A Paradigm Shift in Simulation: Experiential Learning in Virtual Worlds and Future Use of Virtual Reality, Robotics, and Drones


A Paradigm Shift in Simulation: Experiential Learning in Virtual Worlds and Future Use of Virtual Reality, Robotics, and Drones

E. LaVerne Manos / Nellie Modaress


Hundreds of leading schools and universities across the globe employ multiple user virtual worlds (VW) such as Second Life® (SL) as an innovative part of their educational courses and programs. Online VWs have multiple uses for teaching and learning. This environment enhances student engagement with course content, develops a sense of community among and between students and faculty, and creates a powerful platform for interactive experiences that brings new dimensions to support best practices for learning. In this virtual environment, students and faculty work together from anywhere in the world giving education a global perspective and an expanded reach.

A major challenge for online education is student engagement and the evaluation of skill attainment. Virtual worlds provide an online, virtual laboratory that addresses this challenge. Faculty and student avatars can interact with each other, physically and verbally, in real time, thus facilitating simulations where students engage in demonstrating skill acquisition. Faculty can coach the skill development, as they now control the environment and can see what the student is doing. This type of evaluation in a real or simulated environment was previously unattainable in an online course. Furthermore, the VW environment provides a forum for student presentations and interactions with a live audience. Field trips to other VW environments create opportunities to hone skills in information searching and observation of activities and settings that can be viewed by the faculty and other students. The practice of virtual learning environments alongside advance uses of digital devices has grown to include virtual and augmented realities. In addition, virtual learning environments have led practitioners to contribute to research on experiential learning.

This chapter is an in-depth discussion of the educational application of virtual worlds with emphasis on Second Life and a look toward the future use of several technologies in healthcare education including an introduction to newer innovative technologies. An exemplar describing current innovative implementation of technology and a use case to explore potential future use of innovative technologies in education are also presented. Exemplars and use case examples at the end of the chapter are related to virtual reality (VR), mixed reality (MR), augmented reality (AR), robotics, and drones.


Second Life (www.secondlife.com), a 3-dimensional (3D) VW developed by Linden Lab and uniquely imagined and created by its residents, was launched in 2003. Virtual worlds and augmented reality are subsets of virtual reality, which is defined as “an artificial environment which is experienced though sensory stimuli (such as sights and sounds) provided by a computer and in which one’s actions partially determine what happens in the environment” (Merriam-Webster, n.d.-b).

SL is considered the largest virtual world with tens of millions of square meters of virtual land and more than 36 million registered users. Currently, SL is the most mature and popular virtual world platform being used in education. There are several dozen VWs giving SL serious competition Most of these are still small, and even the largest does not come close to matching Second Life’s massive land and user base. Over the past decade, a large number of colleges and universities have established a presence in SL (Michels, 2008; Knapfel, Moore, & Skiba, 2014; Vrellis, Avouris, & Mikropoulos, 2016). These efforts are largely for teaching courses, but they also include recruitment activities for prospective students, fund raising, and research endeavors. Today, disenchanted with commercial VWs but still convinced of their educational value, some institutions have started to build their own environments in which they have more control over the learning space (DePaul, 2018; Young, 2010).


Teaching in a virtual environment differs from teaching a traditional online course due to the 3D setting and use of avatars to represent the participants and the sense of presence (Hellyar, Walsh, & Altman, 2018; Johnson, 2009; Calongne, 2008; Richardson & Swan, 2003).

The lack of sense of presence has always been a major difficulty and critique of online education, and educators of distance learners face pressure to meet the needs of the students. Technology is a platform that provides opportunities to reduce the online learner’s sense of isolation and distance. Virtual worlds such as SL facilitate real-time interaction between faculty and students when they are geographically apart. Furthermore, the environment can be controlled or simulated to create learning experiences designed by the faculty member to achieve pedagogical goals. These planned learning environments previously had to be in one physical place (e.g., learning laboratories, clinical facilities). SL supports online education by moving the geography to a virtual space, thus creating a sense of presence for the faculty and students. The sense of presence is important for learner engagement, regardless of whether the experience is real or virtual. Presence is defined as “the subjective experience of being in one place or environment, even when one is physically situated in another” (Witmer & Singer, 1998). When in-world, the students feel as if they are actually in the virtual environment. A sense of immersion is also necessary for learning, immersion is the sense of being enveloped by and interacting with the environment. Involvement is “a psychological state experienced as a consequence of focusing one’s energies and attention on a coherent set of stimuli or meaningfully related activities and events” (Witmer & Singer, 1998). Second Life activities and simulations create presence and immersion for faculty and students, whether they are in traditional classes or online classes. Students involved in the SL learning experience report a “sense of presence and connectedness” (Tiffany & Hoglund, 2014).

Faculty use virtual environments for learning activities that require students to use higher order thinking. Students have the opportunity to exercise higher order thinking skills through creativity, application of concepts, analysis, synthesis, and problem-solving using course content and previous knowledge. Teaching strategies include role-play, gaming, simulation of social and clinical skills, collaboration, social networking, and participation in live events such as lectures, conferences, and celebrations. Faculty are finding that they can stage clinical simulations, guide students through the inside of cell structures, or present other imaginative teaching exercises that cannot be done in “real life” due to cost, scheduling, location, or safety issues. The truth is we do not yet know all the possibilities of what we can and cannot do with this tool for education. There are active educational special interest groups, conferences, and listservs enabling faculty to share pedagogical strategies, ideas, and simulations. As Knapfel, Moore and Skiba (Knapfel et al., 2014) recommend, continued research is needed to explore best practices for use of virtual environments in education and practice.


Although it is not the purpose of this chapter to discuss learning theory in detail, it is important to know there are several learning theories that support teaching and learning in virtual worlds. Technology for teaching and learning should always be selected to fit with the pedagogy. First consider the goals for the course, and then select the technology tools and strategies that will help to meet the proposed outcomes.

To begin with, learners in SL are adults, and therefore Malcom Knowles’ (Knowles, 1984) theory of andragogy provides an overarching framework for designing learning activities for adult learners. Andragogy is based on the following assumptions about adult learners: (1) adults are self-directed, goal-oriented, and need to know why they are required to learn something; (2) they approach learning as problem-centered rather than content-centered; (3) they need to recognize the value of learning and how to incorporate that learning into their jobs or personal lives; and (4) they learn best through experiential learning that incorporates their diverse life experiences in the development of new knowledge. Since adult learners take a great deal of responsibility for their own learning, this alters the role of the faculty in learning environments in general but especially in virtual worlds such as SL. It also should be noted that environments like SL are well suited to applying the assumptions of adult learning theory; however, teachers and learners must adapt to this paradigm shift and to this new environment.

Other learning theories utilizing the principles of andragogy that educators most frequently apply to SL are experiential learning theory, social learning theory, constructivism, connectivism, and collaborative learning theory (Kolb, Boyatzis, & Mainemelis, 2000; Bandura, 1977; Bruner, 1966; Bruner, 1996; Siemens, 2004; Smith & MacGergor, 1992). Many of these theories have overlapping principles that can be mixed and matched to enhance best practices in education (Chickering & Gamson, 1987). Technology advancement and social networking tools such as SL provide rich learning environments for developing and facilitating learning activities that promote the use of these theories. In the authors’ opinions, no one model fits best as it will depend upon the goals of the course as well as the teaching and learning style of the faculty and students. Also, some components of a particular theory may not be satisfied in a virtual world like SL. Today, although growth and the use of this technology is explosive, only the tip of the iceberg is being seen by colleges, universities, and training programs using VWs. As the trend and use of this technology continues, educators and researchers will realize the expansion of current theories and develop new theories and patterns of learning.

Designing the Learning Space

Working in virtual worlds is not always intuitive. Faculty need to rethink how the course material is structured and delivered. They need technical assistance to help with complex instructional design decisions that are congruent with the pedagogy, teaching strategies, and outcomes. Faculty should not be expected to be the technology experts; rather, they should team up with a technology professional for design and delivery support associated with technical training and technical issues. As a team they will work together to facilitate, guide, adopt, and integrate this technology as an innovative practice for teaching, learning, and research. The challenge that faces faculty is determining the various nuances of their audience, understanding the content, determining the best approach to deliver the content, and developing a comfort level with the technology (Hodges & Collins, 2010).

The virtual world learning space is generally designed to replicate the traditional learning space. Areas are developed to support broadly defined educational activities. These virtual areas typically include a large lecture hall or auditorium for presentations, smaller classrooms for discussion, an exhibition hall for displaying student work, and faculty office space for meeting with students. However, this real-world approach to VW learning space brings with it similar constraints on the types of teaching and learning that can happen in those spaces (Gerald & Antonacci, 2009). For example, large lecture halls, whether in the real world or the virtual world, are based on an objectivist approach to course design, and such spaces do little to support more collaborative and constructivist learning approaches. Gerald and Antonacci (Gerald & Antonacci, 2009) suggest that in addition to designing spaces to meet traditional learning needs, the majority of the learning space can be designed to meet specifications for course projects. These spaces might include a home to practice assessing and remediating disability issues, a community living center as the context for database development, an operating room simulation for learning complex procedures, a health clinic for interacting with simulated patients and interprofessional team members, or perhaps a grocery store, restaurant, and exercise facility for teaching learners healthy living skills. Faculty should project goals and let individual creativity guide the design. Important factors to consider in designing the VW learning space are orientation and course design.


Calongne (Calongne, 2008) points out that although it is tempting to begin a VW class with an orientation to the software and the virtual world itself, students need action and excitement to help them envision how the technology will enrich their learning experience. She recommends that faculty sell the benefits first, and then discuss how it works. Begin with exciting examples from other classes or research projects to make the experience real, personal, and engaging, then provide a brief introduction demonstrating how to use the tool effectively. Keep in mind that in higher education, not all students in the course are at the same level of technology literacy. Creating an avatar and figuring out how to move, look around, and interact with others may be a challenge for some students, but not all. Getting everyone to the in-world class site may require extra time initially, so plan for it. It may be necessary to provide alternative communication support for added assistance. Finally, if some students are hesitant, mitigating any fears or risks associated with using the technology can help create a safe learning environment.

Orienting students to virtual worlds should follow the precepts of experiential learning. The SL Web site has very clear directions for downloading the portal to the environment and then leading the individual through creating an avatar. Encourage students to engage in this experience of downloading software and creating an avatar by assuring them that they are developing health informatics competencies. Specific orientation to participating in SL is also needed. Within directions for this exercise, a possible statement to achieve this purpose may be:

Second Life is an immersive virtual environment. An avatar is a user’s self-representation in the form of a 3-dimensional model. In Second Life, creating your avatar is part of how you will interact with other residents. Some people design their avatar as a life-like representation of self. As the popularity of Second Life grows, many professional meetings will occur in this virtual world; please dress your avatar in casual or professional clothes. The user controls the avatar through the use of the mouse or keyboard to walk, fly, and sit. An avatar can interact with other avatars through instant messages or the audio function (using a headset).

Once the avatar is created, there are several video tutorials to teach students how to navigate their avatars in SL (see Table 48.1 for suggestions). Upon completion of the tutorials, the faculty and student avatars should be ready to enter SL. Students need to feel competent enough with the technology to carry out required tasks and to meet the learning objectives. Basically, they should be able to move, look around, customize avatars, and interact with each other. During the first SL activity, a support person knowledgeable in SL technology should be available to trouble-shoot problems with software and microphone use. After the first SL experience, students are ready to engage in more activities and openly share their enthusiasm for this type of interaction. As faculty begin to envision more activities, they will need additional support to make these happen without having to take time to become experts in using and building in SL.

TABLE 48.1. Resources for Orienting New Second Life Users


Course Design

Virtual worlds use a mix of media-rich course materials selected to correspond to the learning activities and the students’ learning needs. Learning activities are experiential and can be designed to be synchronous or asynchronous, allowing students to interact with the subject matter to study, discuss, create, and express their views of the content under the supervision of the faculty member. The faculty role shifts from the authoritative expert to that of the dominant expert who stimulates and supervises exploration while providing structure, guidance, feedback, and assessment (Calongne, 2008). Virtual worlds provide immense opportunities for innovation and cultivate new ways to meet higher order learning. Rather than lecture, the class activity may involve teams of students taking a virtual field trip, gathering information, and later submitting their assignment through an SL group chat space or by collaboratively creating a presentation, a project management plan, or some other scholarly product to illustrate application, analysis, synthesis, or evaluation of the learning. The exemplars that follow describe one institution’s design principles and learning activities.


The University of Kansas Background and Experience

The University of Kansas Medical Center (KUMC) is organized into three major schools: Medicine, Nursing, and Health Professions. These schools are supported by the Department of Teaching and Learning Technology (TLT) located within the Division of Information Resources. In the early 1990s, KUMC’s Division of Information Resources, in collaboration with all three schools and the Division of Continuing Education, embarked on a strategic planning process to position the academic environment for the new wave of technology-based education. This planning process resulted in the formation of a re-envisioned academic support department—the Department of Teaching and Learning Technologies (TLT). The department is housed within the KUMC Information Resource Division. Central to its mission, the department has evolved over time to support.

One of these technologies is Second Life, which KUMC faculty use for communication, presentations, immersive learning activities including simulation and role-playing, and research projects. The staff in the TLT department began exploring and researching the Second Life virtual world in 2004, just after it was released from beta. Struck by the educational potential of this new learning space, TLT staff began working with interested faculty to connect real-world course content with virtual world learning activities. Because of the interest expressed by faculty in the informatics, nursing anesthesia, and physical and occupational therapy programs, KUMC administrators in 2007 decided to purchase its own island or private space and named it KUMC Isle. An island or private region allows for restricted access and other levels of control not available on the virtual mainland. Faculty worked closely with TLT to establish goals and objectives for teaching in SL and to build the necessary learning space. Collaboration among the campus academic programs helps to set standards and creates academic environments that are efficient and effective and that model the real-world academic environment. Building on the success experienced in health informatics, physical therapy, and nurse anesthesia, other KUMC programs began to use SL to enhance learning and conduct research studies.

TLT is also aware of promising new technologies and has both the technical and pedagogical support to explore and evaluate the educational possibilities of these tools. As technologies mature, those with the greatest potential to enhance teaching and learning are integrated into our core technologies, establishing a pattern of innovation and success. This infrastructure, which includes instructional designers and technology specialists, has served the campus well over the ensuing years as educational technologies advanced and became more affordable and acceptable. Key to KUMC’s success is the partnership between faculty and the TLT staff to design, develop, and implement courses using enhanced technologies and to work collaboratively across KUMC academic programs to develop a community of technology educators who share ideas and challenge each other.

Graduate Health Informatics Program

Learning to be a health informatician requires developing skills identifying use cases for technology, and workflows in clinical environments. These are experiential skills and are difficult to master in an online environment. Simulations and clinical experiences are the traditional approaches for teaching these skills yet are not feasible in online courses where students reside in multiple states and time zones. Virtual reality environments, however, provide the online platform for simulations in which to experience and practice informatics skills, and SL was selected as the simulation environment for our online health informatics graduate program. These simulations facilitate the development of informatics competencies for future work environments.

In the curriculum, we teach information system design and database development among other skills. An SL simulation was constructed to facilitate learning these skills. The faculty designed the Jayhawk Community Living Center (JCLC), an assisted living facility, for the simulation. The JCLC was designed to include rooms for six residents, a day room, dining room, clinic room, nurses’ station, healthcare records room, medication room, director’s office, and conference room. Landscaping, including a deck over the water surrounding KUMC Island, was built to enhance the reality of the simulation (Fig. 48.1). Cues and artifacts concerning information system requirements were placed in various locations within the JCLC so that students learned to observe the environment. Some of these cues were multiple telephones for residents, computer locations for staff, and floor plans for workflows. Faculty avatars simulated the roles of Director of Nursing and staff nurse.


• FIGURE 48.1. The Jayhawk Community Living Center (JCLC).

The purpose of one particular simulation is to design a fall-risk management information system for the JCLC. This would be the first electronic health record for the JCLC. Students are given a request for proposal (RFP) and information about falls: evidence-based protocols, workflows and policies for the management of fall risk, and resident data concerning fall risk. Their first task is to meet with the Director of Nursing in the JCLC conference room to clarify the requirements for the information system. This meeting is conducted through text messaging within SL so that a transcript of the meeting is available for analysis (Fig. 48.2).


• FIGURE 48.2. JCLC Conference room.

Next the students are taken on a tour of the JCLC, as they would be in real life, to observe and ask questions to clarify the requirements for the fall-risk information system. Students must design the entire system—architecture, software, Internet access, security and confidentiality constraints, and other relevant system functions. The deliverables for the design are storyboards, use cases, use case diagrams, workflow diagrams, and activity diagrams for both current and future states.

In the database theory course, the students return to the JCLC to design and build an access database for the fall-risk management assessments. They must work with the staff again to determine database table structures (conceptual, logical, and physical data models), data entry forms, standard data queries, required reports, and training needs. This time the cues are very important, as the students must realize that each resident has two telephones that must be addressed as fields in the database as well as other physical cues regarding data collection and input. Incorrect field content is a common problem in database design. Information concerning each resident is posted on a “Touch Me” card outside the resident’s room (Fig. 48.3). The database produced by the students must contain all the information and address each design challenge embedded in the simulation (http://www.u.arizona.edu/~nhuber/AmbiguityarticleDRAFT.pdf).


• FIGURE 48.3. “Touch Me” cards with resident information to be placed in the database.

Students enjoy the experience, request more class time in SL, and successfully develop informatics projects. SL is a great way to simulate a facility so students can learn to elicit user requirements for information systems. The challenges are scheduling meeting times, managing group interactions, practicing etiquette in group interactions, and learning to use the technology of SL.

Students present posters in SL as a way to demonstrate learning. Many of the presentations cover usability and design issues, system security approaches, federal regulations impacting the discipline of informatics, and database management systems. The simulation helps students learn to prepare a poster and answer questions of attendees at the poster session. A poster pavilion module was created with six poster boards (Fig. 48.4). This module can be recreated to host as many presenters as required.


• FIGURE 48.4. Poster pavilion.

As a by-product of the primary content covered through simulations in SL, learners gain hands-on experience with a new technology and a greater awareness of and tolerance for ambiguity. Learners often have difficulties with the technology during their activities as they guide their avatars and interact with others. Students may have trouble and need to troubleshoot their microphone use or have difficulty with the avatar function, such as commands that allow the avatar to sit on an object. Various difficulties are discussed, along with an explicit ambiguity tolerance dialogue at the end of the virtual activity as part of postactivity debriefing.

Course Evaluations

A serendipitous finding in using SL was creating the Beach on KUMC Isle as a place to celebrate the end of a course and for students to share with faculty what worked and what did not work. Early on, students suggested adjourning to the beach after the last class. Faculty facilitated the meeting and engaged the students in informal discussions about the use of SL. Students shared their enthusiasm for SL and then began to share perspectives on the course. The informal environment, outside the course, encouraged very productive discussions that led faculty to change several course strategies. Now, a Beach Party is conducted for debriefing. Students continue to be very professional in their desire to help the courses evolve into highly successful experiences. The Beach is shown in Fig. 48.5.


• FIGURE 48.5. The Beach, complete with palm trees, fire pit, places to sit, and tiki torches.

Use of Second Life in Doctoral Nursing Courses

During the first semester, all doctoral students enroll in a technology and informatics course. This course is designed to assist the student in developing skills to complete an online doctoral program, and SL is one of several Web 2.0 programs introduced to the students. Formal presentations of team projects as a simulation of a conference presentation are required. Students use instant messaging and SL to meet as a team to organize the work of their projects, thus enhancing their informatics skills. The presentations are conducted in the conference center using microphones and speakers. Students are able to see the audience, pace the presentation, and answer questions just as they would in the real world (Figs. 48.6 and 48.7). These students also enjoy the Beach Party at the end of the course and have helped to make this course very popular.


• FIGURE 48.6. The Conference Center used for formal presentations.


• FIGURE 48.7. Student giving the presentation and using slides.

Use of Second Life in the Nurse Anesthesia Program

TLT staff in collaboration with faculty in the Nurse Anesthesia Program developed a VW operating room simulation to assist first-year nurse anesthesia students with learning the basic induction procedure. Nurse anesthesia faculty members were already experienced with physical patient simulators, such as SimMan®; however, they were especially interested in virtual simulations because much of their program trains students in specialized processes and procedures. The objective for this project is to learn how the operating room is organized, to navigate the environment, to learn workflow and organizational skills, and to practice the basic induction procedure before stepping into the actual operating room. The SL operating room is designed to look exactly like the operating room at KU Hospital (Fig. 48.8). The clocks, tables, and other objects are in the same locations as they are in the real operating room. This allows the students to be exposed to the layout of the operating room before they experience the real environment. In addition, some of the equipment in the SL space is designed to be interactive so the students can manipulate it and gain confidence. To see how the student progresses through this learning activity and how the objects interact with each other, view the video tutorial of the Second Life Operating Room (http://www.youtube.com/watch?v=70CkcswfDe4).


• FIGURE 48.8. Operating room.

Use of Second Life in the Physical and Occupational Therapy Programs

The physical and occupational therapy faculty partnered with TLT staff to develop virtual home environments in Second Life (Figs. 48.9 and 48.10). The home environment is a critical part of everyday life and participation in activities of daily living and instrumental activities of daily living. The homes were designed with a focus on objects within the home to assist students in identifying environmental barriers and support and to make critical decisions regarding environmental and task modification for clients. The student learning outcomes include interprofessional collaboration, patient-centered decision-making, and appreciation of the environmental and social context of functional mobility and occupational performance.


• FIGURE 48.9. The row houses for home evaluations.


• FIGURE 48.10. Living room and kitchen of one of the row houses, showing safety hazards.

Physical and occupational therapy students working in teams use SL to evaluate the home of a disabled client. There are a series of three homes with different hazards to be identified. Students are given a patient record with information concerning the patient’s abilities and disabilities. They then conduct a walk-through and make recommendations for creating a safer home environment. Faculty control the visual cues and hazards and so know when the students make accurate assessments. Once students make recommendations, the TLT staff modify the home according to the recommendations, and faculty and peers evaluate the modifications based on levels of support, unintended challenges, and client preferences. Seeing the outcome of their recommendations in SL is valuable because students are not always able to see their modifications carried out in the real world (Sabus, Sabata, & Antonacci, 2011).

Use of Second Life in a Dietetics and Nutrition Weight Management Program

A faculty researcher in the Department of Dietetics and Nutrition saw a presentation by a faculty member in occupational therapy who was teaching a class in SL and immediately thought this would be a good environment to use for weight management (Sullivan et al., 2013). Sullivan’s research team studied 20 overweight and obese people in a program that involved either real-life or virtual reality meetings every week for 3 months. At the end of that period, all the subjects took part in a weight-maintenance program using SL. Sullivan found that while VR compares favorably with face-to-face interactions in controlling weight loss, its true benefits were more readily apparent in weight maintenance. In the study, participants created avatars that could interact with the other cyber-dwellers in the group. Training and education took place on KUMC Isle. Participants used headsets and microphones to communicate with others within the group. Since SL can automatically work with Web sites like YouTube® to pull in content to use within the simulation, group leaders could show videos or present other materials during meetings of the avatars in a virtual conference room.

KUMC’s original island environment included a conference room, house, gymnasium (Figs. 48.11 and 48.12), grocery store (Fig. 48.13), restaurant, and buffet. Each space provided the avatars with a setting to interact with each other as well as to check on calorie counts in food items, calories burned during exercise, and other helpful information. By using SL, participants can simulate real-life situations without many of the consequences and repercussions that occur in real life. For example, the avatars can practice meal planning complete with calorie counts for items in the grocery store, dining out, or attending holiday parties, all in the anonymity of cyberspace. The goal of the simulation is to create a friendly environment where people can spend time researching healthier lifestyles without the fear of being judged.


• FIGURE 48.11. Gymnasium for weight management program.


• FIGURE 48.12. Gymnasium for weight management program.


• FIGURE 48.13. Grocery store with note cards.

As a result of Sullivan’s preliminary research, she and her team received a grant from the National Institutes of Health to continue the research. Through this grant KUMC created a new island called KUMC Healthy U that expands opportunities for the participants. On KUMC Healthy U, avatars are able to take advantage of restaurants with cashiers that total the calories on customers’ trays as they check out. A kiosk, known as Fast Food Frenzy, links avatars to the Web sites of various restaurants, which allows them to calculate the calories in their meals. The new island also includes a more elaborate gymnasium, complete with a swimming pool where avatars can register the calories burned as they swim, tread water, or take part in activities in the water. Trainers in the gym are able to help the research subjects by answering basic fitness questions. Avatars can also access fitness videos while doing their simulated running on treadmills. One of the highlights of the new island is trails where avatars can walk, run, or bike while SL keeps tabs on the calories burned. All participants in this study will receive the same weight-loss program for 6 months and then be randomized to either virtual reality or a traditional method for 12 months of weight-loss maintenance. The overall aim is to compare the difference in weight-loss maintenance between the two groups.

The follow-up 18-month randomized trial utilized the new SL isle and included 128 participants (Sullivan et al., 2016). Sullivan’s study included participants who achieved a 5% weight loss following a 6-month weight-loss intervention. The participants were randomized into two groups receiving weight-maintenance interventions: one group received the intervention by phone conference call, the other group received intervention in SL. Sullivan’s findings show that “Internet based virtual reality platforms, such as SL, may be an effective approach for weight maintenance, as there is evidence to suggest that skills and behaviors acquired in virtual environments transfer to the real world” (Sullivan et al., 2016, p. 82).

The resources developed in SL for this research project are also used by other faculty to meet their course objectives. For example, informatics students have developed smartphone apps that can be used for weight loss and maintenance. Undergraduate students can be assigned to shop in the virtual grocery store or dine in the many restaurants to learn about healthy food choices. Virtual worlds are valuable new research tools to study human behavior. Researchers can inexpensively prototype models and explore data visualization in unique ways.


In a very short time, the utilization of innovative technologies in education has skyrocketed. Several technologies in healthcare education fit into the “innovative” group including VR, AR, robotics, and drones. Educators benefit from development and iteration already accomplished in other industries. Integration into learning is cheaper and is therefore growing much faster. Another driver in innovation is the ubiquity of smartphone devices, which can now be used as VR and AR devices, and the apps that are used on these devices for VR and AR as well as in robotics and drones. According to Newzoo® analytics (Newzoo, 2018) the total number of smartphone users worldwide reached 3 billion in 2018. In the United States smartphone penetration is 71.5% of the population. This explosion of development demonstrates the current reality that we are in times of “bring your own device” (Skiba, 2016). All of these trends are driving costs down and making it easier for educators to utilize the technology.

Because of the need for innovative development, wider usage in education, and a better user experience, institutions are building their own VR environments and working with industry to utilize innovative technology for educational purposes. Hewlett Packard’s collaboration with EDUCAUSE® for the Campus of the Future Project is one example (https://er.educause.edu/blogs/2018/8/the-campus-of-the-future). This collaboration involves eleven institutions across the United States that have integrated AR, VR, and 3D printing and scanning within their curricula. HP supported and supplied the hardware, software, and technical support while EDUCAUSE assisted with the design and research aspect of it (DePaul, 2018).

Virtual Reality and Augmented Reality

There are certain differences in virtual and augmented environments. For example, augmented reality allows users to add digital pieces or layers to a “real-time” view mainly by using the camera feature on devices. An augmented experience might include the use of Snapchat lenses or filters or games such as Ingress, Pokemon Go, or Dragon Mania Legends. Virtual reality, on the other hand, is fully immersive through headsets allowing users to experience constructed virtual environments that can be both visual and auditory. The use of VR enhanced by the integration of AR, also referred to as mixed reality (MR), has expanded teaching and learning opportunities for campus-based and online classes.

Smart glasses such as Google Glass® are an example of augmented reality. They resemble a standard pair of glasses integrated with a camera that can take 5.0 megapixel photos and 720p video. The glass has a touchpad, on the temple near the hinge, used to navigate its menu system and voice command activated by saying “OK Glass.” This command activates the glass so that the user can follow up with commands such as “Record a video,” “Take a Picture,” etc. Oculus Rift® is a virtual reality headset that works with gaming software and is integrated with 3D audio and hand-held controllers. Mixed reality smart glasses such as Microsoft’s HoloLens is a head-mounted display connected to an adjustable, cushioned inner headband. The inner headband allows HoloLens to be tilted up and down or forward and backward for better visualization of the display. The user fits the HoloLens on the head by using an adjustment wheel at the back of the head-band to secure it around the crown.

Creating dynamic simulations that go beyond the visual aspects of a VW by utilizing Google Glass, VR headsets, and HoloLens while considering how the student learner/user interacts with the environment will improve learning outcomes. Integrating these instruments increases the degree of immersion and interactivity available in virtual environments, allowing for a greater sense of presence that is believed to contribute to meaningful learning, especially when the course is online.

Robotics and Drones

Robots are virtual or automated or semiautomated entities that are utilized to perform complex activities often mimicking human activities. They also facilitate repetitive patterns of activity and are used in place of humans (Merriam-Webster, n.d.-a). Robots can also be used in activities deemed too dangerous for humans. Use of robots in laboratories and surgical suites began to be seen about 1985 (Hussain, Malik, Halim, & Ali, 2014). Robotics in healthcare include many uses: telehealth or telepresence, robotic-assisted surgery, robotic anesthesia administration, nanorobotics, aid for patients with disability, musculoskeletal-assistive devices, and transferring/lifting patients (All on robots: Medical robots of today and tomorrow, n.d.), (Deloitte, 2016).

Use of robotics in the healthcare education is lagging. The expanded use of robotics and drones will change how students learn and enhance what they need to know to practice. Like other technologies in healthcare, the best way to teach is to have student users experience the use as it is happening in care. Furthermore, the environment can be controlled or simulated to create learning experiences designed by the faculty member to achieve pedagogical goals.

Robotics can be used in healthcare education to bring faculty expertise to students in remote areas where expertise is lacking. This can be done using a faculty robot as a virtual faculty expert. The robot is a mobility base that moves forward, backward, and can turn 360 degrees and has a display monitor where the distance faculty appears on the screen. The mobility cart is equipped with camera, printer, and the display that rotates 360 degrees. The mobility base equipment is controlled by the distance faculty. The robot can be used with simulation and teach-back methodology.

Unmanned aerial vehicles (UAV) more commonly known as drones are essentially flying robots. These vehicles are various types of aircraft without a human pilot. UAV may fly by means of a remote control with a human operator or autonomously through the use of onboard computer systems programmed with flight plans and utilizing global positioning system, or GPS, receivers (https://www.dronezon.com/learn-about-drones-quadcopters/what-is-dronetechnology-or-how-does-drone-technology-work/). With increased need to expand healthcare in rural areas and in a cost-effective manner, the use of drones is part of the technology toolbox of the future.

Administrative Considerations: Creating a Supportive Environment

Educational innovation is a process of bringing new teaching strategies to satisfied learners and future knowledge workers. It is a conversion of new knowledge into value-added outcomes enhanced by novel teaching strategies. Innovation in education involves not only technological advances, but also pedagogical approaches.

Most innovative educators are recognizing and experimenting with the educational possibilities of innovative technologies including VR, VW, robots, and drones. Student enthusiasm for these learning formats is also strong, creating uniquely powerful interactive and compelling educational possibilities. At the same time, for many faculty members, teaching with innovative technologies can be daunting. Learning the new technology, meeting the needs of the technologically diverse students, understanding innovative technology pedagogy, and managing workload and time are some of the challenges. It is up to academic administrators to provide the support and resources to encourage faculty to use new technologies such as Second Life and other emerging technologies. The goal is to minimize organizational barriers to student and faculty success. Challenges at the organizational level need to be anticipated, and policies, procedures, and guidelines should be in place to help mitigate their impact on faculty and students. Faculty who desire to use innovative technologies need to be heard, to feel supported, and to have an infrastructure in place that not only supports the present but allows for growth and rewards faculty efforts. Creating a supportive environment for successful adaptation of innovative teaching strategies requires resources, but, more importantly, it requires a cultural shift for many academic institutions.

A Culture of Innovation

As technology advances, today’s learning environment needs to convey a culture of innovation and strategically plan to meet the challenge of change. Every academic organization has a culture; the issue is whether and how that organization supports innovation. A culture of innovation provides a competitive edge, because the organization is more nimble with an increased ability to respond to change. To be successful, a culture of innovation should reflect a balance between an openness to allow ideas to flow and the creation of controls and supports around those ideas.

Academia is steeped in a tradition of hierarchical beliefs in which research and scholarship is rewarded and educational innovation is not. To fully integrate a culture of innovation within the organization, key concepts need to be reflected in the organization’s mission, vision, leadership, core values, hiring practices, metrics, rewards, and compensation. These concepts call for new interactions and partnerships involving a team approach to teaching, learning, and research. Success also requires clear communication from leadership that describes how the institution understands educational innovation and then builds that understanding into the organizational behavior modeled by the leader. Faculty and staff should feel comfortable and supported to take risks without fear of failure or retribution. As Melnyk and Davidson point out, “Success in an innovative culture is viewed as going from one failure to the next with enthusiasm” (Melnyk and Davidson, 2009, p. 2).

School of Nursing Administrative Support

The School of Nursing (SON) administration fully supports teaching in SL and serves as a liaison between the faculty and the TLT administrator to assure academic innovation and maintain quality and integrity of academic programs. Clear communication about the pedagogical needs of faculty is essential to good outcomes and assures that faculty receive the support they need. Faculty who are champions in this new learning environment need to be encouraged to take risks and should be rewarded for their efforts. To demonstrate its commitment to innovation, the SON revised its appointment, promotion, and tenure criteria, using Boyer’s model of scholarship, to reflect the value of innovation in education, practice, and research. Boyer proposed an expanded definition of scholarship within the professoriate based on four functions: discovery, integration, application, and teaching (Boyer, 1997). He argues that all forms of scholarship should be recognized and rewarded, and that this will lead to more personalized and flexible criteria for gaining tenure. Boyer proposes using “creativity contracts” that emphasize quality and innovation in teaching, while fostering professional growth that supports individuals and their passions (Boyer, 1997). A balanced focus on all forms of scholarship is critical to meet the challenges in creating and sustaining innovative academic programs. Using this model, faculty are encouraged, supported, and rewarded for risk taking, pilot testing, and design thinking in their teaching practices.

The technology service support in the SON is another example of administration’s support for the use of SL and other technology-supported practices. These services include an advanced technology environment for all faculty and staff, coordinated with all services at the KUMC campus level. The SON supports a dedicated professional who exclusively serves the technology needs of the school. The school’s support staff also provides services such as notebook computer support for faculty and staff, assistance in purchasing hardware and software to support research and educational innovation, and assistance with mobile computing devices. Teaching with innovative technologies often requires a computer with hefty specifications to run properly. Through these technology services and futuristic planning, the SON assures that faculty have what it takes to successfully teach using innovative technologies. (See Table 48.2 for resources.) Faculty are the most important factor in the overall success of using innovative technologies and innovative teaching strategies. If faculty feel well supported (technology, design, administration) and have a voice in determining policies and procedures for fostering innovative environments, they will be more willing to adapt and adopt the use of innovative technologies. Specifically, faculty need training, professional development, and release time for initial increased workload and design issues. Since faculty work collaboratively with instructional design and technology specialists, recognize that training needs shift from training faculty on software to training them on new teaching approaches, instructional design strategies, and workload management topics. Keep in mind that use of innovative technologies in teaching may not be for everyone; work with your champions and let them be the driver and set the standard. Celebrate your successes by having your champions showcase their work at faculty meetings and professional development sessions.

TABLE 48.2. Faculty Resources for Learning More about Virtual Reality and Virtual Worlds

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Jul 29, 2021 | Posted by in NURSING | Comments Off on A Paradigm Shift in Simulation: Experiential Learning in Virtual Worlds and Future Use of Virtual Reality, Robotics, and Drones

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