It’s coming up to a year since we interviewed DeeAnna Nagel and Kate Anthony and discussed counselling in online environments broadly and in virtual environments more specifically. Over that time, the Online Therapy Institute has continued to grow. One example of this is the announcement of a five-hour course on online supervision.

Anyone who works in a counselling role will understand the importance of supervision as both a development and protective mechanism for a practitioner, let alone one working in an online environment. Additionally, a key plank of more widespread acceptance of online therapy is formalised governance mechanisms that provide peace of mind in regards to quality. Small steps like the ones taken here are helping to achieve just that.

The wider challenge is establishing e-health standards that ensure confidentiality, the ability to confirm practitioner credentials and good service navigation for face-to-face intervention when required. That sort of integration is potentially years off, but in the meantime counselling professionals are doing a great job of filling in the gaps.

If you’re involved in counselling in a virtual world environment, I’d love to hear from you to find out more about your work.

Update: an interview with the Online Therapy Institute in Second Life is now available:

The Journal of Medical Internet Research has published a study on the outcomes of a a pilot postgraduate medical education program at the Boston University School of Medicine presence in Second Life.

You can read the full paper here, but the synopsis of the study is:

1. Fourteen physicians participated in the pilot, with twelve providing feedback.

2. The learning exercise was related to Type 2 diabetes, with participants surveyed on any change in confidence and performance, as well as attitudes toward the virtual learning environment itself.

3. Confidence increased after the Second Life event, in respect to selecting insulin for patients with type 2 diabetes, initiating insulin and adjusting insulin dosing.

4. There was an increase to 90% (from 60%) of participants initiating correct insulin dosages.

5. The percentage of participants who provided correct initiation of mealtime insulin increased from 40% to 80%.

6. All twelve participants surveyed agreed that their experience in Second Life was an effective method of medical education.

7. All twelve also agreed that “the virtual world approach to CME was superior to other methods of online CME, that they would enroll in another such event in SL, and that they would recommend that their colleagues participate in an SL CME course.”

8. Two of the twelve disagreed with the statement that Second Life provided a superior to face-to-face option for continuing medical education.

The take-home message? Nothing new really: virtual environments can be very useful for education. The small sample size is obviously worth noting. Additionally, I remain amazed at the positive feedback garnered for education sessions held in Second Life given the rudimentary aspects of the platform itself i.e. the need to type responses in chat and viewing what’s essentially a Powerpoint presentation (as shown in the picture above). That’s not to take away from the work the University of Boston have done, it’s just one key aspect for future studies: how much of the positive feedback on virtual environments is the ‘wow’ factor experienced by newer users versus the well-established data on immersion and its benefits?

Another key point for me was this:

Our search of English language peer-reviewed publication databases did not identify any formal evaluation of the educational effectiveness of health professional training in SL or other virtual worlds.

Studies like this one are helping to address that gap, but there’s plenty more to be done. What’s fairly certain is that work is underway and within 12-18 months there’s likely to be a significant body of work pointing out the opportunities and challenges virtual worlds present for health-related training and education.

“I am looking for participants, male and 18+ to complete a survey regarding both their real world and virtual world body images and psychological states.”

He needs 300 or so participants to take the survey. It’s a fairly intensive process, which takes around 15-20 minutes. If you have that time to give, then go make a contribution toward the increased understanding of how we perceive ourselves in the virtual and real worlds.

Link to the survey

Coming from a nursing background myself, I’m always fascinated by the work going on in virtual environments in regards to nurse education. To some extent it’s a natural fit in that clinical simulation is a pivotal part of the education process for nurses anyway – using virtual environments is simply an extension of recognised practice.

Evelyn McElhinney (SL: Kali Pizzaro) is a Nurse Lecturer in the post-registration department of Glasgow Caledonian’s School of Health. She teaches a number of advanced practice modules including modules within the Nurse Practitioner pathway. She joined the university full time 3 years ago, and was a lecturer/practitioner working in an advanced practice role within the National Health Service prior to that and has worked in a number of acute care areas including anaesthesia. Evelyn also happens to be active in the use of Second Life in Nurse Practitioner training, so I caught up with her to discuss her work to date and some broader issues around collaboration.

Lowell: From a nursing education viewpoint, what are your key areas of professional interest / research focus?

Kali: Advancing practice, physical examination, clinical simulation, and recently the use of virtual worlds for Nurse Practitioner Education.

Lowell: When you say nurse practitioner, can you define that a little? I’m assuming you mean someone undergoing their undergraduate nursing education?

Kali: Ah no in the UK Nurse Practitioners are Registered Nurses who are advancing their practice. A nurse who takes a history, physical examination, diagnoses, prescribes and treats.

Lowell: Ok, that’s similar to Australia then. So are there particular advantages for using virtual worlds with more experienced nurses like practitioners rather than nursing students?

Kali: The advantages are that they need flexibility as they have competing demands on their time. So any medium that allows for extra practice in a time conducive to them is attractive. However, virtual worlds can do more than the usual virtual learning environment.

Lowell: When did Second Life become a consideration in your work?

Kali: I considered Second Life after seeing a project by one of my colleagues. I had know about it’s existence as the University had a project exploring it’s use for marketing. That was in March this year.

Lowell: Can you describe the work you’re doing in Second Life and how it links to the University’s CU There initiative?

Kali: I am trying to develop a virtual patient which will be used by Nurse Practitioner students to practice history taking. I have also embedded heart sounds into the avatar’s chest to enable the student to link the history to the heart sounds they hear. They must click on the correct anatomical position to hear the sounds. This work links to the CU There project as it fulfills the criteria for use of virtual worlds in education. By creating an AIML bot/bots the students have the flexibilty to practice at any time either as an individual or as a group. I plan to have a number of patients and to build on the sceanrios to create longer problem-based learning scenarios. The bot we use were developed by myself and the School technician Andy Whiteford aka AndyW Blackburn.

Lowell: So what level of work has been required to get the lab to this stage and how much more is involved to get it to where you’d like it to be?

Kali: The clinical skills lab was designed by the CU There team with guidance from the head academic in charge of the simulation lab . The build was done mainly by a computer student who is seconded to the team. There are plans to build an ITU for a scenario for 3rd year students. For my scenario it is mainly me thinking of ways to expand each scenario in alignment with the needs of my students.

Lowell: The most common feedback I’ve gotten from nursing academics is a skepticism on what virtual worlds offer that a well integrated curriculum with comprehensive leraning management tools can’t, that is, aside from the advantage of not needing to get students to a real-world simulation lab, are there other benefits of working in environments like this?

Kali: The immersive environment enables authentic scenarios to be developed. There is also the ability to offer syncrounous text and voice communication, as well as the ability to show the whole class videos etc. We can also simulate things that would be difficult in real life.

Lowell: Is there an example of that you currently use?

Kali: Not at the moment. However, for undegraduates it could be useful for them to be inside a heart or lung to understand the anatomy and physiology. It is also much more interactive than other VLE’s.

Lowell: I suppose that’s the crux of the challenge for nursing educators using virtual environments: convincing others that things have moved beyond the gimmicky, would you agree?

Kali: Yes, you need to show them something that is pedagologically sound, something they can see is useful.

Lowell: On pedagogy, what do you see as the key foundations in your work and in virtual environments more broadly?

Kali: Constructivism and social constructivism are the key learning theories in my work. By linking history and heart and lung sounds to other parts of a clinical scenario, I am building on the students previous knowledge to create new knowledge. People in simulations tend to act the same as they do in real life. The ability to capture the text allows for reflection on the decision-making of this particular group.

Lowell: What has the feedback been from students?

Kali: Positive- they can see they value. They feel they are in the sceanrio. However, it is early days. We have only had a few folk through as a pilot. We will be using it more in the next two semesters.

Lowell: Are there formalised evaluations planned on clinical skills training in Second Life ? Will there be comparative studies on those who used such tools versus those who didn’t and their subsequent outcomes?

Kali: Yes, a number of academics are evaluating their projects and one is plannning to compare in-world and out-of-world simulation. Some of these are through a University scheme, Caledonian Scholars.

Lowell: What’s your take on nursing research in virtual environments internationally? Is it fair to say it’s still very early days?

Kali: Yes, there are a number of good projects. However, it is still in it’s infancy. Simulation seems to be the most popular project.

Lowell: Is there any research completed or underway that has particularly interested you?

Kali: Many projects have impressed me. For example the work of John Miller at Tacoma, the Imperial College in London and the Ann Myers Medical Center. However, any project which is being used by students impresses me. With regards to research most are evaluations, however, my own university has just completed some research into student nurses’ clinical decision making (Dr. Jacqueline McCallum, Val Ness, Theresa Price, Andy Whiteford).

Lowell: Can you discuss what it’s found?

Kali: It’s still in publication, however a lot of what the students said was that they wanted to experience areas they had not been to, and that they also found the scenario exhausting. Interestingly, they did not do a single observation in an hours sceanrio in a busy surgical ward. They also did not know what to do with a patient who was demented and kept leaving the ward. I think they were too busy thinking what to do next, this was despite being prompted to do observations.

Lowell: You raise a very interesting point – perhaps virtual environments make a more natural stage for making errors as there isn’t the stress of the educator looking over their shoulder?

Kali: Maybe, although this sceanrio had educators involved. Although that is the beauty of simulation – make mistakes and no-one dies

Lowell: For the nurse who has been working in either a hospital or community setting for five years or more, how do you make virtual environments like Second Life an appealing and logical extension of their professional development needs?

Kali: By making the scenarios authentic and as realistic as possible. Also they must be available at all times to ensure maximum flexibility. The student must see the value to be motivated to take part. If they are fun, then great.

Lowell: Do you think Second Life is at a stage of usability that it can achieve that now?

Kali: Not yet in the UK – it is still not widely know as a social tool. However, if it is introduced in education they may see more value, as it helps them to learn.

Lowell: On usability though – it’s still quite a learning curve to actually use, particularly for those not as net-savvy as others?

Kali: Well you could say that about any VLE, and it is really only arrows and clicking. Changing clothes is not mandatory for education. Well, not all education. I think most folks would get it in a short space of time with some guidance.

Lowell: Again specific to nursing, is there any great degree of collaboration going on internationally in regards to projects like these? How do you think nursing faculties could further improve collaboration?

Kali: We are exploring a couple of collaborations. I know Scott Deiner in New Zealand has collaborated with American colleges. However, there is the potential for major collaboration both nationally and internationally. Although you need to have a firm idea about what you want to collaborate on. Also there is still a little bit of folk finding their feet, so to share is still scary methinks.

Lowell: Do you think there’s the critical mass for organised collaborative structures such online journals or other formats for working together?

Kali: There could be, and the Virtual World Watch here has opened up avenues for collaboration by highlighting the people who are involved with virtual worlds, although there is a bit to go.

Lowell: So for a nursing academic looking to integrate virtual environments into their teaching or research, would you have any simple advice?

Kali: Make sure you think about what you want to use it for. Script the scenario and look around at other people’s work to find out what the virtual world is capable of. Also visit educational areas and talk to other academics or join a group. Make sure there is a strong pedagogical structure to your idea and show it to folks when you have something to show!! Seeing is believing.

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To view the publicly accessible clinical skills laboratory in Second Life, go here.

On the 6th December there is a workshop session on games for health, supported by HISA. Registrations are through http://www.gameconnectap.com/register.html (Forum pass, Sunday only).

This event is a key part of the strategy to create momentum in games for health in Australia, so if that’s an area of interest for you, this is a must-attend event.

Over the past few weeks, there’s been a spike in mainstream media interest around virtual environments and health. I thought it’d be worth showcasing three notable stories / issues that you may not be aware of.

Amputee Support

A press release from ADL Company Inc. and Virtual Ability, Inc. touts the launch of a project to provide peer-support to those who have undergone amputation of a limb. The project’s impetus has come about due to some sobering US-based facts:

Recent US military casualty figures for Operation Iraqi Freedom and Operation Enduring Freedom indicate that between September 2001 and mid-January 2009 over a thousand amputation injuries occurred. Of the 935 amputations considered major, one in five wounded warriors lost more than one limb. While the rehabilitation goal is for the soldier to return to active duty, many reintegrate into their civilian communities. In either case, military amputations are often accompanied by additional wounds, depression, fear, phantom limb pain, and post traumatic stress disorder.

Spouses and family members often become the caregivers of military amputees after they are released from military hospitals and rehabilitation programs. Family support members have their own grieving process to go through related to the amputation and to the change to family life.

The platform for the project is the recently released Second Life Enterprise product, meaning that users have a greater deal of privacy to explore issues in a group context. You can also read about the project from the perspective of ADL Inc’s President, and regular virtual worlds writer, Doug Thompson (SL: Dusan Writer).

Avatars: Perceptions of Self

New Scientist has a good article on a study looking at brain activity (as measured by MRI) when discussing perceptions of real self versus a heavily played World of Warcraft character. The methodology:

To probe what brain activity might underlie people’s virtual behaviour, Caudle’s team convinced 15 World of Warcraft players in their twenties – 14 men and 1 woman – who play the game an average of 23 hours a week, to drag themselves away from their computers and spend some time having their brains scanned using functional MRI.

While in the scanner, Caudle asked them to rate how well various adjectives such as innocent, competent, jealous and intelligent described themselves, their avatars, their best friend in the real world and their World of Warcraft guild leader.

For the early results, read the article, but essentially things aren’t black and white about how we perceive ourselves versus our avatars. No big surprise there. One particularly interesting signpost for future research is the idea that those who perceive themselves and their avatars in a similar way may be the individuals at higher risk for addictive behaviours in regards to their use of virtual environments.

Health Games Research

Health Games Research is a website well worth perusing. It’s a US-based organisation devoted to “research to advance the innovation and effectiveness of digital games and game technologies intended to improve health”. There are yearly grants for research into games and health, with the 2009 funding round announced last week.

The purpose of R.I.S.E. U.P is singular: to provide an interactive, engaging way for people to find out more about lymphoma. For the veteran Second Life resident, there’s nothing particularly ground-breaking about the approach, but that’s not really the point. Given the importance of the health topic, it needs to be communicated clearly and somewhat simply – it’s about retention not entertainment. R.I.S.E. U.P. achieves that – there’s links to traditional web content, streaming media and a ‘Node Man’, which provides an effective way of showing the myriad of lymph nodes around the human body.

Collaborative partnerships

A noteworthy aspect of the project is its backing by the medical profession, private enterprise, key peak bodies and a range of people who have lymphoma. I took the opportunity to shoot some questions to Professor Jeff Szer, Clinical Haematologist at the Royal Melbourne and Western Hospitals to get his take on the project:

TMJ: What for you would demonstrate that the presence in Second Life has been successful?

Professor Szer: Pairs of eyes – how many people attend the general public presentations on lymphoma, as well as the number of YouTube replays. How many questions received during the presentations – there were a few during the first presentation this week.

TMJ: Do you believe there is growing acceptance of the use of virtual environments as a health education tool within the Australian medical profession, or is it still a case of pockets of innovators fighting against significant scepticism?

Professor Szer: My view is that there is growing uptake of this form of communication. The patients and families are better at this than the profession so we need to engage it proactively.

TMJ: As virtual environments continue to evolve, are there further education or actual interventions you’d like to be able to offer in regards to lymphoma or related disease states?

Professor Szer: I can see many educational opportunities for this type of live interaction. Another patient group that values education is the multiple myeloma population and there may be some interest from the patient groups (such as Myeloma Australia in Australia) in pursuing such an event. Currently, many of these activities are conducted through webinars or the like and this adds another possible dimension of interaction. My only concern is the behind-the-scenes work involved in setup which I suspect was far greater that I was exposed to.

I also had the chance to ask some questions of a lymphoma sufferer, 60-year old Anna Blyth, who I’d like to particularly thank for taking the time to respond (see Anna’s experience with lymphoma at the end of this post):

TMJ: Are virtual worlds like Second Life something you see as being useful for receiving health information i.e. does it provide something that other routes of communication like traditional websites can’t?

Anna Blyth: My experience with virtual worlds is very new and I’ve found that in comparing the communication of information with traditional websites, they are very different. When I looked for information on non-Hodgkin’s lymphoma (NHL) on traditional websites I was pretty overwhelmed. There was a lot of medical language that I didn’t understand very well. There was also a lot of research data that I couldn’t quite follow. And because there are so many types of lymphoma, I found it difficult to find information on the specific one that I have. I also found many sites conflicting with other ones in regards to long term outcome and the benefits of different forms of treatment.

Going to Second Life and visiting R.I.S.E. U.P., I was very impressed. The graphics are great and I felt that I was actually in a place that ‘real’ – as is intended of course. But the feeling is a good feeling and a calming feeling when looking for information regarding my health. I found it exciting visiting the different places and reading the information available on lymphoma. The information is direct and easy to understand and going into the Node Man was great also because I could see exactly where lymph nodes are and relate that to my body.

TMJ: How would initiatives like R.I.S.E. U.P. have helped you in your particular circumstance if it had been available?

Anna Blyth: When I was diagnosed in 2007, apart from websites to look up my cancer there wasn’t anywhere else to go. I got totally confused which really increased my overall state of anxiety. If I had been directed to the virtual world of R.I.S.E. U.P. I believe that I would have stayed away from the traditional sites and focused on the virtual world. With the simplicity of the tour, the information available and other events such as lectures etc., I think I would have understood my cancer much better. As I described in question one… the overall feeling of being in a real world would have helped me to not feel so alone and I would have had a much more positive experience as I learnt about lymphoma. Instead I was in a state of constant anxiety and fear as to what to believe from which traditional website.

Finally, I asked some questions of Libby Day, Roche Products’ Australian Director of Corporate affairs:

TMJ: Can you outline why Roche chose to get involved in virtual environments as a health education tool?

Libby Day: Roche Products has been committed to improving the health and well-being of people across the world for more than 50 years. Lymphoma is the most common blood cancer and the incidence has doubled over the past 20 years for no known reason, yet new statistics released by Lymphoma Australia reveal that one in five Australians do not know what lymphoma is, and less than 20% can name at least one common symptom. Furthermore, nine out of ten people don’t realise exactly how common lymphoma is within the population, even though more than 4,000 Aussies are diagnosed with the cancer each year.

Australians are increasingly going online to search for health information. After consulting with their doctor, the internet is the most popular source of health information. With the support of a number of health consumer organisations, Roche Products is aiming to meet this need by providing easily accessible lymphoma information to the general public through R.I.S.E. U.P. For many people, receiving a diagnosis of lymphoma is a particularly frightening and overwhelming experience because they have a low awareness of the disease. Furthermore, early detection can make a huge difference in the ability to combat this often life-threatening cancer, making the provision of accurate information critical.

There is a lot of misinformation about healthcare on the internet and Roche is committed to helping ensure that people are accessing correct and accurate resources.

TMJ: Does Roche have any involvement with Second Life outside of this project?

Libby Day: R.I.S.E. U.P. is the first Roche health awareness initiative to be launched within Second Life and is currently in its pilot phase – future plans for the initiative will be confirmed once it has been tested and evaluated. Roche is pioneering the provision of virtual health education amongst the pharmaceutical community and is, as yet, the first organisation to do so.

TMJ: Outside of this project, dose Roche see virtual environments as a means of maintaining competitive advantage in a competitive marketplace?

Libby Day: The virtual space is a growing area for all business sectors. With regards to education, as mentioned previously, we know that people searching for information regarding health are increasingly turning to the web. Projects such as R.I.S.E. U.P. will hopefully fill a void.

With regards to maintaining a competitive advantage, it is early days but even in this pilot phase, the virtual world technology is promising. At this early state, Roche Australia is only piloting the program and needs to address the technological barriers which have been detected during the test. This technology means Roche delegates can communicate in an engaging manner, at anytime and anywhere. From here, Roche Australia is working to strategise on how best to maximise the value of this technology.

TMJ: Does Roche have any plans in Second Life or other virtual worlds for the future?

Libby Day: The R.I.S.E. U.P. initiative is currently being piloted in Second Life and future plans for the initiative will be confirmed once it has been tested and evaluated.

Upcoming events at R.I.S.E. U.P

For those wanting to find out more or to enjoy some of the activities going on in coming weeks, here’s the details:

Until Saturday 24 October: Robin Roar, a R.I.S.E. U.P ambassador and Second Life expert, will be available to answer any questions you may have about R.I.S.E. U.P. and take you on a tour of the facilities. AEST: Tues‐Sun, 12:00‐17:00. Second Life time: Mon‐Sat, 05:00‐10:00.

Tuesday 27 October – Professor Jeffrey Szer, Clinical Haematologist at the Royal Melbourne and Western Hospitals in Australia, will hold a brief seminar on lymphoma signs and symptoms in the Auditorium. Professor Szer will be available to answer any questions R.I.S.E. U.P. visitors may have. AEST: 14:00. Second Life time: 21:00.

There’s also some music events going on – check out the details on R.I.S.E. U.P itself.

The Sum Up

As a health professional myself, I’ve long had a passion for using a range of methods to get crucial health information disseminated within the community. VIrtual environments are no exception to this, and given their growth, initiatives like this are key early steps. Skeptics may point to a lack of clarity around outcomes versus the cost of implementation. That tends to miss the point to a large extent. As Professor Szer stated: it’s consumers who are driving the momentum in the use of social media for health information. If companies like Roche Products are going to engage in brand recognition exercises in Second Life, I can’t think of a better way for them to do so.

Finally, the machinima created for the project gives a nice summary of R.I.S.E. U.P’s intent:

Check it out in-world

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Anna’s story:

• Anna noticed a large lump above her collar bone in late September 2007 and was initially advised to have it removed for cosmetic reasons
• However, five weeks later, Anna was diagnosed with Hodgkin’s Lymphoma
• Anna was not prepared for this, as she was initially told she wasn’t at risk of a cancer diagnosis
• She found it particularly difficult to tell her husband and four children about her diagnosis, as her family is very close
• Later that week, Anna underwent blood tests, a CT scan and a surgical biopsy. She was soon admitted to Cabrini Brighton Hospital and found herself in intensive care following an anaphylactic reaction to one of the anaesthetic agents. She was unconscious for over an hour until the medical team were able to revive her
• Following surgery, Anna was official diagnosed with Follicular Lymphoma and her diagnosis was a shock. She felt physically and emotionally exhausted and found herself in a surreal state
• Anna’s treatment consisted of twelve weeks of chemotherapy and a targeted biologic therapy. Throughout the treatment, she felt 100% supported by her family and a group of great oncologists
• On the ninth week of treatment, Anna’s oncologist informed her that the treatment was successful and she was cancer free
• Anna has now officially been in remission since April 2008 and she is a proud wife, mum and grandmother