Metaverse Health

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:

In the past week I received a note from Kerri McCusker (SL: Kerri Macchi) about a project completed for the Serious Games and Virtual Worlds Team, University of Ulster in Northern Ireland. Second Lives sets out to demonstrate a more recent approach to dealing with Crohn’s disease: autologous stem cell transplant.

You can view the Second Life aspect for yourself, or the video below explains the project in its entirety. I’ve also appended a section of the in-world notecard explaining the stem cell transplant history in some detail.

It’s yet another example of simulation as a useful adjunct for wider learning experiences. The level of complexity of this simulation is more at the patient education level rather than as a health professional training mechanism, but with further evolution it could obviously achieve both aims. I certainly learned a lot more about newer treatment options for Crohn’s disease. Anyone who’s been involved in the care of an individual with the disease knows that anything that improves health outcomes is a highly desirable thing.

Appendix: Sample of information provided by Second Lives Clinic

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Welcome to Second Lives Medical Clinic.
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This virtual clinic is a showcase of the process of the autologous stem cell transplant in Crohn’s disease.

Cellular therapy with stem cells is revolutionizing the focus of treatment of many serious diseases. Replacing the cells of damaged tissue with other new cells from the same patient is already a reality. This is the basis of cellular therapy and regenerative medicine, the latest great advance in biomedicine. In this line, Hospital Clínic, Barcelona is leading the world in the application of an innovative cellular therapy that uses stem cells to treat Crohn’s disease, a chronic genetic disease that affects 1% of the population in Spain and which has considerable impact on the quality of life of the patients. The procedure is based on an autologous bone-marrow transplant (when patients receive a transplant of their own stem cells) and now constitutes a treatment option to cure an intestinal disease that sometimes does not successfully respond to drugs and requires highly complex surgery that does not provide a cure.

Hospital Clínic, Barcelona is one of the few hospitals in the world to apply this new therapeutic option for patients with Crohn’s disease, and it does so with the guarantee of success experienced in the US and Italy, where the technique has been tested with excellent results: in an average follow-up period of 6 years, 80% of transplant patients are in a phase of total remission of the disease and the remaining 20% have shown considerable improvement following the transplant, and are now responding favorably to drugs. Dr. Julián Panés and Dr. Elena Ricart over the Gastroenterology Department of Hospital Clínic, Barcelona are the driving force behind this therapy in Spain and began to implement regenerative cellular therapy in patients with Crohn’s disease in August 2008. To date, a total of 6 patients are benefiting from this new treatment. The transplant requires several weeks of admission to hospital before patients receive their own cells. The procedure is the same as that carried out in bone-morrow transplants to cure leukemia or myeloma.

Autologous Stem-Cell Transplant: Phases of the Procedure

When the case is detected (that does not respond to drugs or surgery), the patient undergoes an autologous stem-cell transplant, which is a bone-morrow transplant in which the immune system is reset to prevent it from attacking the intestinal flora. The process lasts approximately 2 months and consists of 6 phases:
1. Initial Chemotherapy (Cyclophosphamide + G-CSF). In this initial phase, the reduction of the number of leukocytes (immune-system cells) in the blood is induced in the patient.

2. Migration of Stem-Cells to the Blood. Following the previous immunosuppression, the organism reacts by releasing stem cells from the bone marrow into the blood; these are the cells which will later be used for the transplant.

3. Collection of Stem Cells by means of Apheresis. Apheresis is a technique that separates components of the blood. Here, the stem cells that previously migrated from the bone marrow are separated.

4. Cryopreservation of Stem Cells. When the stem cells have been collected by apheresis, they are frozen and preserved until ready for transplant.

5. Second Chemotherapy. In this phase, total leukopenia is induced; that is, the immune system is left devoid of leukocytes, ready to be reset with the stem-cell transplant.

6. Autologous Stem-Cell Transplant. The patient receives the transplant by means of transfusion with his or her own stem cells. The immune system is reset, leading to remission or reduction of the abnormal inflammatory process of Crohn’s disease.

A comprehensive new resource has been released by the UK’s University of Derby and Aston University, Titled Best Practices in Virtual Worlds Teaching: A guide to using problem-based learning in Second Life, this 40+ page publication covers a lot of ground in an easy to understand way. It’s available as a free download of a little over 6MB in PDF format.

The pivotal section for me is the one on making problem-based learning work in Second Life, with the succinct message being:

The possibilities for education within Second Life are limitless and one must be careful not to use this resource for the sake of it. Any teaching resources provided within Second Life must be embedded within traditional learning methods and fulfil a direct need within the course. Simply using Second Life for the sake of it will require time and effort from students and staff that is unwarranted and provides no additional benefit. There must be a direct applicable benefit to the material contained within Second Life, so purpose-driven use is advised rather than speculative-use.

As I’ve mentioned previously, the documentation of teaching methods in virtual environments continues to improve, and this document provides a superb overview for those new to the approach. From a health viewpoint, some good examples of Psychology projects undertaken in Second Life are given.

Thanks to Virtual World Watch for the heads-up

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.

An Italian virtual worlds developer, ISN, has announced the roll-out of the Oasis Foundation Virtual World Project. Funded by a non-profit organisation in Italy devoted to assisting the elderly and disabled, the project aims to:

1. Act as communication and collaboration environment to inform, communicate and interact with the public in an innovative way.
2. Be a collaboration and activity platform for the disabled.

Some of the activities which will be held include:

1. Virtual Learning sessions on various topics in the Oasis Virtual University.
2. Conference and conventions in the various meeting areas of the virtual world.
3. Workshops for virtual goods production.
4. A virtual school for video production and machinima, connected to a real life TV.
5. Assistance and help sessions for families. Contact with a psychologist.
6. Exhibitions of different kinds.
7. Sessions and discussion on religious topics, cultural differences and lectures.

Second Life is the platform of choice for the project. None of the aims or activities are particularly new for anyone used to interacting in virtual environments. That said, the comprehensiveness of the project is impressive and I’ll be following this to see how the end product ends up.

Jon-Paul Cacioli is a Doctor of Clinical Psychology student at Deakin University, and he’s currently conducting a study on body image in virtual worlds. In his words:

“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

A quick post to wish everyone the best for the coming year.

I’ve made some broader predictions for the coming year, but I’m particularly excited about the prospects in regards to health interventions, research or education. It’s still relatively early days, but over the past year I’ve been struck by some of the great work going on in regards to health and I can only see that growing.

Some highlights from 2009 for me:

1. The superb work done by the SLENZ project on midwifery and birthing in Second Life.

2. The fascinating insights of the University of Sydney’s Andrew Campbell on addiction and virtual environments.

3. The perspectives of DeeAnna Nagel and Kate Anthony on psychotherapy in an online environment.

4. The interesting approach taken by a UK company facilitating paramedic training in Second Life.

5. The emerging evidence of the efficacy of virtual environments in nurse education.

I’m looking forward to covering some exciting stories during 2010 and perhaps contributing some research or health work myself. As always, I’d love to hear your thoughts or to find out more about your projects.

Here’s to a fruitful 2010!

Second used as a demonstrative medium for real-world software:

Not the most innovative way to use an immersive environment but I suppose it gets the message across.

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.

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.

It’d be great to hear from anyone interested in conducting their own research into the area, as I have an interest in undertaking some research myself and would love to discuss potential collaborations.