• Linden Lab
• E For Everyone

You are expected to carry out multiple tasks at the same time. For example 2 staff on a morning whilst open you have to cash up the night befores takings look for errors bank it, whilst pulling in a delivery that turns up at random inconvenient times with 5-9 cages, whilst doing a cash collection for a security firm which should be done with 2 staff, whilst answering phone calls from. A new solution to griefing in Second Life. Posted on 2013-01-13 by Hal Jordan. Sandbox Sign. The Linden sandboxes can be interesting and fun places to hang out.

Abstract

Background

Oncology nurses often experience intense emotional reactions to patient deaths but may be forced to ignore or hide their feelings because of work-related responsibilities. The complexity of nurses' work and personal lives creates obstacles for participating in traditional support groups where grieving nurses can bond and share. We hypothesized that using a web-based, three-dimensional (3-D) virtual world technology (Second Life) may provide a venue to facilitate peer storytelling to support nurses dealing with grief.

Methods

We used a mixed-methods approach involving focus groups and surveys to explore the use of peer storytelling for grieving oncology nurses. Nine acute and ambulatory oncology nurses in groups of 3 participated using avatars in 5 group moderator-guided sessions lasting 1 hour each in a private 3-D outdoor virtual meeting space within Second Life. Baseline information was collected using a 12-item demographic and professional loss survey. At the end of the study, a 20-item survey was administered to measure professional losses during the study, exchange of support during sessions, and meaning-making and to evaluate peer storytelling using Second Life.

Results

Overall, nurses reported peer storytelling sessions in Second Life were helpful in making sense of and in identifying a benefit of their grief experience. They felt supported by both the group moderator and group members and were able to personally support group members during storytelling. Although nurses reported Second Life was helpful in facilitating storytelling sessions and expressed overall satisfaction with using Second Life, open-ended comments registered difficulties encountered, mostly with technology. Three central themes emerged in sessions, representing a dynamic relationship between mental, spiritual, and emotional-behavioral responses to grief: cognitive readiness to learn about death, death really takes death experience, and emotional resilience.

Conclusion

This study suggests a potential benefit in using peer storytelling sessions in Second Life to facilitate oncology nurses' grief resolution. In particular, Second Life provides a nonthreatening venue for participating nurses to share their innermost feelings and accrue their own inventory of stories. Through these stories, each nurse's relational experience in expressing and coping with grief is realized.

INTRODUCTION

Cancer deaths not only affect patients and their families but also the oncology nurses who care for them, both during the continuum of treatment and at the time of death. Nurses frequently experience intense emotional reactions to patient deaths but may be forced to ignore or hide their feelings because of work-related responsibilities. Although these reactions may physically manifest as sleep disturbances, eating disorders, and generalized irritability, numerous studies also report that stress among nurses dealing with chronic exposure to death leads to burnout and attrition.¹

The Bereavement Task Model describes 4 activities oncology nurses use in grieving over patient deaths: finding personal meaning in loss, restoring and maintaining integrity, managing affect, and realigning relationships. Support groups are one method that facilitates these tasks by providing an opportunity for grieving nurses to bond and share experiences. Macpherson reported a positive correlation between the number of peer-supported storytelling sessions and grief resolution in a small group of pediatric oncology nurses. However, the complexity of nurses' work and family responsibilities pose obstacles to participating in support groups. Dominick et al, in a study of 67 bereaved individuals, reported that grief was normalized by improving adaptive adjustment using an internet-based educational and self-help intervention supplemented by video testimonials. Although little research is published in this area, web-based, three-dimensional (3-D) virtual world technology (Second Life) may provide a venue to facilitate peer storytelling to support nurses dealing with grief.

The sequelae associated with nurses' grief not only pose a risk to nurses' health but also negatively impact the retention of experienced nurses in oncology. The process of facilitated peer storytelling was expected to result in the development of effective skills in working through grief. Storytelling has a history in nursing and nursing research; it has been used to evoke memories, facilitate meaning-making, and help guide nursing practice.^, Successful completion of bereavement tasks through storytelling may better equip nurses to cope with future patient deaths and to assist colleagues, patients, and families to effectively cope with grief.

The proposed benefits for using Second Life to facilitate peer storytelling vs a traditional support group include participation from any geographic location with internet access; peer interaction in the comfort of a private, nonthreatening environment; and the pseudodisguise associated with using an avatar (a computer representation of an alter ego) that may foster sharing of deeper emotions.

Specific Aims and Research Questions

This investigation sought to describe the use of Second Life in facilitating oncology nurses' peer storytelling about recent patient deaths. This mixed-methods study included thematic analysis of group session transcripts and nurses' evaluations of the peer storytelling experience in grief resolution conducted via survey. Two research questions guided this scientific inquiry:

• How do oncology nurses express and process grief surrounding patients' deaths through peer storytelling in Second Life?

• 2.

  Do oncology nurses report a benefit of using peer storytelling in Second Life in dealing with grief related to patients' deaths?

METHODS

Design

A mixed-methods approach involving focus groups and surveys guided scientific inquiry to explore the use of peer storytelling for grieving oncology nurses. This research methodology was the most appropriate because of limited evidence surrounding peer storytelling for addressing nurses' grief and the lack of published studies describing the use of Second Life to facilitate grief support. We used survey methods to capture nurses' self-reports regarding patient-related grief and to measure perceptions about using peer storytelling and Second Life for processing grief experiences. The qualitative analysis of peer storytelling sessions (focus groups) was important to enhance understanding of the potential benefit of Second Life for facilitating peer storytelling and to provide insight in refining the use of Second Life for storytelling.

Sample and Sampling Procedure

We used a purposive sample of 9 oncology nurses, using 3 groups of 3 nurses each, to answer the research questions. Acute and ambulatory oncology nurses who met inclusion criteria and who worked at 1 tertiary care facility were solicited to participate in the study. Nurses were eligible to participate if they had at least 12 months of experience as a registered nurse (RN), self-identified feelings of sadness/grief associated with patient deaths within 6 months, and self-reported confidence in computer skills that would allow engagement with Second Life. Exclusion criteria included inability to participate in 5 focus group sessions and prior enrollment in another group associated with this study. Criteria for administrative withdrawal from the study included determination by the group moderator that the participant was too emotionally upset to continue in the storytelling session and/or that an immediate intervention was required. Premature closure of the study related to unforeseen circumstances was also a criterion for administrative withdrawal. Nurses were recruited to participate in this study by providing information at staff meetings, flyers, and through snowball sampling. Participants were paid $25 for a 1-hour orientation session and for each of the 5 storytelling sessions, totaling $150.

Sample Size

The sample size of 9 participants was based on constraints associated with enrolling small groups of nurses reporting grief and being able to schedule storytelling sessions within the limited study period. It was particularly important to limit each group to 3 to provide sufficient time for all nurses to share their stories and comment on those of their peers during the 60-minute session. Approximately 16 hours of transcripts resulting from 5 storytelling sessions per group exhibited sufficient data saturation to answer the qualitative research questions.

Setting

The use of the internet has become widely established in the delivery of education, training, and research. Online programs provide affordable and easy access without logistical issues of time and distance for travel.⁷ Technological improvements in hardware and bandwidth have enabled evolution from conventional internet-accessed virtual programs to 3-D multiuser virtual environments (MUVEs).^-11

One of the largest and most widely used MUVEs is Second Life, created by Linden Labs in 2003 (www.secondlife.com/destinations/learning). Second Life enhances realism by allowing participants to interact as avatars and gain a sense of presence, a key element in the immersive experience. Witmer and Singer define presence as the subjective experience of being in one place or environment, even when situated in another, and accepting the computer-generated virtual space as a physical locale.¹² Higher levels of realism and stimuli infused within an avatar-mediated virtual environment can increase the sense of presence and therefore the level of immersion experienced by participants.

A private 3-D outdoor virtual meeting space within Second Life was used for this study (Figure 1). To access the private meeting space, study participants signed into Second Life as avatars and were teleported directly to the virtual meeting where they seated themselves on cushions, facing each other and the group moderator.

Second Life outdoor space used for peer storytelling sessions.

Peer Storytelling

Participants received an orientation about Second Life after providing informed consent. These individual orientation sessions familiarized each nurse with the use of Second Life. Storytelling groups consensually determined Second Life session dates and times using an online scheduling program. Storytelling sessions met every other week for approximately 1 hour for 5 sessions. All sessions occurred in the early evening.

A group moderator with grief management experience facilitated sessions. The role of the group moderator was to provide supportive grief counseling, elicit feelings, assist grieving nurses to regain focus and perspective, and move toward grief resolution. Each participant had an opportunity to share her story about a recent patient death(s), talking through a computer microphone headset. The group moderator established a normative culture by reciting ground rules prior to each session that included the following reminders: this experience was a research project, participants were to use Second Life pseudonyms and refrain from using real names, no views were right or wrong, participants were to speak up and feel free to share their opinions even though they may disagree from another's, only one person was to speak at a time, sessions were being recorded to capture all comments, everything said was confidential and not to be repeated outside of the group, and researchers strived to assure complete confidentiality.

The Bereavement Task Model (Table 1) was used to guide storytelling group questions in each of the sessions. Each session had a predominant task, and questions were devised to elicit responses relevant to the task. The bereavement tasks were understanding the emotional experience by finding meaning, restoring and maintaining integrity, managing affect, and realigning relationships. The corresponding variables of interest were professional loss, support exchanged in storytelling sessions, grief, meaning-making, focus group content, and the value of Second Life as a venue for processing grief through storytelling.

The Bereavement Task Model guided the first 4 focus group sessions, but the fifth session was a debriefing of what transpired throughout the 10-week study period.

Measurement and Instruments

Baseline information was collected using a 12-item demographic and professional loss survey. At the end of the study, a 20-item survey was administered to measure professional losses during the study, exchange of support during sessions, and meaning-making and to evaluate peer storytelling using Second Life. The 2 surveys were adapted with permission from surveys developed by Macpherson. Survey items were formatted as open-ended responses, multiple-choice options, and a 10-point rating scale to measure variables of interest. Table 2 describes how the survey items and focus group sessions were linked to measurement of variables of interest.

Table 2.

Linkage of Variables of Interest with Survey and Focus Group Methods

Data Collection

Participants completed an online demographic and professional loss survey within 7 days prior to the first storytelling session. All storytelling sessions were audio and video recorded using Camtasia Studio 7 software (TechSmith Corp.). Participants completed the end-of-study survey within 7 days following the last storytelling session. SurveyMonkey (www.SurveyMonkey.com) was used to collect survey data.

Human Subject Protection

Three institutional review boards representing 2 academic institutions and the sponsoring agency approved this study. Each participant gave informed consent prior to data collection. Participants were instructed to develop a unique avatar to be used exclusively for the peer storytelling project to ensure confidentiality. Only researchers knew the real-world identities of avatars, not the group moderator or nurse participants. All storytelling sessions occurred in a private location within Second Life to prevent nonparticipating avatars from entering the area. All storytelling sessions were audio and video recorded using an encrypted, password-protected computer. Recordings were stored on an encrypted and password-protected external hard drive accessible only to the principal investigator and another researcher.

Analysis

The 16 hours of audio and video recordings from the 15 peer storytelling sessions in Second Life were transcribed verbatim. Discussions and stories were analyzed using thematic analysis assisted with NVivo9 (QSR International Pty Ltd., Version 9) analysis software for data management, searching, and retrieval.^13, All 3 researchers participated in the data analysis: one researcher performed the coding, and the other researchers reviewed and discussed coding and thematic development, reaching consensus.

Trustworthiness

The trustworthiness of qualitative findings was addressed through research strategies and operational procedures directed at credibility, transferability, dependability, and confirmability. To achieve credibility, nurse participants received a synopsis of their comments and verified that their ideas, concerns, and experiences were accurately represented. In addition, credibility was enhanced by encouraging participants to be candid and speak frankly; recruiting participants from inpatient and ambulatory oncology sites; iterative questioning with probes; peer scrutiny of the research project and findings; and thick descriptions. Transferability was addressed by providing sufficient contextual information about the data collection procedures and information about participants and setting. Dependability hinged on reporting sufficient details about design and implementation and the effectiveness of the research process. Researcher triangulation, reaching consensus over data analysis decisions, and the use of diagrams contributed to confirmability.

RESULTS

Nine nurses, all female, agreed to participate and completed all study-related procedures. The mean age of participants was 39.5 years (SD=10.0) with a mean RN experience of 12.3 years and 8.3 years in oncology. The nurses' educational level included 1 diploma RN, 4 associate degrees, and 4 baccalaureate degrees. All participants currently worked in an inpatient or outpatient oncology setting, and each had experienced the death of a patient within the past 6 months and felt grief. None of the 9 participants voluntarily withdrew or was removed from the study by the research team.

Quantitative

The primary purpose of the prestudy survey was to gather baseline information regarding the participants' self-reported grief prior to beginning peer storytelling sessions. Prestudy survey findings about nurses' estimates of patient loss appear in Table 3. Findings were not normally distributed; therefore, mean and median values are reported. Participants reported that an average of 27 patients in their care died each year, with about 20 dying in the past 12 months. Respondents reported that an average of 5 patients died in the past 12 months whom they considered “special.” Although nurses entering the study did self-report grief related to recent patient deaths, they did not report feeling extremely overloaded with loss either in prestudy or poststudy responses. Using a 10-point rating scale (1 = not at all to 10 = extremely overloaded), nurses reported for a mean score of 4.33 in the prestudy survey reflecting loss during their entire oncology career and 3.22 in the poststudy survey using only the study period as a point of reference (Table 4).

Table 3.

Prestudy Survey Results About Nurses' Estimates of Patient Loss (n=9)

Nurses quantified their grief-related loss related to patients' family members' pain, close nurse/patient relationships, and their own expectations or beliefs. In the prestudy survey, nurse participants reported more grief-related loss related to patients' family members' pain compared to the other measured types of grief-related loss (Table 4).

QualitativeStudy Question 1: Expressing and Processing Grief

Using thematic analysis, the researchers identified related patterns as themes and subthemes and created a cohesive experience from the story components. Three central themes emerged, representing a dynamic relationship between mental, spiritual, and emotional-behavioral responses to grief: (1) cognitive readiness to learn about death, (2) death really takes death experience, and (3) emotional resilience. The first theme, cognitive readiness to learn about death, was comprised of 2 subthemes: nurses receive little formal education and nurses learn about grief from colleagues. The second theme, death really takes death experience, represented spiritual insights and vulnerability to experiencing grief. Finally, emotional resilience included 4 subthemes: strategies to manage discordant families, strategies to manage intense emotions, unresolved conflicts, and remembering and reflecting.

Central Theme: Cognitive Readiness to Learn About Death

Nurses discussed how they learned about the skills and competencies required to care for dying patients. While formal education was lacking, collegial relationships formed the foundation for acquisition of this knowledge. Nurse participants in all focus groups repeatedly remarked on the cohesiveness, support, and reliance on each other that they all felt. They reported these qualities to be fundamental to their own sense of confidence and job satisfaction.

Subtheme: Education

Nurses reported receiving very little formal educational preparation for patient death, dying, and their own grief. In sessions, participants made the following comments about their grief education: (1) “Grief? Not at all.” (2) “Grieving was not covered. I don't remember anything about grief in my school. Maybe a 5-minute discussion. In school, it was the last thing on my mind. We learned the stages of grief, in the psychology class, not nursing.” (3) “We went over death and dying but not how nurses deal with it, never as part of coursework.”

Subtheme: Colleagues

Nurses reported learning about grief through the support and guidance of colleagues and coworkers. A participant made the following comment about support from colleagues: “We talk in the lunchroom when it's tense. But when we leave work, I try to get on with my life.” One nurse summarized how she taught a novice nurse about grief:

I say that it was an inevitable thing. Shine a positive light on the experience and her part in it. Try to give feedback about her role in the whole thing, how the family responded, how the patient responded. Basically, [I] let her know she did a great job in a situation that was inevitable and that she did the best she could and really added to the experience for the patient and the family. We have to do that for each other as nurses. The family, in their grief, [is] overwhelmed with sorrow and pain and you sometimes internalize that. You need someone to tell you that you did great, you did what you could do. The families are not in a position to tell you that.

Nurses provide guidance and support for each other in a number of ways. “Nurses talk about it among ourselves and that is where our support system is.” More experienced nurses support less experienced nurses in communicating with patients:

See, I think you're great at that. You underestimate how helpful you are with that. I see you talk with them all the time and give them comfort. You must get outside yourself when you do that. I think you should treat yourself a little better. I've seen you. You have that gift. You're really kind when you talk to people.

Today I got a comment from a nurse that the patient said to say thank you for everything and that she thought about me and she told somebody to make sure they told me thank you. I don't really feel like I did that much but it's good to know that I guess I did. I can't even remember who she is, was, you know? We probably touch a lot of people's lives that we don't realize. And I feel honored.

One nurse's story about the loss of a patient and her grief was inconsistent with the other stories told in her group. She cried while driving home after a patient died, “and I live an hour away from work. I didn't know who to ask for help.” This nurse was the least experienced of the participants, having only been on the oncology unit for a few years.

Nurses said they were comfortable expressing feelings of grief and sadness to each other but often did not involve their families and friends in such discussions. Nurses related how they allowed themselves to cry with a patient but did not disclose these feelings or events to family and friends.

Central Theme: Death Really Takes Death Experience

All 3 groups shared stories about learning from each patient's death experience once they were cognitively ready. Cognitive readiness and learning from the death experience are aspects of a dynamic process across career spectrums.

Subtheme: Spirituality

A gradual shift toward a more spiritual viewpoint across nursing careers plays a fundamental role in learning about death and the growth of emotional resilience. Questioning the meaning of life and death is the foundation of spirituality. Is there a good death? Many of the nurses confirmed some deaths were better than others and examples of good death exist. “I basically believe that it's natural to die. A given. Do you want to go out kicking and screaming? Or peaceful with your mind put to rest about the thing you're concerned with?”

An old man signed a DNR [do not resuscitate order] the day he was admitted and was telling his wife how to plan the finances. It reminded me of my husband and how I would like things to go. Sometimes I would walk into the room and they would be crying together, holding hands. Then he would tell her a funny story, all the good times. It was a “rock star” death.

I had one patient I had taken care of for quite some time. It's almost like they take you in. You become part of their family. They want to know what is going on in your life and they share everything going on in theirs. I remember this one very clearly. I just felt like it was a privilege to be there and when I got the chance to say goodbye, it was “thank you for allowing me to share in your life and taking an interest in mine.” I learned from him, him and his family. I really got to see love, love between him and his wife, him and his daughters. He made it a gracious and joyous thing, not morbid. They were at peace with it, knew it was coming. He was able to pass on his own terms, knowing he did everything he could to make it easier for her [his wife], that she was going to be okay.

Subtheme: Vulnerability

Nurses acknowledged their vulnerability through being open and aware of their feelings and limitations in managing emotions about patient-related death. The nurse participants unanimously expressed a tremendous sense of sadness and helplessness when confronted with treatment failures and patient relapse. “See them come in and get diagnosed. The chemo doesn't work. That's the hardest part—finding out it didn't work. Wanting them to be fixed. Then watch them die. That's really hard.” Another nurse echoed, “We send them home. They're in remission. Then they come back and they're a mess. So much hope at first, it's hard to encourage them to get through it.”

So she went into remission and now she's back in the hospital and she is very depressed. When I see her in the hallway tomorrow I don't want to say, “Hey, you're back” or “I'm sorry to see you're back.” “I'm here,” and that's all I can say. That's hard. You know what's coming down the road—at this point, so does she. Anytime they come in with relapse after getting all that chemo with all the knowledge they accumulate, trust me—they know where they're going to.

Because of their schedules, nurses who provide care to patients and feel a sense of attachment are not always present when those patients die. However, they do hear about the deaths. Reactions vary and nurses cope in different ways. “I'm angry, upset. Sometimes I feel guilty. I don't know who the anger is at. I feel like they should be fixed. I feel helpless. The predominant emotion is sad, upset.” Another nurse stated, “One time I think I cried the whole way home. I live an hour away.”

Many participants disclosed that while feeling angry, sad, or helpless, they need to compartmentalize these feelings to fulfill their nursing responsibilities. “I want to run away and say, ‘Let somebody else be your nurse today, until I can think about this.' I don't have that option—no processing time.”

Death is a frequent occurrence on the nurse participants' units, and they reported rarely having time to prepare for the next death because they are processing the current patient's death. They readily expressed the vulnerability these numerous deaths generated. “I haven't come up with a way. If a patient comes in that I get attached to, I wonder every day, ‘What would I do?'” Managing personal feelings of loss is an ongoing challenge.

Nurses struggle with what to say and do when caring for terminally ill patients. They shared ways they allowed their vulnerability to be expressed. One nurse stated, “I don't know the right thing to say. I go get someone else to take that part.” Nurses stressed communication has to be genuine and heartfelt. “They don't want to hear the clichés: ‘Maybe it's for the best.' ‘She won't be suffering anymore.' They don't want to hear that from nurses. Everybody else says that stuff.”

If I walk in and she cries, I'm almost glad because that is something I can help her with. And I don't mind crying with her. I think it's very sweet because I think it helps them. It's a good release. Don't go in there expecting to say something. Wait and see what her mood is because it's her life. It's her terms. I shouldn't have to worry about my emotions, because I'm there for her. I have fear, fear of not knowing what to say. But I wait and see what she says first.

Central Theme: Emotional Resilience

The stories nurses shared consistently demonstrated some degree of emotional resilience in processing death-related experiences and managing complex emotional reactions. Interactions with dying patients provided opportunities for nurses to foster and build emotional resilience.

Subtheme: Discordant Families

Often families are in a state of discord at the bedside of a terminally ill patient—“not on the same page”—and are a source of conflict, inducing emotional reactions from many of the nurses. Families in the throes of anticipatory grief display a wide range of emotions as they watch beloved family members die. Feelings of loss and helplessness often overwhelm families who are unable to process the intensity of their emotions, and they often transfer their anger and frustration onto the nursing staff.

They [a family] were pissed at all of us. For 3 days the father kept saying, “Don't you want to live?” The son didn't want to do anything anymore. The patient is ready and the family members' heads are like these big bricks and you cannot penetrate. It's wrong. We literally had to keep that child alive until the father agreed to let him go.

Nurses reported sometimes feeling the need to advocate for patients' interests when disruptive family reactions seem to agitate patients.

One patient I was sending home on hospice and the family [two sisters] were in there fighting over her possessions in front of the patient. When they came into the hall I said, “You can't do this fighting when she's gone? Put her first.” They were taken aback, “We've been doing this all our lives,” and I replied, “Well, that is not what this is about today.” So they listened to me and behaved better. But that doesn't happen all the time, that people believe me. I was angry. I don't know where that stuff comes from—sometimes it just pours out.

Families often request nurses deliver their loved one from suffering, presenting a great source of conflict and distress for many nurses.

She was a young woman, married to a nice guy. We knew all of her family. They were at the bedside, the husband already grieving. I got in that morning and the mother asked me, “Is there a shot you can give her, to help her?” To hasten her death. I got upset and started crying. I don't do that. “Tell her it's okay to go,” was all I could say.

Conversely, many families emphatically insist their loved one be kept alive despite prognosis, condition, and exhaustion of all treatment options. One nurse stated that she has received requests both to “help them along” and to maintain their life despite any reasoning. “I hate for somebody to ask me that [to hasten death]. I am asked that once in a while. Or the opposite—keep them alive.”

Subtheme: Intense Emotions

Nurses shared stories about managing intense emotions during the throes of imminent death. Families turn to nurses for advice and guidance. “One family asked, ‘What should I do?' I don't think I should say anything.” Other nurses offered their insights on how best to answer inquiries from anxious family members.

There's a way you can say it without deciding it for them. I just say, “You know, none of us here are going to live forever, so think how you would want this to go for your loved one. If you believe in your heart that what the doctor says will help your mother, then go with that. But if you don't believe, then you need to talk to your mother and see what y'all need to do.”

I don't hold back like I used to. I used to be like a little support and just do whatever the family wanted, whatever the doctor wanted. Now I try to stay outside and tell them what I see, not what I feel. Not what I would do, but point out the facts. “Your mother is going to die anyway, how do you want this to go? What questions are you not asking the doctors?” For some reason it takes the load off of me—I didn't tell them what to do.

The same experience-based wisdom guides how nurses interact with patients and approach conversations with terminally ill patients. “Don't say anything. Wait and see what she says first. Allow her to control the situation—she can just take one look at me and start crying and I know I will cry with her. You have to go with where she is at.”

Although nurses readily discussed how they managed intense emotional conversations with patients and their families, they said they avoided sharing these feelings with their own families and friends. “We can talk to each other—our feelings. We can't go home and talk about this stuff with our families, but we can talk to each other.” “I suspect we look at life and death totally different than normal people who don't deal with it.”

Subtheme: Unresolved Conflicts

Although nurses share many positive experiences with other healthcare providers, they discussed emotionally charged situations that fuel their discontent. Physicians were sometimes identified as a source of conflict, frustration, and anger. Nurses reported feeling that physicians often avoid direct, honest discussions with families. “I get angry at the physicians for dancing around the issues about patients.”

That is where my anger comes from. You have information but you are not allowed to act on it. I talk to the doctors and say, “Are you going to go in there and tell them how serious the situation is?” And they say, “They will be back next week and maybe we can give them another course [of chemo or radiation].” Yeah, instead of giving them that time, to process information and spend more time with family, they just drag it out. They [the patients] are almost dead by the time they call the family in.

Nurses also voiced concern and distress over treatments physicians want to perform on terminally ill patients: “The doctor was pushing chemo on this lady, an investigational thing. Is it going to cure her? Make anything better for her? I was very upset.”

Subtheme: Remembering and Reflecting

Emotionally resilient nurses learn from their vulnerability associated with loss, allowing adversity and pain to make them stronger. Developing a new perspective generated the discovery of new meaning about the lives and deaths of their patients.

One day I was cleaning out some drawers. I found a large envelope and it was full of poems a patient had given to me, 10 or more years ago. I couldn't remember his name, but his face came to me all of a sudden. Those poems were in my hands and I didn't know what to do with them, those beautiful poems. I wish I had one to read to you now. Later, I suppose, we still grieve for people that come to mind. Grief is not always a bad thing—you remember and it brings back memories, so they are not forgotten. You forget the bad things and remember the good things, cherish them. It is a beautiful process when people come back to you, the memories come back to you.

Study Question 2: Benefit of Using Peer Storytelling

To answer the research question regarding the benefits of using peer storytelling in Second Life to deal with grief related to patients' deaths, nurses used a 10-point rating scale to answer 8 questions (Table 5). Overall, nurses reported peer storytelling sessions were helpful in making sense of (mean = 8.88) and in identifying a benefit of their grief experience (mean = 8.67). They felt supported by both the group moderator (mean = 9.56) and group members (mean = 9.44), and were able to personally support the group members during storytelling (mean = 8.56). Although nurses reported Second Life was helpful in facilitating storytelling sessions (mean = 7.78) and overall they were satisfied with using Second Life (mean = 8.44), open-ended comments addressed difficulties encountered. While 3 of the 9 participants made explicit comments stating that they did not identify any difficulties using Second Life to engage in peer storytelling sessions, 5 reported having technical problems related to computer graphics, sound, and/or internet connections. Another participant reported that using the virtual venue did not allow the listener to interpret nonverbal cues, making it difficult to grasp a sense of the storyteller's emotions.

Table 5.

Nurses' Perceived Benefit of Peer Storytelling and Second Life in Dealing with Grief (n=9)

DISCUSSION

This study is one of few that explore how within a virtual environment nurses express and process grief surrounding patients' deaths. The 9 nurses who participated in the 3 groups shared stories that supported 3 themes. These themes depict a dynamic process whereby the foundational aspects generate more enriched and sophisticated strategies that enable nurses to process and express grief related to patient deaths. These themes were evaluated against the literature to further understand the factors that contribute to nurses' cognitive readiness to learn about death, death really takes death experience, and emotional resilience.

Cognitive readiness to learn about death is the catalyst for progression to spirituality and openness to vulnerability, which is foundational to the death really takes death experience trajectory. Based on the work of Morrison and Fletcher, cognitive readiness to learn is the “mental preparation (including skills, knowledge, abilities, motivations, and personal dispositions) an individual needs to establish and sustain competent performance.”¹⁵ Nurses' cognitive readiness to learn about death was supported by 2 subthemes. Despite the lack of formal education on death and grieving, nurses sought opportunities to learn from oncology nurse peers, mirroring the work of others.^- The more experienced oncology nurse participants readily shared their support and guidance with less experienced peers on how they were able to process and express grief. In this way, they demonstrated how to cultivate learning through peer storytelling and foster building a cadre of nurses equipped to remain in oncology nursing. Not all nurses evenly progressed through the learning process, as reported by the novice nurse who was unsure of what she should ask regarding helping patients and families through death and whom to ask for guidance in dealing with patient death and grieving.

As one participant reported, death really takes death experience. Only through mastery of cognitive readiness were oncology nurses able to develop spiritual insights and openness to vulnerability in expressing and processing grief related to the deaths of special patients. Similar to the work of others, both the quantitative survey data and focus group transcripts supported the notion that nurses are able to quantify the number of special patients and recall details about those who died throughout their careers.^,19 In addition, participants recalled and shared emotion-laden stories about their patients. Nurses shared spiritual insights that death was a part of life, and they were able to find meaning in both good and bad death experiences.

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Death really takes death experience involved lifelong reflection to gain knowledge and understanding of death as a life event. Caring for the dying, as experiential learning, bridged cognitive readiness and the development of emotional resilience. Resilience developed over time as a process rather than a trait. Resilience is an adaptive strategy learned through surviving adversities and is nurtured through peer relationships and supportive environments.²⁰ Peer storytelling provided a vehicle to reveal previously unspoken thoughts and feelings about how nurses responded to the adversity of patient death. Storytelling cultivated emotional resilience through the linkage connecting peers and meaning-making from their stories. Ablett and Jones and Macpherson reported similar findings.

In this study, emotional resilience manifested as nurses' strategies to manage the intense emotions, behaviors, and conversations of patients and families facing imminent death. Nurses articulated a sense of the insider-outsider phenomenon in that only those who care for the dying understand the emotional sequelae. In a similar fashion, these nurses and the work of others established a normative rule to protect family and friends, who were outsiders, from exposure to the emotional turmoil resulting from working with the dying. In tandem, they strived to develop strategies for managing their own intense emotions and to build resilience. They described fragile relationships with physicians, characterized by anger and frustration, further creating conflict. Ethical conflicts arose over who was the gatekeeper of patient prognostic information because of imposed constraints on the nurses' authority to disclose. Likewise, witnessing the perpetuation of aggressive treatment at the end of life contributed to the undercurrent of moral distress. Such unresolved conflicts and distress, supported by this study and others, provide tremendous potential for learning and growth of emotional resilience.^,19 The true hallmark of actualizing emotional resilience was embodied in remembering and reflecting on the lives of the patients through powerful stories that generate new meaning, insight, and understanding.

This dynamic process, revealed through the participants' stories, represents a nonlinear transition from fundamental learning to insightfulness and finally to resilience. The interchange between cognitive readiness to learn about death and death really takes death experience represents the fluid nature of cognitive and experiential learning rather than a sequential process. Similarly, experiential learning fosters emotional resilience through an interactive feedback process. At any point in nurses' careers, their abilities to express and process grief are changing within the themes. The Gestalt effects of the 3 themes build a story of how nurses express and process grief. Figure 2 is a schematic representation of the 3 themes.

Thematic map of how nurses express and process grief.

Using Second Life for Peer Storytelling

Both quantitative and qualitative data supported that nurses and facilitators perceived a benefit in using peer storytelling in Second Life to express and process grief. These findings are particularly important because nurses in several studies have reported a benefit in managing patient-related bereavement by talking to peers about grief using debriefing and/or support groups.^,

This virtual environment, like the real-world environment traditionally used for qualitative methods, produced an abundance of robust data. Second Life was a novel environment free from the usual distractions and commitments of the real world, providing an avatar-mediated disguise that fostered anonymity and disclosure. Storytelling in Second Life did not present obstacles to sharing powerful stories that yielded insights into how oncology nurses express and process grief. All participants talked and told stories in sessions that embodied laughter, solemnity, and support.

Limitations

The small sample size limited the generalizability of the findings and precluded the calculation of statistical estimates of reliability and validity for the surveys. Use of only one facility limited transferability because of varying supportive resources that may be in place in other organizations. Technical difficulties with individual internet connections and computer hardware supporting sound may have interfered with some data capture.

Linden Lab

Implications

Findings highlight the need for additional educational preparation of nurses and other providers, particularly in interprofessional venues. Organizational leadership should explore environments conducive to debriefing, including the use of virtual spaces that are capable of facilitating psychological safety where conflicts and ethical issues can be openly discussed.

Recommendations for research include investigating the feasibility of using other nontraditional venues for grief debriefing and support groups and exploring the impact of grief support on retention of oncology nurses. In addition, this study should be replicated to further develop a model that explains how oncology nurses express and process grief.

CONCLUSION

Powerful stories yielded insights into how oncology nurses express and process grief. This study suggests a potential benefit in using peer storytelling sessions in Second Life to facilitate oncology nurses' grief resolution. In particular, Second Life provided a nonthreatening venue for participating nurses to share their innermost feelings and accrue their own inventory of stories. Through these stories, each nurse's relational experience in expressing and coping with grief is realized. Nurses who are able to effectively express and process their grief are less likely to compartmentalize their feelings and are more likely to therapeutically engage with the patient and family dealing with life-limiting and life-threatening disorders such as cancer. As nurses continue to share stories about their experiences and those of their peers, healthcare professionals, patients, and families experiencing grief may benefit from the stories that are told.

Footnotes

This study was partially funded by the DAISY Foundation's J. Patrick Barnes Grant for Nursing Research and Evidence-Based Practice Projects. Otherwise, the authors have no financial or proprietary interest in the subject matter of this article.

This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care, Medical Knowledge, Interpersonal and Communication Skills, and Professionalism.

REFERENCES

Anshe Chung is an avatar (online personality) of Ailin Graef in the online world Second Life. Referred to as the Rockefeller of Second Life^[1] by a CNNjournalist, Graef has built an online business that engages in development, brokerage, and arbitrage of virtual land, items, and currencies, and has been featured in a number of prominent magazines such as Business Week,^[2]Fortune^[3] and Red Herring.

Background[edit]

According to Chung, she had already created fortunes in purely virtual currency on other MMORPGs such as Asheron's Call and Shadowbane,^[4] but had never converted that to real tender. This changed when she entered Second Life, where the in-game currency, 'Linden Dollars' (L$), can be officially exchanged for real money.^[5][6]

In her early Second Life days, prior to founding the business that made her famous, Anshe Chung had a goal of using virtual wealth to support an orphaned boy in a developing country in the real world. With her first Linden dollars she was able to sponsor a boy named Geo from the Philippines through a German church organization.^[7] She raised funds through event hosting, escorting,^[3][8] teaching^[9] and fashion design.

Business[edit]

According to Chung, in June 2004 she began selling and creating custom animations and then used this money to buy and develop virtual land. This is also considered the beginning of her business where, for the first time, she kept and reinvested funds instead of giving them away. Chung currently owns thousands of servers' worth of land, most of which are sold or rented to other users as a part of her 'Dreamland' areas. Within Dreamland various levels of zoning rules are enforced; most other land in Second Life is unzoned, with multiple different types of business or housing located in adjacent areas.^[10]Philip Rosedale, the former CEO of Linden Lab – the company that produces Second Life – has referred to Anshe as 'the government' when referring to the role she plays managing her regions.^[11]

According to Dr. James Cook of Linden Lab, 'Anshe adds significant value to Second Life'.^[12]

In February 2006 'Anshe Chung Studios, Ltd.' was legally incorporated in Hubei, China ^[13]

In November 2006 Chung announced that she had 'become the first online personality to achieve a net worth exceeding one million US dollars from profits entirely earned inside a virtual world'.^[13]

Meanwhile, Anshe Chung's business employs more than 80 people full-time, most of them programmers and artists. She counts several Fortune 100 companies among her clients as well as high-profile organizations such as the government of Baden-Wuerttemberg and LifeChurch.tv, whose Second Life entry her firm developed.

In January 2007 Anshe Chung Studios received venture capital investment from the Samwer brothers, who purchased a stake in the Anshe Chung Studios.^[14][15] In September 2007 the Gladwyne Partners, who had previously funded the Electric Sheep Company, also obtained stake in the Anshe Chung Studios.

Since 2006 the company has been active in IMVU, a 3D avatar chat. She has since been operating the largest currency exchange and content creation business for that platform, with about half of the 100 top selling products in IMVU originating from her company in Wuhan, while a considerable amount of the remaining top sellers are said to be coming from people who were originally trained in her company. During Anshe Chung's involvement with IMVU, that service's userbase has increased 50-fold, outgrowing Second Life in late 2007.^{[citation needed]}

New Champion of the World Economy[edit]

In 2007, the Anshe Chung Studios were chosen as a 'New Champion of the World Economy' by the World Economic Forum, describing the company as a business with a major technical or economic impact and the potential to become a Fortune 500 company within the next 5 years.^{[citation needed]}

From 2005 until January 2009, Anshe Chung also owned a 30% share in Virtuatrade, a Pennsylvania-based company operating the site XStreetSL.com, a virtual goods trading site similar to eBay but specializing in Second Life items. The company was eventually sold to Linden Lab. XStreetSL has now become an integral part of Second Life called the 'Second Life Marketplace'.^[16][17]

E For Everyone

In July 2008, a new portal site called AnsheX ^[18] became available, operated by her company in Wuhan. The new site merges the services, communities and currency exchanges of several monetized virtual worlds, attempting to bridge the gaps between them.

According to several sources, including a title in the October 2009 issue of Avenue Magazine, Anshe Chung joined the founders of Skype as a key investor behind the 3D fashion games developer Frenzoo.^[19][20]

In 2010, Anshe Chung helped fund a new venture called the 3D Avatar School,^[21] which is using virtual world technology to create immersive language teaching environments.^[22]

In 2012, the 3D Avatar School won both the Red Herring Asia 100 and Red Herring Global 100 awards,^[23] while Frenzoo landed a hit on Android and iOS with the world's first 3D dress-up game, Style Me Girl.^[24]

By early 2014, Anshe Chung Limited had acquired an investment portfolio with several additional Internet and technology startups including Sellfy,^[25] Beyond Games,^[26] Makibox,^[27] IMVUCE,^[28][29] and ArtsCraft Entertainment, developer of MMORPG game Crowfall.^[30][31]

Target of griefing[edit]

In December 2006, while conducting an interview for CNET with Daniel Terdiman on her economic assets, the virtual studio in which the interview took place was bombarded by flying animated penises. The griefers managed to disrupt the interview sufficiently that Chung was forced to move to another location and ultimately crashed the simulator entirely.^[32] Video and images of the incident were posted on the website Something Awful, and the incident received notice in some blogs and online news sites.

This attack in Second Life later became a template for a real life flying penis attack on chess world champion and Russian presidential candidate Garry Kasparov.^[33]

See also[edit]

References[edit]

1. ^Sloan, Paul (December 1, 2005). 'The Virtual Rockefeller'. CNN. Archived from the original on December 12, 2006. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
2. ^'My Virtual Life'. Business Week. May 1, 2006. Archived from the original on January 5, 2007. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
3. ^ ^abParloff, Roger (November 28, 2005). 'FROM MEGS TO RICHES'. CNN. Archived from the original on January 4, 2007. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
4. ^'Press Kit – Anshe Chung'. Anshe Chung Studios. November 27, 2006. Archived from the original on January 5, 2007. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
5. ^'Economy'. Linden Lab. Archived from the original on January 3, 2007. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
6. ^'LindeX Market Data'. Linden Lab. Archived from the original on January 3, 2007. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
7. ^The Herald Profile: Anshe Chung Walker Spaight, The Second Life Herald, 2005-01-25. Retrieved 2007-01-17.
8. ^'Anshe's kinky past revealed'. The Age. Melbourne, Australia. January 17, 2007. Retrieved January 20, 2007.
9. ^Diaz, Cristiano (aka Cristiano Midnight) (November 28, 2004). 'Introducing The Chat History Interview – Anshe Chung'. SL Universe. Archived from the original on December 31, 2006. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
10. ^Why Anshe Chung is a MillionaireArchived September 27, 2007, at the Wayback Machine
11. ^'The Virtual Rockefeller'. CNN. Retrieved June 2, 2019.
12. ^Virtual goods, real incomeArchived September 30, 2007, at the Wayback Machine
13. ^ ^ab'Anshe Chung Becomes First Virtual World Millionaire'. Anshe Chung Studios. November 26, 2006. Archived from the original on January 7, 2007. Retrieved January 5, 2007.Cite uses deprecated parameter deadurl= (help)
14. ^Samwer Brothers Take 10% Stake in Anshe Chung StudiosArchived March 17, 2007, at the Wayback Machine
15. ^GmbH, Frankfurter Allgemeine Zeitung. 'Echtes Geld fuer die Virtuelle Welt'. FAZ.NET. Retrieved June 2, 2019.
16. ^'Second Life Marketplace'. marketplace.secondlife.com. Retrieved June 2, 2019.
17. ^'Linden Lab Acquires Virtual E-Commerce Sites XStreetSL and OnRez: The Numbers, Strategy, and Controversy'. New World Notes. Retrieved June 2, 2019.
18. ^'Sims from Anshe Chung for 6799 L$/week!'. AnsheX. Retrieved June 2, 2019.
19. ^'Frenzoo - 3D Mobile Games For The World'. Frenzoo - 3D Mobile Games For The World. Retrieved June 2, 2019.
20. ^'AVENUE Magazine SLCC 2009'. Issuu. Retrieved June 2, 2019.
21. ^3DAvatarSchool.com^{[permanent dead link]}
22. ^'Jvwresearch.org'. jvwresearch.org. Retrieved June 2, 2019.
23. ^'2012 Top 100 Global Winners'. Red Herring. Retrieved June 2, 2019.
24. ^'Play.google.com'. google.com. Retrieved June 2, 2019.
25. ^'Create an online store for your digital products'. sellfy.com. Retrieved June 2, 2019.
26. ^'Beyond Games'. Beyond Games. Retrieved June 2, 2019.
27. ^Makibox.comArchived February 7, 2014, at Archive.today
28. ^'IMVUCE.com'. Archived from the original on January 27, 2013. Retrieved September 12, 2018.Cite uses deprecated parameter dead-url= (help)
29. ^'Anshe Chung Portfolio'. anshechung.com. Retrieved June 2, 2019.
30. ^'Crowfall - Throne War PC MMO by ArtCraft Entertainment, Inc'. crowfall.com. Retrieved June 2, 2019.
31. ^'Angel.co'. Archived from the original on April 2, 2015. Retrieved March 19, 2015.Cite uses deprecated parameter dead-url= (help)
32. ^Terdiman, Daniel (December 20, 2006). 'Virtual magnate shares secrets of success'. CNET. Retrieved September 7, 2019.
33. ^Hutcheon, Stephen (May 21, 2008). 'Kremlin critic gets genital reminder about who's in charge'. The Age. Retrieved June 2, 2019.

External links[edit]

• BusinessWeek title story and magazine cover
• Second Life Safari – Room 101 v. Anshe ChungSomething Awful's coverage of the griefing incident