare services through such communication technology has not been adequately examined. This article will consider the potential importance of technologies to delivery of nursing care to positively impact patient outcomes. This type of care delivery might be especially appropriate to provide education and/or primary care to geographically diverse patient groups. We will describe this technology, offer a brief review of outcomes from technology and simulation in nursing, and discuss an exemplar and out findings. VWs point to a new avenue of research to expand the reach of both nursing care and nursing education beyond the physical limits of space and location.

Three Dimensional Virtual Worlds

VWs are “sophisticated pieces of software that enable their users to project an identity into a generated three dimensional reality through the use of advanced computer graphics and through the eyes of this digital persona or avatar –interact with other players and wander through this computer generated reality” (Mayer-Schönberger & Crowley, 2006, pg. 1781). VWs have pushed the boundaries of the virtual experience by creating a cyber version of the real world. Users, through their unique 3D graphic representations called avatars (Nowak, 2000), perform various activities in VWs, such as moving around, manipulating objects, and interacting with others. Users “live” in the virtual world through their avatars, participating in a wide range of social, educational, and collaborative activities that include building homes and offices; going to social events, such as clubs, discussions, or political meetings; participating in seminars and educational debates; undertaking virtual commerce; and making products.

VWs are classified based on target users and the level of fantasy, extent of simulation, and social interaction supported. Most VWs target teens and have themes that represent popular culture (e.g., Barbie^® Worlds, Barbie^® Girls, Disney^® Virtual Magic Kingdom), sports, movies,and games. Such VWs are geared toward social interactions and fun activities and do not enable the building of customized virtual environments by their patrons. The second type of VWs is called “mirror worlds,” which allows one to create objects such as chairs, tables, buildings, offices, museums, hospitals, universities, and cities similar to real world objects without many constraints. In these worlds, one can own land, a building, or a whole island. The most popular and well-developed VWs in this category are Active Worlds, Second Life^® (SL), and There.Com^®. In this article, we use the term virtual worlds to mean three-dimensional mirror worlds.

VWs, particularly SL as its most popular exemplar, differ from online games because they emulate real-world experience by providing a “world” in which participants “live” through their avatars and take part in various activities. SL has been used in multiple fields, including commerce, education, healthcare, customer service, business hiring, consulting, entertainment, and social networking. Successful activities in SL have included educational classes and seminars and providing health services (Karlsson, 2008; Miller & Jensen 2014). SL provides new opportunities for online interactions, as well as 3D platforms for many current social activities done on the two-dimensional web.

Healthcare Initiatives in VWs

VWs, particularly SL, are being explored as a tool for healthcare-related initiatives... VWs, particularly SL, are being explored as a tool for healthcare-related initiatives, including disseminating health information, training health professionals, and facilitating patient education and awareness. There are a host of experiments and numerous discussions that explore the potential of VWs for delivering healthcare education and improving skills (e.g., patient interview, delivering bad news, conflict resolution in hospital situations, rapid sequence intubation) (Aebersold, Tschannen, Stephens, Anderson, & Lei, 2012, Boulos, Hetherington, & Wheeler, 2007; Gorini, Gaggioli, Vigna, & Riva, 2008; Hansen, 2008; Miller & Jensesn 2014; Trangenstein, Weiner, Gordon, & McNew, 2010).

Nonprofit organizations, government departments, hospitals, and educational facilities have interest in utilizing and experimenting with SL capabilities for healthcare-related activities. For example, an extensive study conducted by Beard, Wilson, Morra, and Keelan (2009) examined 68 SL-based health-related initiatives and detailed opportunities available to nurses and other providers, and students, in virtual environments. Many of these related to patient education and support, skills that are common to nurses and extremely valuable to patients in today’s fast-paced healthcare environment. An overview of health-related SL-based activities for nursing students has also been detailed by Peck and Miller (2010).

...VWs likely have great long-term potential to provide healthcare services on a global level. Ghanbarzadeh, Ghapanchi, Blumenstein, and Talaei-Khoei (2014) summarized a decade of healthcare research and activities in VWs. The authors looked at a sample set of 62 research papers and divided them into six distinct health-related activities based on their primary focus: academic education, professional education, treatment, evaluation, lifestyle, and modelling. The majority of VWs related to the education categories, but even the lesser represented categories offer a great potential for nurses to impact patient outcomes by using tools such as SL to connect with patients, families, and even community groups. The study by Ghanbarzadeh and collegues (2014) considered only the United States and the United Kingdom; however, VWs likely have great long-term potential to provide healthcare services on a global level. Table 1 provides a brief overview of several healthcare education and service initiatives by governments, nonprofit organizations, educational institutions, and hospitals in virtual worlds with focus on SL.

Table 1. Second Life^® Health Initiatives

Nursing Initiatives and Outcomes

Healthcare researchers are among many embracing SL for educational purposes, including simulation, emotional learning, and transformational learning. Healthcare researchers are among many embracing SL for educational purposes, including simulation, emotional learning, and transformational learning. Next, we provide overview and examples from the literature of various nursing simulations and outcomes primarily based on the SL platform, followed by overview of our research in SL.

E-Simulations

Simulation as an educational tool is becoming increasingly prevalent in nursing education (Cant & Cooper 2014, Norman, Dore, & Grierson, 2012). In the context of healthcare education, simulation is regarded as a “technique, device or activity that aims to authentically recreate, imitate or amplify characteristics, processes, and experiences of the real world for the purposes of teaching, acquiring and assessing knowledge, skills and attitudes” (Guise, Chambers, & Välimäki, 2012, pg 411). In this paper, we specifically look at electronic simulation (E-simulation) created in a virtual world environment that is a representation of aspects of the real world, or those in which a user can create and manipulate situations in order to learn skills and values.

Simulation can range from paper-pen case studies, role play with simulated or standardized patients (e.g., postpartum hemorrhage simulation), video sessions, anatomical modelling, and more recently e-simulation (Cant & Cooper 2014; Norman, Dore, & Grierson, 2012; Sun, Tsai, Finger, Chen, Yeh, 2008). E–simulation is an emerging technology facilitating various nursing education strategies based in the virtual classroom.

Second Life^®  is used in multiple nursing programs to simulate real encounters. SL is used in multiple nursing programs to simulate real encounters (Aebersold et al, 2012; Honey, Connor, Veltman, Bodily, & Diener, 2012; Tiffany & Hoglund, 2013). A common theme is to provide students a real-life experience which may not be possible in an educational setting. Honey et al. (2012) reported a collaboration between two nursing programs (University of Auckland, New Zealand, and Boise State University, Idaho) which produced a 10 step guide for other nursing programs to develop an extensive SL-based e-simulation.

In a novel e-simulation based in SL, researchers created a new SL application for teaching and training in intensive care units (ICU) with particular emphasis on nurse-to-nurse handoffs. The major outcome of this work was a VW environment for training nurses in the shift handover process, designed and developed for use by postgraduate nurses in training (Brown, Rasmussen, Baldwin, & Wyeth, 2012). Other examples of SL based e-simulations include ‘critical life’ (emergency department) (Rogers, Miller, & Firmin, 2012), virtual clinics (Wang & Burton 2012), and conflict management (Tschannen, Aebersold, McLaughlin, Bowen, & Fairchild, 2012). All of these nursing related initiatives in SL demonstrated positive outcomes, such as increased collaboration, increased knowledge, and development of competencies related to leadership and management skills (Aebersold & Tschannen, 2012; Cant & Cooper 2014).

Emotional Learning: Dealing with Patient Death

Patient deaths not only affect family members and friends but also caregivers, including nurses (Rice, Bennett, & Billingsley, 2014). In the work setting, nurses often suppress feelings and reactions which can lead to irritability, sleep disorders, stress, and eventually burnout and attrition (Erickson & Grove 2008). Rice et al. (2014) reported an approach using SL as a venue to facilitate peer storytelling sessions and grief resolutions to support nurses. A private 3D virtual meeting space was designed in an outdoor setting surrounded by trees and nature. Nine oncology nurses participated in the experiment using avatars with pseudonyms. Each group session was moderated by a grief management expert and followed an established bereavement task model (Saunders & Valente, 1994) using peer story telling in SL to express and process grief. Outcomes from this study were highly positive and provided evidence that use of virtual worlds did enable nurses to learn from experienced nurses taking part in the sessions and develop sophisticated strategies to process and experience grief related to patient deaths.

Transformational Learning: Poverty Simulations

College students (nursing and non-nursing) may have limited experience of being poor (Vandsburger, Duncan-Daston, Akerson, & Dillon, 2010) and may develop negative attitudes toward people who live in poverty (Noone, Sideras, Gubrud-Howe, Voss, & Mathews, 2012). This can interfere with the quality of care for healthcare providers and civic engagement of students after graduation (Vandsburger et al., 2010). Face-to-face poverty simulations have demonstrated positive outcomes in terms of nursing student attitudes towards poor people (Menzel, Clark, & Darby-Carlberg, 2010). However, the cost burden related to purchasing such simulations, despite their value, has been major deterrent for nursing programs to adopt them.

In an e-simulation developed by Menzel, Willson, and Doolen (2014) in SL, the goal (unlike other nursing simulations) was not to teach a new skill, but to stimulate transformational learning and self-reflection by changing students' attitude through participation in a “disorienting dilemma,” a concept previously developed in work with social work students (Vandsburger et al., 2010, p. 304). A total of 98 nursing students took part in the e-simulations over three semesters. The final results showed positive transformation in nursing student attitudes (e.g., reduced negative feelings about persons who live in poverty, increased recognition about causes of poverty). The researchers also recommended that faculty incorporate social justice concepts throughout the curriculum for enduring affects.

Technical Learning: Medical Device Training

Medical infusion devices (pumps) are commonly used in medication delivery. However, even with advent of “smart” infusion pumps - medication, administrative, and programming errors are frequent (Barker, Flynn, Pepper, Bates, Mikeal, 2002; Cummings & McGown 2011). A collaborative group that included an anesthesiologist, an associate professor in surgical education, an infusion pump training specialist, a 3D graphic designer, a bioengineer, a senior research associate and two Intensive Therapy Unit (ITU) nursing specialists at Imperial College London designed a VW scenario for the management of adverse events associated with infusion devices. The scenario, which included an infusion device and clinical environment, was implemented in SL and included creation of reception areas, changing room, nurse office, and a hospital ward. Forty nurses took part in the simulated training. Outcomes of this e-simulation strongly demonstrated the acceptance by nurses of SL-based virtual scenarios. The results also verified the viability of such e-simulated trainings, through SL, as an easy to disseminate and cost-effective training method appropriate to a larger nursing audience.

Our Exemplar

Delivery of Medical Services: A Study in Second Life^®

In this section, we will briefly report on our work (Zahedi, Walia, & Jain, 2016) which examined the feasibility of delivering of medical services via SL. In short, the conceptualization of our design was based on synthesis of communication theories and technology adoption theories. We developed empirically examined a model that included design features (social presence and lack of privacy concern), outcome constructs (understanding, perceived effectiveness of group, trust, intention to use) as well as a host of control variables such as group size and patient attributes. Out results strongly supported the proposed model. The intent of this description is not to disseminate the full results of the study (Zahedi et al., 2016), but rather to describe an innovative process of creating and using VW in SL intended as a venue to provide virtual healthcare to patients either individually or in a group.

A simulated experiment was carried out with students playing the role of patients at a large Midwestern university. Participants were trained before the start of sessions. We told them that they were going to experience a new way of going to the doctor’s office. Each participant was provided a list of symptoms and a script but was encouraged to communicate with the nurse and physician in a natural manner. The attending nurse and physician (researchers) were well-versed in the diseases included in the experiments in experiment scenarios.

The theoretical foundation of our work has been strongly influenced by the effectiveness and immersive nature of the mediated environment to promote the perception of “social presence” between the provider and patient. Social presence is defined as “the extent to which an individual psychologically perceives other people to be physically present when interacting with them” (Carlson & Davis, 1998, p.337) and posits that a medium that strongly resembles a face-to-face interaction will generate increased perception of social presence (Jahng, Jain, & Ramamurthy, 2000; Qui & Benbasat, 2005). The theoretical concept of social presence has been primarily explored in studies related to virtual reality, telecommunications, web-based entertainment, and tele-operators (Klein, 2003; Li, Daugherty, & Biocca, 2002; Qui & Benbasat, 2005).

In comparison to telemedicine technologies, VWs use avatars to offer appearance, gestures, directional voice, and ability to interact with the environment and virtual artifacts. We considered VWs (e.g., SL) to be an extension (or natural evolution) of communication technologies such as 2D videoconferencing, 3D videoconferencing, teleconferencing, and telemedicine (Business Wire, 2012; Lewis, 2012; Young et al. 2011). In comparison to telemedicine technologies, VWs use avatars to offer appearance, gestures, directional voice, and ability to interact with the environment and virtual artifacts. Videoconferencing simulates face-to-face communication quite authentically (Fayard, 2006), but the visual view provided by videoconferencing, that is, an individual’s head and shoulders (known as “talking heads”) is still fundamentally different from sharing the same physical space. In our proposed approach, we leveraged unique aspects of VWs and combined it with other existing technologies (e.g., video–telemedicine) to efficiently deliver high-quality healthcare to larger segments of the population.

We have developed a medical campus and built-in multimedia functionalities in a private island in SL. The medical campus has number of structures, including a reception area, physician offices, auditorium, user training area, and an arrival point. A number of tools, signage for clicking and moving to different locations (teleporting); a communication stick for managing talks in group visits; and external links to simulated patient records were also developed in this facility. Additionally, the unique “Diagnosim Medical Simulation System,” a first-of-its kind architecture for simulating and “role playing” in the medical process and patient flow, was also implemented. The following sequence of events in the figures and descriptions below take place as patients arrive at the medical campus. The patient on entry arrives at the arrival area (Figure 1). At the arrival area, the patient is greeted by an attendant or medical assistant if it is the first time the patient is visiting the campus.

Figure 1. Arrival Area (Participants)

The patient is then taken to the reception office for registration. The reception office is designed to create an immersive feeling of visiting the reception area of a physician office (Figure 2) The reception area has the receptionist desks, waiting area, new patient registration, and teleport facility. Once at the reception area, the patient can provide registration and other information to the receptionists. The virtual reception area has been built to accommodate up to 25 patients at a time. At the end of registration process, the patient is greeted by a nurse and taken to the physician office. This is the initial point of contact with a nurse in this medical campus.

Figure 2. Reception Office (Receptionists/Medical Assistant)

The campus has a dedicated medical office building, which has multiple offices for one-on-one examination as well as a group room for meeting with multiple patients simultaneously. The patient interacts with healthcare providers in one of the examination rooms (Figure 3). Healthcare providers (nurses and physicians) attend to the health issues of patients in these examination rooms through their avatars. Each examination room is designed to facilitate effective communication first between patients and a nurse, followed by meeting with physician one-on-one or in in a patient group environment. The examination room can be used by both nurse and physician for their interactions with the patients.

Figure 3. One-on-One Examination Room (Nurse and Patient)

In addition to the medical offices, the campus also has a conference room for training healthcare providers and patients (Figure 4). The conference room has a speaker podium and chairs and can accommodate up to fifty participants (via their avatars). Each chair has a computer screen to communicate information to each attendee.

Figure 4. Conference Area

The campus has a training walkway next to the arrival area, which has training information on educational boards for visitors who are not familiar with SL and the campus (Figure 5).

Figure 5. Training Area

We have used the campus to examine the feasibility of providing healthcare to patients. In a simulated study, physician avatars provided medical advice to students as part of a simulated session. A nurse supported the patient’s visit and guided the patients throughout the simulated session. We were interested to see the extent of participants’ satisfaction with SL and the service provided to them through the healthcare provider’s avatar. The results from more than 170 observations indicated positive patient’ perceptions about SL and a high degree of satisfaction. Figure 6 (top) illustrates that, on a scale of 0 (lowest) to 10 (highest), SL was rated high in terms of satisfaction. Furthermore, interaction with avatars was also rated high. A common concern about using SL is the quality of care. In our simulated experiment, the patients rated quality of care provided by the physician in terms of being responsive, prompt, helpful, polite and clear in communication. The results indicated a high assessment of service quality (Figure 6, bottom).

Figure 6. Satisfaction and Service Quality

...our initial outcomes indicated the effectiveness and acceptance of the SL-based medical campus. Thus, our outcomes indicated the effectiveness and acceptance of the SL-based medical campus. These results are particularly encouraging from the perspective of physicians, nurses, and other caregivers. One of main reasons given for nurse reluctance to adopt a communication medium (e.g., chat, video, VWs) is the loss of service quality. Our results demonstrated that with the appropriate design and protocol, it is possible to supplement face-to-face nursing care through SL-based systems.

There are multiple opportunities to expand the use of the medical campus for nursing care. There are points for nurses when the patient arrives to the medical campus that simulate areas where nurses might typically interact with patients in an office setting: introductions with patients at the reception room, close interactions with patients in one-on-one examination room, interaction with a group of patients in the group examination room, and educating patients in the conference room. The advantage of the group examination room is that patients participate through their avatars. Therefore, their true identity can be hidden from other patients, thus allowing them to more freely share their health concerns within the group. Moreover, nurses from multiple locations and facilities could participate in the educational activities or provide care to patients.

...nurses from multiple locations and facilities could participate in the educational activities or provide care to patients. While our project was based on physician delivered medical care with nurse support, application of this care delivery model to provide primary care by advanced practice nurses in a VW could be a natural expansion of this innovative platform. We are excited by the positive outcomes from this project and anticipate great opportunities to use facilities such as our SL medical campus to supplement face-to-face patient care.

Conclusion and Future Extensions

The usability and flexibility of using a virtual immersive environment allows nurses with a variety of work schedules the ability to practice or attend educational sessions during nontraditional times. The VW and the use of an avatar to increase feelings of immersion and social presence make unique environments for education, research, and delivery of healthcare services. The usability and flexibility of using a virtual immersive environment allows nurses with a variety of work schedules the ability to practice or attend educational sessions during nontraditional times. Nursing is a practice-based profession primarily focused on skills and decision-making typically related to an aspect of holistic patient care (Cant & Cooper, 2014). The use of this technology can enhance a nurse’s reach to assist patients in general; manage their caseloads; and improve overall responsiveness and communication. VWs can serve as a supplemental solution to the ongoing nursing shortage by making it possible for nurses to interact with patients from a diverse geographical area in a group situation. This might be particularly useful in critical conditions such as infectious outbreaks, where the need to serve a large group of potential victims is a possibility. The return on investment of this technology might be seen in reduced costs associated with nurse and individual patient face-to-face visits. In addition, there is unlimited opportunity for VWs in nursing education and simulation to create a realistic, non-threatening environment to practice decision-making and skills at no risk to patients (Miller & Jensen 2014).

VWs can serve as a supplemental solution to the ongoing nursing shortage by allowing a single nurse the potential to interact with patients from a diverse geographical area in a group situation. VWs can serve as a supplemental solution to the ongoing nursing shortage by allowing a single nurse the potential to interact with patients from a diverse geographical area in a group situation. There is great potential to supplement face-to-face nursing care by reaching patients through VWs, such as SL. For example, the platform of VWs can be further explored to assist patients with disabilities, and to facilitate care for elderly patients, both vulnerable populations who often find it difficult to travel to healthcare facilities. Future studies using VWs with a focus on various levels and types of nursing care; nursing and continuing education; and patient education by disease types and/or geographic location would be helpful to further establish models and document potential positive outcomes (e.g., increased in/or improved patient communication, care delivery efficiency, cost reduction). Our review of literature, as well as our own on-going research project, both suggest positive early outcomes and point to new opportunities for enhancing nursing care view the use of virtual worlds.

Authors

Nitin Walia, PhD
Email: nwalia@ashland.edu

Nitin Walia received his PhD degree in Information Systems from the University ofWisconsin-Milwaukee. He also holds M.S. degrees from Oakland University, MI andPune University, India. He is currently an Assistant Professor inAccounting/Information Systems Department, Ashland University. His main researchinterests include business analytics, data mining, healthcare delivery systems,online marketplaces, and web-design interface issues. He is also working onissues related to providing medical services through a virtual world. His workhas been published in several national and international journals including Journals of Management Information systems, ElectronicCommerce Research, IEEE Transactions on Software Engineering, IEEEIntelligent Systems Journal, and International Journal of Electronic BusinessManagement.

Fatemeh Mariam Zahedi, DBA
Email: zahedi@uwm.edu

Fatemeh Mariam Zahedi is a professor and Roger L. Fitzsimonds Distinguished Scholar at the Sheldon B. Lubar School of Business, University of Wisconsin-Milwaukee. She has received her doctoral degree from Indiana University. Her research is focused on individuals’ encounters with information technology and the design of systems to enhance such encounters. Her present areas of research include web-based system designs and issues related to healthcare, security, privacy, trust, loyalty, personalized intelligent interface, DSS, and web analytics for business. She has served as SE and AE of MIS Quarterly, editorial board of JMIS, and AE of ISR. She has published more than 120 referred papers in premier journals and conferences, including MIS Quarterly, Information Systems Research, Journal of Management Information Systems, Management Science, IEEE Transactions on Software Engineering, Operations Research, IEEE Transactions on Systems, Man, and Cybernetics, IIE Transactions, and Review of Economics and Statistics, and others. She has been the PI of grants funded by NSF and other agencies. She is the author of two books, Quality Information Systems and Intelligent Systems for Business: Expert Systems with Neural Network. She has received several research, teaching and best paper awards. Her work has been featured in TV and print media. The list of Professor Zahedi’s publications is available on her Google Scholar profile.

Hemant Jain, PhD
Email: Hemant-Jain@utc.edu

HEMANT JAIN (hemant-jain@utc.edu) is W. Max Finely Chair in American Business: Data Analytics, at the College of Business, University of Tennessee Chattanooga. He received his Ph.D. in information systems from Lehigh University. He specializes in service-oriented architectures, component-based development, real-time enterprises, data analytics, text mining, and health-care informatics. His work has appeared in Information Systems Research, Journal of Management Information Systems, MIS Quarterly, and other journals.