Although the metaverse is still in its early exploratory stage in the field of nursing, it is gradually demonstrating its potential in digital health and telemedicine care, transforming the traditional nurse-patient interaction model through digital tools and the internet. The "metaverse" represents the merging of two worlds into an immersive, online, virtual, connected environment in which participants actively engage with 3D content and interact using digital avatars. The metaverse entails many possibilities and challenges in attempts to introduce new methods of nursing. This technology has many applications, particularly with respect to assisting in surgery, enhancing chronic disease management, reshaping nursing education, promoting telemedicine, and facilitating psychological interventions. While obstacles may be encountered in various areas, such as trust and security, technology, legislation and regulation, the use of non-fungible tokens as a secure asset for patient data is a potential solution to these issues.
Michael Seropian, Bonnie Driggers, Jana Taylor, Paula Gubrud-Howe · 5 authors
The purpose of this article is to describe the unique statewide effort in Oregon to implement multidisciplinary/multisector simulation education in schools, health systems, and community training centers. This article describes the development of high-fidelity simulation education programs throughout Oregon. It is important to recognize that this project was not the result of the work of one person or institution, but rather it was a collaborative effort between multiple individuals and groups. THE NEED The need for an efficient, reproducible model for simulation program development and implementation is more pressing now than ever. Health care institutions are eagerly seeking a method of teaching healthcare-related skills in a risk free environment. The forces that are propelling simulation into practice and education in Oregon do not seem to be based on concrete validation of the methodology, but rather based on workforce, patient safety, and regulatory pressures1–3. Over the past several years, as healthcare institutions across the state of Oregon began to recognize the importance of simulation training, many began to independently investigate medical simulation as a teaching method. Initially, simulation manikins cost upward of $150,000. The high cost of equipment limited access to technology to a wider audience. In 2000-2001, manikins became much more affordable as companies introduced lower-cost alternatives.4 The lower price-point provided access to a greater segment of the market. Nationally, institutions started to buy equipment as the prices became more affordable, but they had not developed strong plans or implementation strategies for their simulation technology.5 The results of the “buy first, think later” approach were costly in some cases. In general, buying simulation equipment without utilization and implementation plans in place has the potential to stall the process, as well as result in the purchase of inappropriate or inadequate equipment. Many institutions and health systems that purchase simulation equipment look for program implementation guidance but find scarce resources and encounter daunting operational expenses.5 The Oregon Simulation Alliance (OSA) grew out of a statewide need to make sound purchasing and implementation decisions in the field of healthcare simulation. THE OREGON APPROACH Prior to this collaborative project, the only substantial high-fidelity simulation experience in Oregon was at Oregon Health and Science University (OHSU). As a result of the Oregon Simulation Alliance, by the end of 2005, at least 20 simulation education programs/facilities will be in use in Oregon. These programs are at various stages of development and serve multiple disciplines and healthcare sectors. To our knowledge, this is the first comprehensive, successful attempt of large-scale simulation-based education implementation. The core objective of the Oregon Simulation Alliance was to address the demand for quality simulation by making expertise accessible and by developing a system that was sustainable and robust. The type of simulation was not specifically defined other than to encourage the use of manikins, virtual reality, and other methods consistent with a high-fidelity simulation experience. The initial focus of OSA, however, was manikin-based simulation. The implementation model (Fig. 1), developed through the OSA, was based on core fundamental concepts, outcomes and goals (Fig. 2). At the time of this writing, some of the outcomes achieved by the OSA include:FIGURE 1.: Oregon Simulation Alliance phased implementation strategy.FIGURE 2.: Oregon Simulation Alliance desired outcomes and goals. Procurement of $1,050,000 to help fund equipment purchase, simulation specialist training, and faculty development. Simulation education and program readiness assessment with advice for steps in program implementation. Fundamentals in simulation training courses offered statewide. Simulation specialist training apprenticeships covering 16 individuals over 1 year. A statewide summit promoting networking and addressing common core issues. Re-evaluation of the Oregon Simulation Alliance mission and structure to adapt to the progress made. Development of new simulation facilities. THE OREGON SIMULATION ALLIANCE Who Is The Alliance? The Oregon model included the establishment of a collaborative statewide simulation organization. The Oregon Simulation Alliance (OSA) is a group of individuals with a common purpose: simulation education. The group represents most healthcare sectors and its makeup is described in Table 1. The group included representatives from the Governor's Office, organization vice presidents, university and community college deans, public health officials, Area Healthcare Education Centers (AHEC) officials, and simulation experts. Simultaneously, the Governor of Oregon created a statewide Healthcare Workforce Initiative that included the establishment of a network of simulation centers. Early on, it became obvious that there was a common need to incorporate healthcare simulation across disciplines. Although nursing seemed to have the most pressing desire and need, the group ensured it remained representative of most health care disciplines and sectors. In this way, the Oregon Simulation Alliance was established (November 2003).TABLE 1: Participating Disciplines and OrganizationsThe OSA recognized that simulation implementation would be greatly facilitated if resources were pooled and efforts centralized. All schools, and healthcare institutions were included as members as of the OSA unless they opted not to participate. The participation rate has been 100%. The Governor's office appointed a coordinator for the OSA who devoted time to the development and implementation of the OSA. It was clear from the outset that members of the OSA were not interested in acting as a controlling agency nor were they interested in determining what simulation education should be. The group sought to be effective in acting as an information and referral resource. The ability to act as a conduit for best practices was also appealing. To be successful in a statewide venture, the OSA sought to accomplish several things: To educate institutions and individuals about the essential elements of simulation program design.6–8 To provide a conduit for efficient knowledge transfer, networking, and collaboration. To provide funding for initial program assessment and advice. To provide funding for the purchase of startup equipment. To make simulation specialist training and faculty development accessible. In addition to the above goals, the OSA recognized that the success of the alliance would be based on trust. Alliance leaders needed to trust that the other members had something to offer, and were able to contribute to the goal of creating a statewide simulation network. The initial OSA leadership recognized the need to form a vision as a group to work effectively and successfully. This was not an instantaneous process; it required time, enthusiasm and commitment. The makeup of the group was crucial. Professional and employment responsibilities, leadership skills, and commitment to a shared vision were factors that influenced the collaborative environment. The members decided that all parties would have a stake in the final outcome of the organization, and that decisions would not be made solely by the few members with experience. Members of the OSA agreed that regardless of institution or discipline, success for the OSA was measured by the effectiveness of successful implementation irrespective of site or discipline. With this common understanding, the member institutions have been able to work collaboratively to bring simulation to many institutions in Oregon. INVOLVING THE STATE AND FUNDING In Oregon, workforce issues (especially in nursing) were a top priority for executive decision-makers. This was also one of the focal points for the Oregon Governor's Health Care Initiative. The initiative had multiple parts that focused on patient care as well as workforce enhancement. The case was made to funding agencies that simulation, although not a magic bullet, would be a tool to facilitate increasing healthcare training capacity and the healthcare workforce, while improving patient safety9. Arguments specific to workforce included: Simulation can increase the number of graduates by increasing education efficiency, and decreasing the strain on clinical sites. Simulation can be used as a method to shorten orientation time for new hires. Employers can use targeted simulation scenarios that address competencies specific to specialties. In this model, new hires have the opportunity to demonstrate competencies. Any gaps in skill knowledge or performance can then be addressed. Through these compelling arguments the OSA obtained funding from a variety of sources including: the Oregon Workforce Investment Board, the Federal Department of Labor, the Oregon Department of Public Health, and the Northwest Health Foundation (a private granting agency). Each of these organizations was approached individually, with separate proposals. The total funding for the year of 2004 was $1,050,000. This was considered seed money for the overall process. The OSA lacked any legal status, so all funds, with the exception of private foundation monies, were routed through a state agency that acted as the fiscal agent. The state agency was mandated to disburse monies as per the recommendation of the OSA. STATEWIDE SIMULATION: THE PROCESS The statewide simulation process included visits to communities, development of coalitions, simulation specialist education, faculty development, and a mechanism for allocation and distribution of funds. The successful implementation of the OSA vision was dependent on each of these elements. LOCAL SITE VISITS Irrespective of the OSA multidisciplinary makeup, it would be foolish to assume that we as a group understood the fundamental issues at each different location. Beyond being identified as a resource, the OSA elected to visit each community with an interest and need, and thus tailor the consultation to the site. This allowed the OSA to deliver education around simulation, initiate discussion on program development, and offer sound basic implementation strategies. Simultaneously, the OSA gathered information at each location that would allow it to develop both a statewide and site-specific strategy. These visits were funded through a public–private collaboration between the state of Oregon and the Northwest Health Foundation. The assessments were designed to capture the state of “readiness” for simulation at the different locations in Oregon. An in-depth analysis of the data was reported in February 2005.5 The report included formative suggestions for next steps to help sites develop simulation programs, as well as site readiness scores to serve as a gauge for future comparison. The data showed that the majority of sites had at least the basic foundations in place to succeed in program implementation. This was valuable information in our delivery strategy. The majority of sites had a strong desire for simulation but lacked substantive business plans, executive directives, and funds to sustain a simulation program. The lack of a plan to address simulation specialist training and faculty development was also readily apparent. The site visits had the added benefit of acting as a bridge for communities to lessen the effects of traditional barriers between healthcare disciplines and sectors. The OSA left the communities with a good sense of the basic issues and necessary next steps. Communities that were not ready for simulation were not falsely encouraged to immediately implement but were guided with ideas that would help them improve their state of readiness. The data from the site assessments continues to provide a comprehensive nonindustry-sponsored view of the elements that will help individual communities implement simulation programs. The findings of this report will be published in the near future. DEVELOPING MULTIDISCIPLINARY COALITIONS Rather than prescribe regional coalitions, the OSA coined the phrase “let local define local.” If coalitions formed that sought a regional center, then that would be their decision, not that of the OSA. In this way, respect for geography, diversity, historical relationships, and more was maintained. The OSA development model attempted to fully embrace the diverse needs of each location, helping participating organizations attain their goals. It was well understood that dispersing the burden and knowledge across many institutions with similar needs would provide significant increases in efficiency at multiple levels. One function of the OSA was to show the importance of functional coalitions, and to provide ideas for potential partners that may not have been considered. At each location, the challenge was to attract multiple disciplines to this process simultaneously. This was facilitated by the multidisciplinary makeup of the OSA group (nurses, executives, legislative liaisons, physicians, paramedics, etc). Disciplines were encouraged to consider simulation program development not as single entities but rather as a coalition with other interested parties. This was not a mandatory element but was a key consideration. Failure to consider this early on could preclude the opportunity in the future, as ownership issues (figurative and literal) act as potent barriers. Similar to the OSA's internal definition of success, we encouraged separate local coalition members to shed traditional measures of success and measure success as the ability of the group to complete its stated goals for development. ACCESS TO SIMULATION SPECIALIST TRAINING Over the last decade, simulation education training facilities have been slow to materialize. Simulation specialist courses at existing facilities are generally comprehensive and well regarded and range from 1 day to a full week in duration. Not unexpectedly, individuals who take these courses often return home with many questions and challenges. Simulation specialists take months, if not years to develop. The OSA felt it was important to train specialists and trainers with multiple repeated experiences, realizing that skill and knowledge is rarely instantaneous, especially when it is complex. At the request of the OSA, OHSU developed a training curriculum and program that requires prospective simulation specialists to not only complete an introductory course but to join an operational and experienced simulation team and to work as part of that team. The specialist moves from being the curious observer to an integral member of the simulation team over the period of several months. The goal was for the trainee to show comfort and basic competency in all aspects of high-fidelity manikin-based simulation, while having the opportunity to develop a professional network for future shared scenario development and implementation. Basic competency was based on simulation specialist standards in place at OHSU. The training curriculum, as structured, involved travel and time expenses for the trainees. The OSA allocated funds to provide training at no cost and to travel and A statewide of training was and individuals for were by an OSA appointed The process into geography, skill and regional The introductory courses were throughout the The training at has now been for months. The program is and has included participation from from and systems, paramedics, and have not in this initial of training as their commitment to simulation is developed than that of other disciplines. interest is increasing as by the of the of to standards for the use of simulation for will be offered as demand in simulation has not been The training process in Oregon is not to be It that on expertise our will help greater to the expertise that has over the faculty from the for Simulation to develop expertise in the The 20 was and were able to access from the OSA. not only they had the opportunity to network and that their are ACCESS TO development simulation education training with an on and of simulation as the Oregon for Education and the OSA made faculty development a The used by the group has to be but a and process to have simulation specialists and course faculty plan on the use and of simulation. Simulation specialists act as in the delivery of simulation that are consistent with curriculum goals. on the other have the to and the course faculty and simulation specialists time to develop an of the The developed a course to faculty who would not simulation specialists but who would be involved in course and The course has been offered for years and has been well The local site training and all provided faculty and with a of the and to simulation in As a result of these collaborative shared curriculum and simulation scenario now between FUNDING THE PROCESS As the OSA $1,050,000 from a variety of The allocation of was as for equipment and for faculty development, specialist training, site and operational The allocation was in the importance of the simulation programs, not the equipment (Fig. for equipment were through a for process. or coalitions could for a of for equipment. coalitions agreed to by the of the OSA and and to work collaboratively with multiple sectors. for funds were and by an The system elements as organization, and was to who that showed clear fiscal a plan for faculty and simulation specialist development, a plan for into a statewide and a plan for future The made its to the greater OSA for Not all institutions the full were funds through this process. The fiscal agency acting on of the OSA the funds. of these included coalitions of and These included the purchase of and high-fidelity One was specific for a based for across multiple institutions throughout the and funding STATEWIDE AND LOCAL the Oregon An integral part of the local site assessment process included what forces were in for simulation in Oregon. The method for analysis involved the use of a assessment tool developed at OHSU. The information gathered allowed the assessment team to offer guidance to the communities of Oregon. This analysis also the OSA to simulation should be through Oregon. a needs it was important for to recognize that different would and embrace simulation at different to in the nursing systems systems medical and The that all parties were not ready at the well into our phased implementation are now the and implementation of simulation for team training and medical education. The OSA, through the site training and other to show that the purchase of simulation equipment business and issues be considered to and of the equipment should be The need to these questions is not to the are several companies in the simulation that are early in their process and more making should request that companies provide and of The OSA facilitated to by them to show their at as the Oregon Simulation in in were also encouraged to travel to to the different The purchasing of a Oregon was were to a plan specific to OSA All were the of the individual institution as the OSA had no as a purchasing agent. The of plans was an for many The process that in Oregon was guided by relationships, basic concepts, and collaborative were many in the Oregon however, there are several that could have been An effort to disburse funds site visits rather than The funding that was required the OSA to and the funds a time The site visits by the OSA were important and coalitions the basic foundation information to make their had to the site visits to the time on the funds. time would have allowed coalitions to their and more for their use of the equipment while not being as a Although this may seem to be it is and are not To of the institutions are the of the was one in were not At the a clear process was not established to with a member institution not Although each institution is required to provide a report to the OSA, the lacked addressing any for not as in the The standards of in place when the were were on good With and process, this could have been in a more efficient a for the The OSA members offer their on a for a has from the Governor's The was to of the of the A for this would have provided access to more consistent have now been to an individual for this on a Through collaboration of key healthcare representative Oregon created a statewide the Oregon Simulation included the health systems, public and private multiple community public health and the Governor's The goal of the OSA was focused on the overall success of statewide simulation program implementation irrespective of or The group is a to all healthcare sectors and it is not a A to this collaboration included common goals, relationships, and coalition The Oregon sought to institutions should approach simulation program implementation and of our goals included: The development of required elements. to comprehensive simulation specialist and faculty for and sustainable program development. A common and The of and The development of a of accessible trainers of The Oregon Simulation Alliance has facilitated the implementation of statewide simulation-based education. The process focused on early establishment of and the necessary for The majority of the goals have been through the described in this The process has been as important as the goals Healthcare and institutions now have access to simulation training, and a statewide network of simulation The process will to and with funding and The success of this can be considered as of for the Oregon The OSA continues to and is its structure to best the simulation in Oregon. individuals to the core will that is but funds are being The Oregon Simulation Alliance has needs as it much of the in simulation around the state is now being funded by the The future plans for the OSA are to training and access to are being by multiple parties to the alliance has been effective and simulation is effective in increasing and decreasing orientation This data will take several years to as programs more established and develop greater The $1,050,000 in seed funding is when with the made by the programs. The OSA has increases in but data take several years to as many factors to the end of 2005, Oregon will have at least 20 simulation education multiple disciplines and over institutions (Fig. This project is unique and will act as a model that can be developed for and successful simulation program Simulation in Oregon as of would to and all the members of the Oregon Simulation this statewide could not have