Lori I. Kidd, PhD, RN, CNS; Samantha J. Knisley, BSN, RN; and Karyn I.

Morgan, MSN, RN, CNS

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28 Copyright SLACK Incorporated
V
irtual reality technology is
being used increasingly in
health care education and
practice. Virtual technology incorpo-
rates graphics, sounds, and other senso-
ry input to create a computer-generated
world in which the user can interact.
A sense of presence, or seeming to
experience real stimuli, is important for
a successful program (Gregg & Tarrier,
2007, p. 343). Virtual worlds such as
Second Life

(SL) provide this experi-

encean opportunity to interact with
a make-believe reality. SL is an online
tool that allows students to enter an
alternate reality and create a cartoon
animated human representationor
avatarthat is able to virtually interact
with other avatars. A unique applica-
tion of this virtual technology devel-
oped by mental health nursing course
faculty will be reported in this article.
BACKGROUND
One factor driving development of
virtual technology in nursing educa-
tion is higher acuity in hospitals, which
may compromise student learning and
patient safety. Virtual technology can
simulate expensive or potentially dan-
gerous activities in an accessible and
safe manner (Richardson, Hazzard,
Challman, Morgenstein, & Brueckner,
2011, p. 40). In mental health clinical
rotations, physical presence of the in-
structor during one-on-one interactions
between student and patient changes
the interpersonal dynamic, thus mak-
ing direct evaluation of outcomes such
as communication and mental health
assessments impossible. Mental health
nursing courses have traditionally used
process recordings, role-playing, or
completion of psychosocial assessment
tools to evaluate student learning.
Other options have included simula-
tion with human patient simulators
(Kameg, Mitchell, Clochesy, Howard,
& Suresky, 2009) or use of standardized
patients (Robinson-Smith, Bradley,
& Meakim, 2009). However, human
patient simulators and standardized
patients can be very costly in terms of
nancial and human resources (e.g.,
equipment, instructor time, limited
laboratory space) (Brown, 2008).
In a mental health nursing course,
faculty emphasize development of com-
munication skills in establishment of
therapeutic relationships, but in reality,
such relationships are often hindered by
challenges of high acuity, short length
of stay, and student anxiety and stigma
about psychiatric clients (Kameg et al.,
2009). With virtual simulation, mental
health faculty can standardize experi-
ences for students, including situations
that are high risk or occur infrequently.
They may also incorporate technology
that younger students are familiar with
and enjoy (Brown, 2008).
The Community of Inquiry edu-
cational model (Garrison, Anderson,
& Archer, 2000) provides support for
this study. The Community of Inquiry
framework states that core elements of
a collaborative constructivist learning
environment are teaching presence,
cognitive presence, and social presence
(Garrison et al., 2000). Psychiatric
nursing theorists acknowledge the im-
portance of presence, an interpersonal
process that may result in improved
mental health for clients and nurses
(Finfgeld-Connett, 2006). Teaching
presence is supported through instruc-
tor involvement in the virtual interac-
tion and through debrieng. Cognitive
presence is supported as students have
to make in the present decisions
about how to respond to patients be-
havior. Students attain social presence
and strengthen relationships when they
imbue their avatars with their own per-
sonal characteristics. SL simulation
can help learners construct meaning
through virtual experiences.
STUDY PURPOSE
The purpose of this study was to
measure the effectiveness of a SL virtual
simulation as a teaching strategy. The
research questions were:
How effective is a SL virtual
simulation as a teaching strategy for
undergraduate mental health nursing
students?
How technically difcult is a SL
virtual simulation program for under-
graduate mental health nursing stu-
dents?
ABSTRACT
Learning may be enhanced in mental health nursing educa-
tion by applying virtual reality technologies in which students
may safely practice communication and assessment skills with
simulated patients. The purpose of this descriptive study was to
assess the eectiveness of a Second Life

(SL) virtual simulation

as a teaching strategy for undergraduate mental health nurs-
ing students. Data were collected via a researcher-developed
survey questionnaire. Students perceived the simulation to be
moderately eective as an educational strategy and slightly dif-
cult as a technical program. Positive aspects included client
assessment in an environment where mistakes were without
consequence, working from home, and novelty. Drawbacks
were dressing and maneuvering the avatar and lack of realism.
Correlations were found between educational eectiveness and
technical diculty and between educational eectiveness and
age of the computer. SL virtual simulation has potential to pro-
vide unique, easily accessible, safe, and fun learning for mental
health nursing students.
29 1OUPNAL OP PSCHOSOC|AL NUPS|NG - vOL. 50, NO. 7, 20l2
LITERATURE REVIEW
Advantages of Virtual Technology
Barratt (2009) examined the effec-
tiveness of videorecorded reality educa-
tion for nurse practitioner students and
found that students appreciated online,
visual learning that was convenient, al-
lowed exibility with time, and provided
opportunity to reect on the experience.
Highly realistic online environments
immerse students in experiential learn-
ing without disrupting patient care.
Health care students may practice skills
without the worry of making real-life er-
rors (Johnson, Vorderstrasse, & Shaw,
2009).
From a pedagogical standpoint, vir-
tual technology appears consistent with
learning styles of the new millennial
student generation (Bonnel, Fletcher,
& Wingate, 2007, p. 302). Content is
practical and relevant and allows stu-
dents more active engagement than
reading a textbook (Bonnel et al., 2007).
Virtual technology has been described as
exible and programmable and mimics
real life (Richardson et al., 2011, p. 39).
Challenges and Limitations of Virtual
Technology
Community structure, process, and
emotional aspects need to be considered
when designing virtual worlds (Gallagh-
er-Lepak, Reilly, & Killion, 2009). Ko-
kol, Blazun, Micetic-Turk, and Abbott
(2006) found barriers to virtual technol-
ogy include lack of personal contact, lack
of transfer, Internet connection issues,
fear of technology, and lack of technol-
ogy knowledge. Virtual reality simula-
tions have the potential to be confusing,
difcult to understand, and may involve
a steep learning curve (Inman, Wright,
& Hartman, 2010). Although younger
generations seek out and expect the use
of new technology in their classrooms
(Chang, Gtl, Kopeinik, & Williams,
2009), older generations may have dif-
culty understanding how to navigate a
virtual simulation and may not see value
in the activity (Inman et al., 2010).
While virtual technology has the po-
tential to benet teachers and students
in the classroom, concerns exist about
using too much technology in nurs-
ing education. Technology is not a re-
placement for more traditional learning
methods (Kokol et al., 2006). A balance
of clinical practice and technology is
required for optimal learning (Gregg &
Tarrier, 2007).
Second Life Simulation in Nursing
Education
SL has been used in baccalaureate,
accelerated baccalaureate, and masters
nursing programs (Skiba, 2009) and of-
fers access to experiences that students
may not be able to benet from in clini-
cal rotations. Applications of SL tech-
nology have included virtual home visits
for public health nursing students (Stew-
art, Pope, & Duncan, 2009), construc-
tion of campus replicas where research
seminars and international conferences
are held, and even virtual ofce hours
in SL, eliminating travel time for com-
muter students and faculty (Richardson
et al., 2011).
Some benets nursing programs have
cited about SL are that it enables role
playing, collaboration, real-time inter-
actions between students and faculty,
and experimentation (Skiba, 2009, p.
129). Nursing students have rated SL
more highly than webinars and a learn-
ing management system in terms of per-
ceived quality of instruction (Johnson et
al., 2009). Situations in virtual worlds
can also be standardized; thus, learner
performance can be easily monitored, re-
corded, and evaluated (Kilmon, Brown,
Ghosh, & Mikitiuk, 2010). Finally, SL
holds great promise as a tool for distance
learning (Inman et al., 2010).
Difculties with SL have been tech-
nical (e.g., slowness of computer down-
loading, crashes, freezing), cultural
(abusive or pornographic comments
and behaviors from avatars), and time
required to build and populate environ-
ments (Inman et al., 2010). Increased
workload related to learning how to use
SL, perceived time pressures, and logis-
tical issues of accessing and maneuver-
ing within the program have also been
reported (Chang et al., 2009). Concerns
about SL as a nursing teaching tool in-
clude lack of accessibility to computers
capable of running the program and less
knowledge about virtual worlds among
older students. Students stated that as-
pects of the program are not applicable
to nursing, and some felt uncomfortable
interacting with other avatars (Skiba,
2009). Overall, the majority of nursing
students have enjoyed the experience,
requested more time in SL, and learned
from the program (Skiba, 2009). Obsta-
cles of the program tended to be over-
looked when it came to the students
positive educational experience.
Research Trends. The majority of
virtual reality applications have been
developed in the past 10 years (Gregg
& Tarrier, 2007). Few researchers have
studied the use of virtual reality in
GRADING CRITERIA FOR SECOND LIFE

HOME VISIT SIMULATIONS

1. On time and in right place for scheduled appointment,
wearing professional attire, able to operate student nurse
avatar suciently (gestures, movement, communication
exchanges) to communicate with client avatar
20 points
2. Evaluates home environment with regard to safety and
as it impacts clients mental status
10 points
3. Conducts a mental status assessment 10 points
4. Identies behavioral symptoms that support clinical
diagnosis
10 points
5. Analyzes communication skills in the interactional process 10 points
6. Documents priority nursing interventions, follow-up
recommendations, and summary of clinical impressions
10 points
Figure 1. Second Life grading rubric.
NS
2. Evaluates home environment with regard to safety and
as it impacts clients mental status
10 points
3. Conducts a mental status assessment 10 points
GRADING CRITERIA FOR SECOND LIFE

HOME VISIT SIMULATION

1. On time and in right place for scheduled appointment,
wearing professional attire, able to operate student nurse
avatar suciently (gestures, movement, communication
exchanges) to communicate with client avatar
20 points
2 Evaluates home environment with regard to safety and 10 points
30 Copyright SLACK Incorporated
samples of more than 100 participants
(Gallagher-Lepak et al., 2009). Most
have used smaller samples and newly
developed evaluation tools, challenging
validity, reliability, and generalizability
of ndings. Designs have been conve-
nience sampling in hospitals and schools
(Gregg & Tarrier, 2007). As a whole,
research about virtual technology use
in health care education is limited. No
studies have reported SL simulation in a
mental health nursing course.
Simulation in Mental Health Nursing
Education. In their review, Gregg and
Tarrier (2007) compared effectiveness
of virtual technology as clinical treat-
ment and found that virtual technology
can potentially provide a means for as-
sessing and treating many mental health
disorders or recreate situations that can-
not be re-experienced (e.g., war-time at-
tacks). Yellowlees and Cook (2006) used
virtual reality to simulate hallucinations
for students. Various simulation activi-
ties have been used in mental health
nursing courses, including role-play,
videorecording, standardized patients
and more recently, use of human patient
simulators (Kameg et al., 2009); howev-
er, no research studies or educational re-
ports were found that used virtual reality
simulation such as described in this ar-
ticle. Presence of the instructor as a third
party typically impedes development of
the students therapeutic relationship
with the client (Kameg et al., 2009),
but in the SL simulation, the instructor
could become the patient avatar and be
present to assess the students commu-
nication and assessment skills without
being there physically.
This article describes evaluation of
a unique application of a SL simula-
tion in an undergraduate mental health
nursing course. A nursing student
developed her senior honors project
around evaluation of the SL simula-
tion, working in conjunction with lead
faculty to develop a research question,
review literature, and implement all as-
pects of the research process.
METHOD
Design and Sample
The study used a descriptive design.
A single group of 126 undergraduate
nursing students comprised this con-
venience sample. While completion of
a SL simulation was required for class,
participation in this study was voluntary.
Learning the Technology
Students were provided with a get-
ting started guide that included de-
tailed instructions on dressing and ma-
nipulating an avatar, teleporting (traveling
through cyberspace), and saving chat logs
(providing a record of the interaction).
Being aware that students would need
practice time and have differing levels of
comfort with the virtual technology, fac-
ulty replaced a process recording and an
online seminar assignment (totaling an
estimated 6 to 8 hours of student time)
with the simulation assignment.
Procedures
Participants were selected from men-
tal health nursing classes during three
rotations in the fall and spring semesters.
Each student was required to complete a
SL simulation as part of the course cur-
riculum. Each simulation lasted 45 to 60
minutes and consisted of interaction and
debrieng portions. First, students were
directed to a virtual neighborhood with
two houses on a street. One house be-
longed to a person with paranoid schizo-
phrenia, the other to a person with
major depressive disorder, with the in-
structors acting as the patient avatars. To
Figure 2. Avatar of patient with schizophrenia in his home.
Figure 3. Virtual debrieng area.
tion in an undergraduate mental health
nursing course. A nursing student
developed her senior honors project
around evaluation of the SL simula
but in the SL simulation, the instructor
could become the patient avatar and be
present to assess the students commu-
nication and assessment skills without
being there physically.
This article describes evaluation of
a unique application of a SL simula-
i i d d l h l h
31 1OUPNAL OP PSCHOSOC|AL NUPS|NG - vOL. 50, NO. 7, 20l2
help them prepare, students were given
case histories on their assigned clients.
They were also instructed to review text
content on the clients specic disorder
and provided with a grading rubric for
the assignment (Figure 1). They were to
enter the house, manipulate their avatar
to assess the environment, and interact
with the client (Figure 2).
No standardized scripts were used for
the interactions, but instructors were en-
couraged to guide interactions according
to learning objectives of the assessment,
communication and safety, and case his-
tories of clients. After the interaction,
student and instructor avatars teleported
to a neutral area (away from the house)
to debrief (Figure 3). The rationale for
debrieng in another location was to in-
crease realism of the simulation. Debrief-
ing consisted of instructor and student
Thank you for taking the time to ll out this survey. Your input has the potential to assist nursing faculty to evaluate the Second
Life

(SL) virtual simulation program in the classroom setting. Survey results will help them make changes to this teaching
strategy that will ensure optimal learning. All answers will be condential and will not be used outside of this educational
evaluation. Please check the box next to the answer that you choose.
DEMOGRAPHIC CHARACTERISTICS
1. What is your gender?
_____ Male _____ Female
2. To which ethnic group do you belong?
_____ American Indian or Alaska Native _____ Asian
_____ Black or African American _____ Native Hawaiian or Pacic Islander
_____ White (Caucasian) _____ Other
_____ Do not wish to respond
3. What was your age on your last birthday? _____
4. What year (level/status) are you currently in?
_____ First year (sophomore)
_____ Second year (junior)
_____ Third year (senior)
5. What is the highest level of education you have completed to date?
_____ Some college training _____ Associate degree
_____ Bachelors degree _____ Graduate degree
6. Before this class, have you used SL simulation?
_____ Yes _____ No
7. Before this class, have you used computer simulation?
_____ Yes _____ No
8. Before this class, have you used avatars, such as in video or computer games?
_____ Yes _____ No
9. What computer did you use to access SL simulation in this course?
_____ Home computer _____ College of Nursing computer
_____ Another university computer _____ Other
10. If you used a home computer, what is its age?
_____ Less than 1 year old _____ 1 to 2 years
_____ 2 to 5 years _____ Older than 5 years
Figure 4. Second Life simulation evaluation survey.
l to ass
ill help
will not
1. What is your gender?
_____ Male _____ Female
Thank you for taking the time to ll out this survey. Your input has the potentia
Life

(SL) virtual simulation program in the classroom setting. Survey results wi

strategy that will ensure optimal learning. All answers will be condential and w
evaluation. Please check the box next to the answer that you choose.
DEMOGRAPHIC CHARACTERISTICS
32 Copyright SLACK Incorporated
EDUCATIONAL EFFECTIVENESS
DIRECTIONS: The following items are learning outcomes related to the SL simulation. Please circle the number that best describes the
eectiveness of the simulation in helping you accomplish each outcome.
How eective was the simulation in helping you:
Not At All
Eective
Slightly
Eective
Moderately
Eective
Very
Eective
1. Conduct a mental status assessment? 1 2 3 4
2. Evaluate a home environment for safety issues? 1 2 3 4
3. Evaluate a home environment as an indicator of a clients
mental health?
1 2 3 4
4. Identify behavioral symptoms of schizophrenia? 1 2 3 4
5. Identify behavioral symptoms of major depression? 1 2 3 4
6. Identify priority nursing interventions for clients with
serious mental illness?
1 2 3 4
7. Identify follow-up recommendations for clients with serious
mental illness?
1 2 3 4
8. Analyze strengths and weaknesses of communication skills? 1 2 3 4
9. Document a summary of your clinical ndings from the
home visit?
1 2 3 4
TECHNICAL DIFFICULTY
DIRECTIONS: The following items are technical and psychomotor skills related to SL simulation. Please circle the number that best
describes the perceived degree of diculty you experienced while using the SL simulation.
How dicult was it for you to:
Not At All
Dicult
Slightly
Dicult
Moderately
Dicult
Very
Dicult
1. Make certain that the computer you used met technical
requirements for the simulation?
1 2 3 4
2. Log into the SL program? 1 2 3 4
3. Create a username and password? 1 2 3 4
4. Transport to the Universitys Island? 1 2 3 4
5. Create your avatar? 1 2 3 4
6. Dress your avatar? 1 2 3 4
7. Use gestures, such as walking and sitting? 1 2 3 4
8. Transport to debrieng session? 1 2 3 4
9. Use online chat to communicate with the client? 1 2 3 4
10. View objects in the environment? 1 2 3 4
11. Navigate through house? 1 2 3 4
12. Save the interaction? 1 2 3 4
13. Print a copy of the interaction? 1 2 3 4
14. Log out of SL? 1 2 3 4
OPEN-ENDED QUESTIONS

DIRECTIONS: Write or list a few comments to the following questions.
What did you most enjoy about the SL simulation assignment?
What did you least enjoy about the SL simulation assignment?
Figure 4 (continued). Second Life simulation evaluation survey.
ng outc
u accom
helping you: Eective Eective Eective Eective
1 2 3 4
y issues? 1 2 3 4
icator of a clients 1 2 3 4
comes related to the SL simulation. Please circle the number that best describes the
mplish each outcome.
g you:
Not At All
Eective
Slightly
Eective
Moderately
Eective
Very
Eective
33 1OUPNAL OP PSCHOSOC|AL NUPS|NG - vOL. 50, NO. 7, 20l2
discussing the students strengths and
weaknesses in communication and as-
sessment, as well as a review of symptoms
exhibited. Students could problem solve
what they would have done differently
or ask the instructor ways of handling a
situation. Dialogue could be copied from
a chat log into a document that could
be saved for additional review. Students
were then required to complete docu-
mentation of their visit, which included
assessment, interventions, evaluation,
and recommendations for care.
At the end of the course, partici-
pants were asked to complete a survey
assessing educational effectiveness and
technical difculty of the SL simula-
tion. Survey data were collected after
the nal examination in the mental
health classroom. The Institutional
Review Board of the university granted
approval for the study.
Instruments
The SL Simulation Evaluation
Survey, a 35-item questionnaire com-
posed of both multiple choice and
open-ended questions, was developed
by the researchers (Figure 4). The
researchers chose to develop a new
instrument because existing surveys
were not specic to the SL virtual
technology as applied in the course.
Survey items were informally pilot
tested by course faculty. The sur-
vey consisted of demographic items,
educational effectiveness items, and
technical difculty items. Two open-
ended questions were also included,
asking students to state what they
liked most and least about the simula-
tion. The questions were added after
the rst student group completed the
survey. The researchers believed that
subjective comments would help fac-
ulty in their evaluation by providing
more specic information. A total of
109 students had the opportunity to
respond to open-ended questions.
Demographic items included stu-
dent age, ethnicity, and other items
such as age of computer that could
impact the students perception of
simulation effectiveness (i.e., older
computers could run slower or have in-
sufcient bandwidth to download the
SL program). Educational effective-
ness was measured with original items
requiring participants to rate effective-
ness on a Likert scale ranging from 1
(not at all effective) to 4 (very effective).
Examples of items measured were abil-
ity to conduct a mental health assess-
ment and ability to identify behavioral
symptoms of mental illnesses using the
SL program. Educational survey items
were based on learning objectives of
the activity. The dimension of techni-
cal difculty was measured with origi-
nal items requiring participants to rate
psychomotor skills and abilities need-
ed to use the program. Participants
were asked to rate technical difculty
on a Likert scale ranging from 1 (not at
all difcult) to 4 (very difcult). An ex-
ample of an item measuring technical
difculty was ability to navigate the
avatar through the house.
TABLE 1
DEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE N = 126
Characteristic Mean (SD), Range
Age (years) 26.05 (7.2), 20 to 58
n (%)
Sex
Female 105 (83)
Male 21 (17)
Ethnicity
Caucasian 112 (88.9)
Asian, American Indian, Alaskan Native, or Other 8 (6.3)
African American 6 (4.8)
Educational level
Some college 126 (100)
Bachelors degree 35 (27.8)
Graduate 3 (2.4)
Associate degree 2 (1.6)
Computer experience
Prior experience manipulating an avatar 65 (51.6)
Prior computer simulation experience 43 (34.1)
Prior Second Life

experience 1 (0.8)
TABLE 2
MEANS FOR EDUCATIONAL EFFECTIVENESS AND TECHNICAL
DIFFICULTY OF SECOND LIFE

SIMULATION
Educational Eectiveness Technical Diculty
Group Mean (Median) Mean (Median)
Fall I 29.35 (30) 22.24 (21)
Fall II 25.94 (27) 24.5 (24.5)
Spring I 20.55 (22) 28.57 (28)
Spring II 19.65 (21) 26 (26)
Combined 22.22 (22.5) 26.33 (25)
e
8
Sex
Female 105 (83)
Male 21 (17)
TABLE 1
DEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE N = 126 N
Characteristic Mean (SD), Range
Age (years) 26.05 (7.2), 20 to 58
n (%)
34 Copyright SLACK Incorporated
Data Analysis
Quantitative data analysis was per-
formed using SPSS version 19.0. De-
scriptive statistics were used to provide
information about demographic char-
acteristics of the sample as well as the
students perceptions of the simulation.
Educational effectiveness and technical
difculty were described by percentages
of student responses to the Likert scale
ratings. Correlations were conducted as
well to determine whether a signicant
relationship existed between perceived
educational effectiveness and perceived
technical difculty, between age of com-
puter and perceived educational effec-
tiveness, and between age of student and
perceived technical difculty. Qualita-
tive data were gathered through the use
of open-ended questions.
One hundred twenty-six students
participated in the study. The typical
participant was female, Caucasian, with
previous college education or a bach-
elors degree in another eld. She may
have used virtual simulation and an
avatar before but had not used SL before
this course. Demographic data are sum-
marized in Table 1.
FINDINGS
One students responses were ex-
cluded from the analysis because he
told the researcher he had deliberately
skewed his survey responses (and this
was borne out by review of what he had
submitted). Otherwise, 100% of eligible
students chose to participate and were
included in data analysis. Means for
educational effectiveness and technical
difculty were calculated for the total
sample, as well as for each semester and
each rotation (Table 2). Educational ef-
fectiveness scores had a possible range
of 9 to 36, with higher scores indicating
greater effectiveness. The mean for the
total sample was 22.22. Technical dif-
culty scores had a possible range of 14 to
56, with higher scores indicating greater
difculty. The mean for the total sample
was 26.33.
Results indicated that SL simula-
tion is moderately effective as a teach-
ing strategy (Research Question 1). The
total group mean decreased to approxi-
mately the 60th percentile of possible
educational effectiveness. SL simulation
is also slightly difcult as a technical pro-
gram (Research Question 2). The total
group mean decreased to the 27th per-
centile of possible technical difculty.
Correlations were performed us-
ing Pearsons r to determine degree of
relationship between educational ef-
fectiveness and technical difculty. A
signicant negative relationship was
found (r = 0.472; p < 0.01); thus, if the
student perceived technical difculty to
be greater, he or she perceived less edu-
cational benet. Another signicant,
weaker relationship found was between
age of computer and educational effec-
tiveness (r = 0.188, p < 0.05). Those
with older computers tended to rate
the simulation as less educationally ef-
fective. Finally, correlations were per-
formed to determine whether age was a
factor in perceived technical difculty,
as some research has suggested older stu-
dents may be more challenged by tech-
nology. No signicant relationship was
found; therefore, age was not a factor in
students perception of technical dif-
culty in this SL simulation.
Responses to the open-ended ques-
tions were reviewed by the researchers
and indicated that students identied
several benets of the SL activity. Some
of the aspects they most liked included
the opportunity to conduct a home
health assessment without the potential
safety risks (n = 16). The real-life aspect
of the simulation was enjoyable, requir-
ing quick thinking (n = 11). Some par-
ticipants liked that the simulation was
different than other class assignments
(n = 11). Others liked the focus on com-
munication skills (n = 6), ability to work
from home (n = 4), and ability to save
and review the interaction (n = 4).
Students also identied several nega-
tive aspects of the SL simulation. Things
that they liked least included difculties
in creating and dressing an avatar (n =
17) and maneuvering around the SL
world (n = 12). Some found the pro-
gram time consuming and difcult to set
up (n = 8). During the interaction with
the client, participants disliked waiting
for the instructor to type her response
(n = 7) and did not enjoy the virtual set-
ting, stating the program was not real
(n = 5). The majority of students citing
negative aspects stated avatars took too
much time to create or that they expe-
rienced technical difculties. This was
consistent with previous research about
SL, noting technical issues as a promi-
nent complaint (Gallagher-Lepak et al.,
2009; Inman et al., 2010; Kokol et al.,
2006). One student suggested that pro-
viding the students with readymade ava-
tars would increase effectiveness. Others
found there was not enough time to tour
the house, look at its contents, and have
a sufcient conversation with the client.
I was too rushed and could not multi-
task quick enough, one student stated.
Some students found the experience
inferior to real-life interaction, naming
frustrations such as not being able to
read avatar facial expressions adequately
or not taking the exercise seriously (In-
man et al, 2010).
DISCUSSION
Overall, results suggested that par-
ticipants found the SL simulation to be
a moderately effective teaching strategy
and a slightly difcult technical program.
This study has
important
implications for
mental health nursing
educators who
face challenges of
obtaining safe and
suitable clinical sites,
as well as shortages
of qualied nursing
instructors.
mately
educat
is also s
gram (
group
centile
Cor
ing Pearsons r to determine degree of r
relationship between educational ef- ff
fectiveness and technical difculty. A
signicant negative relationship was
of the simulation was enjoyable, requir-
ing quick thinking (n = 11). Some par n -
ticipants liked that the simulation was
different than other class assignments
y the 60th percentile of possible
tional effectiveness. SL simulation
slightly difcult as a technical pro-
(Research Question 2). The total
mean decreased to the 27th per-
e of possible technical difculty.
rrelations were performed us-
d i d f
tions were reviewed by the researchers
and indicated that students identied
several benets of the SL activity. Some
of the aspects they most liked included
the opportunity to conduct a home
health assessment without the potential
safety risks (n = 16). The real-life aspect n
f h i l i j bl i
35 1OUPNAL OP PSCHOSOC|AL NUPS|NG - vOL. 50, NO. 7, 20l2
Participants found both positive and
negative aspects about the program. In
this sample, no correlations were found
between sex, age, previous education, or
prior computer simulation use and per-
ceived educational effectiveness and per-
ceived technical difculty. Results of this
study were not consistent with previous
research demonstrating moderate corre-
lation between younger age and overall
satisfaction with the program (Cobb,
Heaney, Corcoran, & Henderson-Begg,
2009), but mean student age in this
sample was older than that in Cobb et
al.s (2009) study. Another notable nd-
ing was the correlation between educa-
tional effectiveness and computer age,
suggesting older computers led to more
technical problems and less satisfaction
with the simulation. Participants had
to learn how to navigate and maneuver
around the virtual world, which could
be frustrating at times, especially when
instructors were also unfamiliar with the
program.
Positive aspects were educational in
nature, including the ability to conduct
a home visit in a safe atmosphere, where
mistakes could be made without conse-
quence. In SL, students could explore
homes and interact with clients without
fear of harming or being harmed by the
patient. Virtual reality in health care
may help decrease anxiety and promote
new skill competence, cooperation, and
collaboration (Hansen, Murray, & Erd-
ley, 2009; Kilmon et al., 2010). Many
students found the program realistic and
enjoyed thinking on [their] feet. Also,
saving, printing, and discussing the in-
teraction during a debrieng session
with faculty increased learning, allowing
the student to critique communication
skills. Computer-based experiences may
be easier to schedule than traditional
clinical experiences requiring multiple
instructors or standardized patients
(Kilmon et al., 2010).
It is interesting to note that group
means for educational effectiveness
decreased throughout the study. Fall
I rotation means were highest (29.35,
with perceived effectiveness falling in
the 88th percentile), with Spring II
means lowest (19.65, 50th percentile).
Spring semester means overall may
have been inuenced by the inclusion
of part-time instructors less familiar
and comfortable with SL. Spring II
means may also have been inuenced
by attitudes of students eager for sum-
mer break; in addition, the majority
of this class was accelerated students
with heavy courseloads. The amount
of time required to set up SL may have
seemed more of a burden and inu-
enced their perceptions of educational
effectiveness.
STUDY LIMITATIONS
Limitations included use of a con-
venience sample with no control
group. The survey instrument was
newly developed for the study and
was not subjected to parametric test-
ing; thus, reliability and validity of
the instrument are uncertain. Data
collection methods may also have
had a negative inuence on survey
results. The survey was administered
in class after the nal examination,
which may have forced students to
answer the questions quickly due to
time restraints or because they wished
to leave sooner. Some items were un-
clear to students.
Finally, attitudes of faculty admin-
istering the SL simulation may have
inuenced students attitudes toward
the program. As faculty members
were new to SL, they may have been
lacking in condence and comfort
with technical aspects of the program
or the simulation design itself. In the
fall semester, the program was piloted
by lead course faculty, both of whom
had been actively engaged in concep-
tion and design of the simulation; in
the spring semester, part-time clinical
faculty were added. Part-time faculty
had not participated to any degree in
development of the simulation; they
may also have had difculty investing
the time required to master the pro-
gram. Any impact of faculty attitudes
may resolve as they become more
comfortable with the simulation.
IMPLICATIONS FOR MENTAL
HEALTH NURSING EDUCATION
This study has important implica-
tions for mental health nursing educa-
tors who face challenges of obtaining
safe and suitable clinical sites, as well as
shortages of qualied nursing instruc-
tors. SL simulation has great potential
for distance learning and could be fur-
ther developed for use in other nursing
courses. The study should be repeated
KEYPOINTS
Kidd, L.I., Knisley, S.J., & Morgan, K.I. (2012). Eectiveness of a Second Life Simulation
as a Teaching Strategy for Undergraduate Mental Health Nursing Students. Journal of
Psychosocial Nursing and Mental Health Services, 50(7), 28-37.
1. Virtual reality simulations in online worlds such as Second Life

(SL) can be
used to teach nursing students skills such as mental status assessment and
communication.
2. Mental health nursing undergraduate faculty developed a realistic simulation
that involved client avatars (instructors) in their home environments being
interviewed by student avatars.
3. Students surveyed rated the SL simulation as moderately eective as an
educational strategy and slightly dicult technically.
4. Positive aspects cited by students about the simulation were thinking on their
feet and being able to make mistakes without regard for consequences or
safety. Negative aspects included awkwardness with technical aspects and
insucient realism.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to the Journal at jpn@healio.com.
of
used to teach nursing students skills such as mental status assessment and
communication.
2. Mental health nursing undergraduate faculty developed a realistic simulation
KEYPOINTS
Kidd, L.I., Knisley, S.J., & Morgan, K.I. (2012). Eectiveness of a Second Life Simulation
as a Teaching Strategy for Undergraduate Mental Health Nursing Students. Journal o
Psychosocial Nursing and Mental Health Services, 50(7), 28-37.
1. Virtual reality simulations in online worlds such as Second Life

(SL) can be
used to teach nursing students skills such as mental status assessment and
36 Copyright SLACK Incorporated
with a larger sample at this institution
and perhaps expanded to a multisite
design in future research. Technical
difculties experienced by students and
faculty members need to be resolved, as
this was signicantly related to student
perception of educational effective-
ness. The survey instrument should be
subjected to parametric testing. Most
important, future research could be
more rigorous, going beyond measuring
educational effectiveness based on stu-
dent perception to answering the more
important question of whether learning
outcomes were achieved.
Study results suggest the necessity
of training faculty to use the SL pro-
gram. While integrating virtual tech-
nology simulations into nursing cur-
riculum is exciting, educators and the
teaching presence they provide are an
essential element of both clinical and
simulation experiences. SL simulation
training needs to be made available to
nursing instructors to help them feel
comfortable with the new technology.
More training will also equip faculty to
design and facilitate curricular content
enhancing communication and critical
thinking. It is important that learning
activities are designed to closely con-
nect to course educational objectives
(Kokol et al., 2006).
Students also need time and practice
to feel comfortable with the program.
As implemented in the mental health
nursing course, students obtained an
avatar for a one-time interaction. This
may have seemed too much effort for
too little return. Development of social
presence and building online commu-
nity (more individuals than a dyad)
may require more interaction and col-
laboration to be effective (Garrison et
al., 2000). Some would argue that in-
teraction with an avatar could never
replace interaction with a live person;
therefore, maximum realism of the pro-
gram is essential to enable students to
feel comfortable with their avatars.
CONCLUSION
Results of this study suggest that ap-
plication of virtual technologies provides
a unique learning opportunity. With
growing student enrollments, faculty
shortages, diminishing clinical resourc-
es, and the private nature of communi-
cation and the therapeutic relationship,
SL simulation has real potential as an
effective tool for mental health nursing
educationaccessible, convenient, and
safe for skills experimentation.
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Dr. Kidd is Assistant Professor of Nursing, and
Ms. Morgan is Senior Clinical Instructor, The Uni-
versity of Akron College of Nursing, Akron, and Ms.
Knisley is Sta Nurse, Summa Barberton Hospital,
Barberton, Ohio.
The authors disclose that they have no
signicant nancial interests in any product or class
of products discussed directly or indirectly in this
activity, including research support.
Address correspondence to Lori I. Kidd, PhD, RN,
CNS, Assistant Professor of Nursing, University of
Akron College of Nursing, 209 Carroll Street, Mary
Gladwin Hall Room 201-D, Akron, OH 44325-3701;
e-mail: kidd@uakron.edu.
Received: December 1, 2011
Accepted: May 16, 2012
Posted: June 15, 2012
doi:10.3928/02793695-20120605-04
a uniq
growin
shortag
es, and
cation
SL sim
effectiv
educationaccessible, convenient, and
safe for skills experimentation.
REFERENCES
Kameg, K., Mitchell, A.M., Clochesy, J., Howard,
V.M., & Suresky, J. (2009). Communication
and human patient simulation in psychiatric
nursing. Issues in Mental Health Nursing, 30,
que learning opportunity. With
ng student enrollments, faculty
ges, diminishing clinical resourc-
d the private nature of communi-
and the therapeutic relationship,
mulation has real potential as an
ve tool for mental health nursing
i ibl i d
Inman, C., Wright, V.H., & Hartman, J.A. (2010).
Use of Second Life in K-12 and higher educa-
tion: A review of research. Journal of Interactive
Online Learning, 9, 44-63.
Johnson, C.M., Vorderstrasse, A.A., & Shaw, R.
(2009). Virtual worlds in health care higher
education. Journal of Virtual Worlds Research,
2(2), 3-12. Retrieved from http://journals.tdl.
org/jvwr/article/view/699
K K M h ll AM Cl h J H d
37 1OUPNAL OP PSCHOSOC|AL NUPS|NG - vOL. 50, NO. 7, 20l2
Reproducedwithpermissionofthecopyrightowner. Furtherreproductionprohibitedwithoutpermission.