Nursing Research and Practice Mean 3.14 3.18 3.55 3.07 3.28 3.32 .94 1.05 .87 .98 .92 .85 6 Variable N Preparation for clinical 61 Resemblance of realistic clinical environment 60 Reinforced course objectives 60 Eﬀective learning experience 61 Improved decision making skills 61 Overall positive experience 61 ∗ Scores range from 1 = strongly disagree to 5 = strongly agree. Table 3: Survey responses (n = 61). 1.00 1.00 1.00 1.00 1.00 1.00 5.00 5.00 5.00 5.00 5.00 5.00 Minimum Maximum Standard Deviation The satisfaction survey was completed by 61 students. Student satisfaction scores (Table 3) showed that students rated the variables slightly better than neutral on their agreement with the variables. The scores ranged from 1 (strongly disagree) to 5 (strongly agree). Preparation for clinical was rated at a mean 3.14 (SD .94), realism of the environment was 3.18 M (SD 1.05), and reinforced objectives was 3.55 M (SD .87). Reinforced objectives was the highest scoring item. Consequently the eﬀectiveness of the learning environment scored the lowest at a mean of 3.07 (SD .98). Improving decisions scored 3.28 M (SD .92), and the overall experience was rated 3.32 M (SD .85). Student comments were mixed. One student responded, “I could see this sort of thing happening in a real clinical setting. The real-life scenario (i.e., charge nurse scenario) helped me make better decisions. . ..” Another comment, “I found the experiences displayed in second life were realistic and discussing what could have/should have been done was helpful. . ..” Several comments indicated students did not like the text chat function and found it diﬃcult to read when they were observing. “The simulations were very realistic. If there is a way to make the typed font bigger it would be easier to read”. Another comment, “The Second Life is an interesting approach to clinical—but I prefer the real-life sim because I prefer the verbal “out loud” conversation—it is more real- life.” The EMCRM results show that team communication and professional behavior did show signiﬁcant improvement. This may have improved in part because the students became more comfortable with the virtual world and the interaction with other members (avatars) in addition to the learning that occurred during scenario 1. Subjects in this study did demonstrate improvement in their team leadership skills (total EMCRM score) from scenario 1 to scenario 2; however, the improvement was not signiﬁcant. Many of the behaviors evaluated in the virtual scenarios are complex, such as work delegation and attention allocation, and the two scenarios may have not been enough practice to show signiﬁcant improvement in those areas. It is also important to note that there were a small number of cases in each scenario. Despite the fact that 61 students participated in the virtual simulations, only 8 cases were rated in scenario 1, and 7 cases in scenario 2 were scored because only 2 students could play a role in each of the virtual simulations. This pilot study demonstrates that participation in VR simulation helps students improve performance; however, more work is needed to determine how signiﬁcant the VR simulations contributed to this learning. These results are encouraging as further research using pre- and post-tests could further evaluate improvement in performance with repeated exposure, deliberate practice, and familiarity with virtual world learning. 5. Limitations Several limitations have been identiﬁed in this study. One obvious limitation is the study’s small sample size which impacts the power of the study, perhaps increasing the chance of a type II error in data analysis. There were a small number of cases for each outcome variable of interest and as such, the bounds of normality may be stretched. The sample for this study was a convenience sample of fourth year nursing students from the same university, making generalizability of results to other populations unknown, and a second study limitation. Interrater reliability was not conducted as the scores of the raters were averaged into a single consensus score for each simulation. 6. Conclusions Virtual world simulation environments oﬀer a unique and potentially cost-eﬀective method of teaching nursing skills related to leadership and management skills in facilities that have access to virtual environments such as SL. The university owned space in SL provides a virtual unit envi- ronment that has the potential to oﬀer valuable, practical, real-world experiences for future nursing students. The total cost of the project to set up the virtual hospital was under $3000. This presumes that one has access to a space in SL that is already being maintained, and no additional costs are incurred for space purchase and ongoing costs such as lease fees or information technology fees. The cost would be much higher for educators who do not have access to SL. The cost savings involved would be a savings on lab fees and supplies associated with high-ﬁdelity simulation centers. This type of environment allows for the practice and learning of interpersonal skills such as communication, teamwork, and delegation which are critical to patient safety and improved patient outcomes. Students are challenged with learning both technical and nontechnical skills to achieve competency in their future roles as practicing nurses. Ericsson’s [19] work in the area