Feasibility Pilot Study: Training Soft Skills in Virtual Worlds

Patricia Abshier, MSPH, MSW

Abstract

In a world where funding is limited, training for healthcare professionals is turning more and more to distancelearning in an effort to maintain a knowledgeable and skilled work force. In 2010, Cicatelli Associates, Inc. beganexploring the feasibility of using games and virtual worlds as an alternative means to teach skills-training in adistance-learning environment. The pilot study was conducted with six individuals familiar with generalcounseling and communication skills used by the healthcare industry to promote behavior change. Participantsreported that the venue, although challenging at first, showed great potential for use with healthcare providers,as it allowed for more interaction and activities than traditional Webinars. However, there are significantlimitations that must be overcome in order for this healthcare training modality to be utilized on a large scale.These limitations included a lack of microgestures and issues regarding the technology being used. In spite of thelimitations, however, the potential use of virtual worlds for the training of healthcare providers exists andshould be researched further. This article discusses the need and intended benefits of virtual world training aswell as the results and conclusions of the pilot study.

Overview

Over the past decade, one of the common complaints offace-to-face skills-based trainings has been that they are

too costly and there are not enough funds for both serviceprovision and travel for training. Working with not-for-profitorganizations, this burden on travel has become more andmore apparent, as travel is no longer allowed by many public-funded and government agencies. Cost savings and travellimitations have forced the concept of distance learning. Web-inars and other distance-learning modalities have becomethe focus of training as a result. Traditional Webinars andother distance-learning formats such as white boards, black-boards, and discussion boards are viable avenues for infor-mational-based courses and training. Universities such asKansas State University, Clemson University, Harvard Uni-versity, and Columbia University have been utilizing virtualworlds for the past decade to enhance their programs andpromote education. Government agencies and businesses,such as Sun Microsystems, IBM, the National Oceanicand Atmosphere Administration, and American Society forTraining and Development, have also been represented invirtual worlds in an attempt to increase knowledge regardingthe work they do and their companies. Utilizing various dis-tance-learning modalities, IBM reported, in 2009, a savingsof 200 million dollars by utilizing distance learning for itsemployees.

Virtual worlds as stated above have been utilized by var-ious agencies to impart knowledge. Virtual worlds have beenreported to be effective in training emergency departmentteams and other healthcare personal regarding disaster pre-paredness.1 They have been used to train therapists workingwith families impacted by autism,2 to train psychiatrists andpsychologists,3 and, more recently, to train physicians todeliver bad news or difficult diagnoses.4 In addition, in 2009,as reported subsequently, Boston University successfullyutilized virtual worlds to teach the fundamentals of motiva-tional interviewing.5 The research presented suggests that theuse of virtual worlds can be used to provide training to publichealth professionals in order to enhance their communica-tions and counseling skills. Based on the literature presentedand the desire of Cicatelli Associates, Inc. to develop inter-active engaging distance-learning programs to teach not onlyinformation but also communication and general counselingskills, an informal pilot study was conducted to test the fea-sibility of using virtual worlds in this capacity.

Intended Benefits

This informal pilot study was developed to determine thefeasibility of using virtual worlds as a viable method of dis-tance learning for teaching general counseling skills, com-munication skills, and other ‘‘soft skills’’ used by healthcare

National Training Center for Family Planning, Cicatelli Associates, Inc., New York, New York.

GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical ApplicationsVolume 1, Number 2, 2012ª Mary Ann Liebert, Inc.DOI: 10.1089/g4h.2012.1020

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and healthcare-related service provider agency staff. Basedon extensive program evaluations spanning over 30 years ofCicatelli Associates, Inc. trainings, this skills-training neededto be delivered in one session, incorporating large group in-teractive lectures, small group activities, and role-play skillspractice, while in a distance-learning environment. The skills-focused training also needed to be inexpensive for both thetraining agency and the participants. These design require-ments lead to the use of virtual worlds to provide timely, cost-effective, skills-based training to enhance the quality of carebeing provided throughout the United States.

It is generally accepted that interactive knowledge ex-change can be done though Webinar/videoconferencing withrelative ease. It is also accepted that counseling and com-munication skills can difficult to coordinate in distance-learning settings and even more so within the confines of onesession. Many currently used modes of distance learning donot allow for breaking participants into more than two smallgroups without individuals having to leave one ‘‘classroom’’and log onto another and then log back into the original‘‘classroom’’ to process the activities. The same holds truewith commonly used distance-learning methods for skills-practice role-plays.

Many modes of distance learning in education have beenutilized effectively for conveying information, including vir-tual worlds. The most commonly used methods are webinarsand videoconferences. Webinar, Skype�, and other formatsfor teaching have been used effectively to teach both infor-mation and skills. However, many of these trainings thathave been found to be effective involved multiple sessions,including one teaching specialized skills to therapists whowork with families of autistic children.2 Universities havebeen utilizing virtual worlds to enhance their learning envi-ronments for the past decade. Although much of the learningthat takes place using virtual worlds focuses on the exchangeof information, one of most compelling trainings, as statedpreviously, involved Boston University’s use of virtualworlds to teach motivational interviewing principles.5 Thiscourse focused on a specific belief system and utilization ofskills used by mental health practitioners and included askills development section. Boston University’s ability toteach motivational interviewing in a virtual world environ-ment highlighted the use of this modality to teach other formsof skills-building, resulting in enhanced service providerknowledge and skills.

Intervention

A 3-hour qualitative pilot test was conducted with sixtraining professionals, each familiar with adult learningprinciples and general communication and counseling skill.The group consisted of three trainers, two curriculum de-velopers, and one administrator. Of the six participants, onepossessed a Ph.D. in Psychology, three had master’s degrees,and two had bachelor’s degrees. Participants ranged in agefrom the mid-20s to the mid-40s with varying degrees of ex-perience with technology and gaming: Two of the partici-pants were avid gamers who were versed in a large array ofgames, from action to role-play; the remaining four partici-pants had a general knowledge of games and gaming. Thismix of participants allowed for examination of this trainingmodality from diverse points of view.

The training was conducted via a secured simulationwithin the virtual world. Access to the simulation was limitedto designated ‘‘group members’’ and those who had beenplaced on the access list during the design and build phase ofthe project. Participants were assigned avatars in an effort todecrease the time needed to become familiar with the virtualworld being used. Each avatar had been shaped before beingassigned to a participant, in order for it to look more realisticand less cartoonish. The landmarks and destinations of ava-tars were limited to the training simulation. Avatars wereassigned 1 week prior to the training pilot, giving partici-pants time to familiarize themselves with movements andanimation.

The training simulation was designed with a universitylook on the surface, including classrooms, PowerPoint (Mi-crosoft) projectors, etc. Above the classrooms, approximately100 meters in distance, were small group discussion rooms,and 100 meters above those were small role-play rooms. Eachof the role-play rooms was constructed with a minimum of 30meters between them to insure that local channel communi-cations would not overlap between rooms. Landmarks werepreloaded to each of the training rooms. A chat log wascaptured of those conversations on the local channel, in orderto track the interactions.

The training was conducted using two types of interac-tions: Large group interactive lecture and small group inter-action. Role-play interactions were to be tested at a later date.The factors examined included ease of use, amount of inter-action, comfort with the training modality, and barriers ex-perienced. This pilot training was conducted on the use ofbasic counseling communication skills referred to as ‘‘OARS’’:Open-ended question, Affirmation, Reflection, and Sum-marization. For each skill, a short interactive lecture wasprovided, and then the large group was split up with anactivity. Once the pilot training was completed participantswere asked what was most useful regarding the use of virtualworlds for training, what they viewed as barriers, and howcomfortable were they using the technology.

Assessment/Feedback

Pilot study participants were asked a series of basic ques-tions to determine the feasibility of using synchronous virtualworlds. Participants were asked (1) what was most usefulregarding the use of virtual worlds for training, (2) what theyviewed as barriers, and (3) how comfortable they were usingthe technology. The participants each responded to thequestions, and their responses were evaluated. Each of thepilot study participants was able to provide feedback fromhis or her own unique perspective as there were trainers,curriculum developers, and an administrator. As a result re-sponses included design-related, trainer preparation, andstaff utilization.

Results

Individuals who participated in the pilot stated that the useof text for relaying information facilitated their ability to re-engage in the training, if they had been drawn away. Oneindividual, who had to leave the training for 5 minutes, statedthat she was able to scroll up the conversation and catch up.She further stated that she did not feel like she was missingout. Many of the participants in the pilot training also stated

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that they viewed it as more engaging than classic Webinars orother distance-learning venues. Each of the participants be-lieved that this venue could be used effectively for follow-upinteractions to enhance skills already learned, but believedthat day-long or 2-day-long courses would not be amenableto this mode of training. Although there were advantagesseen regarding this mode of training, there were many chal-lenges as well.

The challenges encountered using virtual worlds, as withany other distance-learning platform, includes the need forlarge amounts of time being designated for troubleshooting.Although their systems met basic requirements to view thevirtual world, participants of the pilot training had varyinglevels of success in actually being able to view objects andavatars once in the virtual world. Two individuals whosegraphic cards were unable to process the information fromthe virtual world required additional technical support. Inaddition, some participants had not entered the virtual worldprior to the training, even though they were provided with auser manual, an avatar, and basic instruction ‘‘cheat sheet’’ aweek prior to the course. These individuals reported moredifficulty with navigation and motion during the training.Those who had explored the simulation and gone through thenavigation familiarization area reported less difficulty duringthe training session.

Avatar gestures seemed to raise the most concerns re-garding the avatar interaction and its usefulness for com-munications and counseling skill trainings. Major bodygestures were seen as advantageous and were seen as a usefulpart of the training. Participants stated that the hand-raisingduring the lecture component helped as it was also pairedwith a text notification. The most daunting of the issues fo-cused on gestures; more specifically, participants reported thelack of facial and microgesturing by avatars during groupactivities. Although base facial movements such as smile,frown, etc., are standard in the avatars for the virtual world,they were deemed inadequate for role-play skill-building.Much of communication is based not only on the major ges-tures we use, but more so on microgestures, which help whendetermining if a smile is a genuine or fake, the level of frus-tration or anger, etc. As technology advances this shouldbecome less of an issue.

Conclusions

The use of virtual worlds does provide a new avenue forconducting informational Webinars and follow-up trainingswhere skills have already been learned by participants. Thesense of being with other individuals is increased and allowsfor greater engagement and interaction. Individuals don’t feelleft behind if drawn away from the training because ofcompeting priorities. In spite of the benefits of using virtualworlds in distance learning, technology is problematic. We

discovered, during the pilot training, that some systems thatmet the basic requirements could not run the virtual worldviewers. More specially, some videocards were not compat-ible with the virtual world viewers.

For this project, the most concerning issue reported wasthe current level of facial gesturing. Virtual worlds havelimited capabilities for teaching the finer skills related tocounseling and communications. In order to overcome this,extra time needs to be spent teaching participants andtrainers to emote (verbally express emotions and body ac-tions). The emotives need to be taught, which include eventhe smallest of body motions or expressions in order toovercome this challenge. This additional level of individualtraining in order to use the virtual world suggests that use ofthis venue, presently, is not realistic for use at Cicatelli As-sociates, Inc., where many of the clientele lack the necessarycomputer skills and/or access to adequate computers. Asvirtual worlds evolve, this barrier to teaching communica-tion and counseling skills will be overcome. More research isneeded regarding the use of virtual worlds for trainingservice providers’ communication and counseling skills foruse with their patients/clients.

Author Disclosure Statement

The author is an employee of Cicatelli Associates, Inc.

References

1. Heinrichs W, Youngblood P, Harter M, Dev P. Simulation forteam training and assessment: Case studies of online trainingwith virtual worlds. World J Surg 2008; 32:161–170.

2. Vismar L, Young G, Stahmer A, et al. Dissemination of evi-dence-based practice: Can we train therapist from a distance.J Autism Dev Disord 2009; 39:1636–1651.

3. Mantovani F, Castelnuovo G, Gaggoli A, Riva G. Virtualreality training for health-care professionals. CyberpsycholBehav 2003; 6:389–395.

4. Andrade A, Bagri A, Zaw K, et al. Avatar-mediated trainingin the delivery of bad news in a virtual world. J Palliat Med2010; 13:1415–1419.

5. Boston University. Virtual worlds, real gains. 2011. BostonUniversity Medicine at the Margins. www.bu.edu/research/magazine/2011/01-2-virtual-worlds-real-gains.html (accessedMarch 2012).

Address correspondence to:Patricia Abshier, MSPH, MSW

Deputy DirectorNational Training Center for Family Planning

Cicatelli Associates, Inc.505 Eighth Avenue, 16th Floor

New York, NY 10018

E-mail: pabshier@cicatelli.org

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