A virtual world is a computer-based simulated environment intended for its users to inhabit and interact via avatars. An avatar is a virtual representation of the user. VWs have been successfully used in commerce, education, customer services, hiring, consulting, entertainment, social networking, and public activities. One of the most advanced VWs is Second Life® (SL). Given the emerging nature of this technology in a group healthcare context, little is known about how patients may perceive this type of healthcare interaction. This study built on previous work that examined patient perceptions of physician-patient interactions for mock and actual group sessions to manage disease considerations. The study purpose was to extend the group sessions to nurse providers in the form of nurse coaching for wellness services.
Methods: The theoretical frameworks that underpinned this quasi-experimental study were the Media Naturalness Theory (Kock, 2009) and Social Presence (Short, Williams, & Christie, 1976) and the Dimensions of Wellness (e.g., social, physical, emotional; Robbins, Powers, & Burgess, 2017). The research question studied the perceptions of participants in an Augmented Virtual Nurse Office (AVNO) who received delivery of wellness services in a group setting via nurse coaching for stress management. The study intervention was an evidence based simulated scenario related to wellness education for stress management (Kaur, Kumar, & Maheshwari, 2016; Laborde, Allen, Gohring, & Dosseville, 2017; Van Diest & Widjaja, 2014). The intervention session was designed to be conducted by a registered nurse coach and presented in a 45-60 minute session to a population of participant actors who identified as having stress. Participants were randomly assigned to low, moderate, and high levels of stress, and each group included a variety of stress levels. The researchers (one doctorally prepared business professor with technology expertise, two doctorally prepared nurses and one master’s prepared nurse) collaborated to create the simulated scenario and 32 avatars, who would be anonymous to the group and the session nurse coach. The simulated scenario for the levels of stress and the wellness education strategies reflected current best practices (Kaur et al., 2016; Laborde et al., 2017; Van Diest & Widjaja, 2014). Protocols for the session delivery were developed to assure consistency among the sessions and nurse providers. Multiple practice sessions were held to increase comfort level of the nurse coaches in the AVNO setting. Participants received prior training with Second Life installation, microphone/speaker testing, and avatar operation and technology support was available in real time throughout each session. After approval from the institutional review board, a pilot study was conducted in November 2017 with 12 total participants in three sessions. Review of this preliminary data informed revision to the simulated scenarios, mostly for clarity and flow. In April 2018 we obtained a convenience sample (n=42) of participants. Four simulated sessions in the AVNO were conducted over a time period of two weeks. Each session had 6 to 12 participants and actual sessions lasted anywhere from 20 to 45 minutes. The session only ended if the participants had no additional questions. Following the simulated sessions, participants were provided information about the evaluation access and given the opportunity to complete a study specific survey tool developed and previously validated in the original study. The survey was adapted to the needs and nature of current study. For example, one modification was made to the tool to change the word physician to nurse. Ratings were 0-10 on a Likert type scale. The survey captured the user perceptions related to the trust in the online nurse; group effectiveness; intention to use VWs for healthcare; and ease of use.
Results: All participants completed the survey. Findings suggested overall trust in the online nurse coach at just under 9 with subscales of honesty, integrity, and caring at greater than 9. Other findings with positive subscales related to perceptions of effectiveness (efficiency, coordinated, understandable), which ranged between 7 and 8; ease of use (communication, understanding questions, understanding answers, interaction), which ranged from 8.9 to 9.3; and intention to use (intent, likelihood, prospect, anticipation), which hovered near or at 6.
Conclusion: The study confirmed the findings of the earlier, physician focused study; participants indicated that they perceived both trust in the setting and effectiveness and ease in sharing a group visit to access the nurse provider in the virtual world. Results also affirmed other positive uses of the virtual world in healthcare that have been documented. This study was limited in generalizability due to the convenience sample; however, we used a large variety of diverse avatars and random assignment to stress levels to increase representation of the sample to a general population of persons experiencing stress. Implications for research include further study with a larger sample of participants and a second scenario for a different wellness topic, and eventually actual patients who experience stress or have other wellness education needs. The use of AVNOs in practice has implications for improving access to health and wellness care for a wide variety of populations. It may also be very helpful to increase awareness of common challenges, educational needs, and health management strategies in specific populations related to a given illness or preventive measure.