McGonigle, C. and McGonigle, D. (2023). Metaverse: Healthcare’s next frontier. Online Journal of Nursing Informatics (OJNI), 26(3), https://www.himss.org/resources/online-journal-nursing-informatics
Background: As we are making sense of adding the realities and AI, a newer concept has emerged based on the capabilities being realized through AR, VR and AI, and is taking the world by storm.
What is a Metaverse: The evolution of the latest frontier of the Internet is defined and described.
Four Facets of the Metaverse: Data, information, and knowledge, people, IoT, and IoE are explored in relation to the metaverse.
Three Components of the Metaverse: Each of the three components plays an important role in realizing the promise of the metaverse. The hardware and software facilitate access, entry, actions, and processing. The content is what the users come to experience within the metaverse.
Use Cases: The cases presented demonstrate how educational, healthcare, and insurance-based organizations are entering and pushing the limits of the metaverse technologies to provide innovative, immersive, and engaging educational, clinical, financial, and recreational experiences in a secure environment that maintains privacy.
Challenges Facing the Realization of the Metaverse: The weaknesses and threats in the metaverse become challenges that must be eliminated.
Nursing Role Specific Challenges: As nurses push the metaverse envelope and continue to create the cutting edge of this frontier, they must always be vigilant to recognize and eliminate challenges.
Conclusion: By anticipating and preparing to mitigate potential pitfalls and creating a patient centered collaborative setting, healthcare providers in the metaverse will generate better expectations for this immersive and unparalleled frontier.
Educators and vendors are finding ways to augment reality, meaning exactly that, the user is immersed as their reality is enhanced by overlaying digital information and media onto their real, physical environment, synchronously. Healthcare practice and education are integrating the realities, meaning augmented reality, virtual reality, mixed reality, and extended reality, into their settings. Educators including nurse educators are applying extended reality (XR) and mixed reality (MR) to their repertoires. Using XR and MR strategies, they immerse the learner in physical and virtual environments along a continuum of augmented reality (AR) through virtual reality (VR). Learners can then experience their environment with these enhancements. VR is providing immersive experiences where the learner dons the head mounted display (HMD) or headset, to enter and interact within a 3-Dimensional digitally generated artificial environment that simulates the real world or is fantastical such as stepping into Wonderland with Alice or going through a themed intergalactic immersive ride at an amusement park (see Table 1).
The user can interact with the environment as well as other users or avatars using headsets, controllers or naked hands, haptic gloves, and other wearable devices such as body suits. This immersion replaces the user’s reality and makes them feel present in the experience. As haptic and wearable technologies advance, the experience will be heightened. The digital world can truly mimic the real world such as a clinical environment, city scape, or educational setting. The user enters this virtual, immersive world as an avatar or graphical representation of themselves. This immersive experience not only engages the learner’s senses of sight and hearing but can also integrate the sense of touch with haptic technologies such as gloves and smell using devices providing scene appropriate aromas and scents. Patients experience VR as a distraction intervention during painful procedures or to facilitate surgery. The patient can visualize their own anatomy so they can see their exact issue that will be treated while allowing the surgeon to practice the procedure in VR before they are performing the surgery on the real patient. The maturing of artificial intelligence (AI) has also impacted and enhanced our capabilities from education to practice. AI has impacted our capabilities by necessitating that everyone must search for and identify student assignments created using AI tools, while it also benefits the educator since it can grade papers. AI has enhanced our practice since it can provide diagnoses and treatment plans without healthcare provider input. For example, it has impacted radiology, since it can out-pace a radiologist’s accurate interpretation of the films.
As nurse educators, practicing nurses and researchers are all trying to make sense of adding the realities and AI to their practice, a newer concept has emerged based on the capabilities being realized through AR, VR and AI, and is taking the world by storm. The metaverse is about to burst wide open with an expected market size of $800 billion by 2024 (Brown, 2022; Wise, 2022). People are talking about and trying to figure out this new entity, what it is, how it will impact their professional and personal lives, and how they can harness its capabilities to enhance the nursing profession and position themselves and their institutions, so they are ready to take advantage of the metaverse. In this article, the authors will define the metaverse, discuss use cases, challenges and why all nurses but especially nurse educators, researchers, and nurse informaticists must help us realize the promise of the metaverse.
The metaverse has entered the everyday conversations of our colleagues and patients but the discussions seem to surround what it means and what impact it may or may not have on us collectively as well individually. The term metaverse has many meanings and is defined in different ways based on the definer’s perspective.
Dee McGonigle has been researching and exploring the metaverse concept since 2003 when the first, beginning of a metaverse, Second Life, was launched by Linden Lab (Linden Research Inc., n.d.). Second Life is a metaverse in the sense that there is commerce, education, employment, and socializing since users interact virtually but it is not yet linked to other virtual worlds. Craig McGonigle entered Second life in 2015, has been pioneering in other metaverses, and has established a public space and private spaces within a truly professional metaverse. There are many definitions and the authors wanted to provide a clear, succinct definition that encompasses all the metaverse can be for us. Craig McGonigle has been honing his metaverse definition since 2021.
It has evolved over time:
The metaverse is another evolution or frontier of the Internet that is expected to be more immersive, social, interactive, and financially sophisticated. The promise of the metaverse as it is conceptualized is to provide the digital space needed to conduct our lives from education, business, work/career, entertainment, socialization, mental and physical health, and wealth perspectives. Accomplishing this promise of the metaverse with a strong feeling of presence and being interconnected in a welcoming space where users can control their access and experiences is paramount.
Think about this for a minute – the promise of the metaverse that is being hyped must be realized!
The metaverse has data, information and knowledge, people, virtual or digital settings, the Internet of Things (IoT), and the Internet of Everything (IoE). Data, information, and knowledge are generated, processed, and shared across the metaverse. People access and enter the metaverse in virtual or digital form as avatars through which they interact with digital assets including objects and the environment and other avatars or people. People engage the metaverse as users, developers, or both to create their user experience. They have a persona in the metaverse and their chosen attire and appearance as well as the digital assets they use allows them to convey the social meaning of their avatar. People can learn, work, play, and shop collaboratively or alone to the extent they desire to engage and become immersed in the metaverse. The IoT or digital objects may or may not be interactive and enable the metaverse to examine, analyze, evaluate, and interact with the real world. The metaverse acts as a 3D user interface to the IoT devices making possible personalized IoT user experiences where the user can make data-driven decisions with minimal training and expending minimal mental energy (Arab, 2022). The IoE is the intelligent connection of people, process, data, and things where objects have sensors to detect, measure, and assess their status. The IoE affixes intelligence to the IoT and extends its communications from machine to machine and machine to people or users.
The components of the metaverse are hardware, software, and content. The hardware refers to the physical technologies, machines or devices used to access, enter, interact within, extend out, or create and build the metaverse. For the consumer or user, it includes but is not limited to HMDs or headsets, controllers, input devices, haptic gloves, wearable technologies, scent diffusers, laptops, tablets, smart phones, cameras, and scanning sensors that track eye and head movements and voice input.
Software refers to Internet connection, apps, or platforms to access/enter, crypto wallets, games, point of sale, avatars, display technologies, digital assets, digital twins, digital representation, blockchain, AR and VR technologies, AI, 3D reconstruction, IoT, cloud computing, and computer programs. Computer programs are those needed for the operation of the metaverse but also those that recognize and generate sights, scenes, and objects, recognize, and synthesize sounds and speech, and output and render motions. The platform refers to the applications necessary to enter the metaverse. Display technologies are needed to bring in the clarity and vividness of the colors in the metaverse. Digital assets include objects such as virtual lands and settings, houses, avatars, and cryptocurrencies. Digital twins are exact replicas of a setting, environment, campus, store, or other assets such as houses, cars, or buildings to name a few. Digital representations are not exact replicas of objects but mimic real-world assets. The term 3D reconstruction refers to the technology that supports the creation of photorealistic objects capable of capturing the realism for virtual spaces. For instance, using 3D reconstruction, a company could create a virtual showroom for its cars where users can explore and even test drive a vehicle.
Blockchain is a digital ledger or database shared across a large network of nodes or computers. The nodes work together to authenticate and verify the transactions that are then stored and chained together in encrypted blocks of digital asset data. The more nodes that are running the blockchain, the safer and more secure it is since a hacker would have to hack more than half of the nodes to be able to make changes. Therefore, the blockchain forms a chronological verification for the data where the digital assets are distributed but not copied or transferred. Blockchain can support the decentralized infrastructure of the metaverse by providing extended storage capacity, trusted powerful data processing and authentication nodes, and interoperability across metaverse projects through seamless interactions and the sharing of related data, information, and resources.
AR and VR technologies are considered the access points for the metaverse and facilitate immersive, engaging, connected user experiences. AI will replace human controlled actions and interactions with computer controlled automated actions and interactions. AI avatars can learn gestures, body language, and language specific conversational exchanges. AI avatars and objects can inform and assist people so they can complete their tasks in the metaverse.
Content is the crucial component of the metaverse providing users with immersive and engaging experiences that can be user generated. Content is important since it “contains story reality, immersive experience, and conceptual completeness” (Ziaul, 2022, para. 19). The content is what the users want to experience and the reason why they enter and interact within the metaverse. As users generate the metaverse spaces such as buildings, campuses, cities, houses, hospitals, offices, meeting spaces, clinics, streets, museums, or other assets they choose the look and feel of the areas, how they are organized, and what services will be supplied. As people create their avatars with the look and characteristics they want for their avatar’s appearance to represent them, the diversity of perspectives and culture will shape the community of the metaverse. Users or people as avatars are the subjects and the realities created within the metaverse are the means for linking and connecting the avatars in the metaverse and users in the real physical world.
Each of the three components play an important role in realizing the promise of the metaverse. The hardware and software facilitate access, entry, actions, and processing. The content is what the users come to experience by making use of the hardware and software within the metaverse.
Individual users as well as organizations will have a profound impact on shaping the metaverse as they enter, explore, and demand more capabilities. To attract the users, the metaverse must be compatible with the user’s social values, providing social meaning and situational context for them. A metaverse might not be the real world but can elicit tangible emotions and feelings. For the metaverse to approximate the real world, the interactions must be seamless and concurrent within an environment with presence. Those born from the mid-to-late 1990s through early 2010s are the upcoming generation, Gen Z, and their social values indicate that they want to move through the realities of their lives with their online and offline persona or presence being the same.
The following use cases in Table 2 demonstrate how educational, healthcare, and insurance-based organizations are entering and pushing the limits of the metaverse technologies to provide innovative, immersive, and engaging educational, clinical, financial, and recreational experiences in a secure environment that maintains privacy. Time will tell how far the metaverse can go under the influence of the enterprises and their constituents.
Challenges Facing the Realization of the Metaverse
As nurses and other healthcare professionals enact use cases and strive to realize the promise of the metaverse, persistent accessible hyperconnected psychosocioeconomic digital and physical presence or a place to learn, work, play, shop no matter where they are physically, there are challenges that must be recognized and met. This brief discussion will begin with challenges facing everyone using the metaverse including nurses and will then include nursing role specific considerations in Table 3.
The relationship between the Internet of Things (IoT) and metaverse is becoming evident since one of the greatest challenges for the metaverse lies in its ability to access, correlate, and map data and information from the real world or real life and meld it into the digital or virtual reality. This data and information must be secured, accurate, organized, have meaning, and be available synchronously, in real time. Since the IoT has been around and in use for several years, there are hundreds of devices including cameras, wearables, and sensors that are available and ready to be used and incorporated into the metaverse. All nurses must assist policy makers to expand their policies to handle the rapid evolution of technologies and capabilities that are and will be afforded as the metaverse develops. Policies typically do not keep pace with the technological evolution and capabilities and the evolution of the metaverse is no exception.
For example, the Health Insurance Portability and Accountability Act (HIPAA) guidelines (Office for Civil Rights (OCR), 2017) have tried to keep up with the expansion of telehealth and mobile computing, however, the metaverse has now entered the patient care arena and lawmakers will need a wide variety of expert input including nursing to help them understand and modernize the necessary guidelines based on the abundance of data and information in the metaverse. In addition, governance of the metaverse will be essential and a set of unified rules must be established. Copyright and ownership issues must be addressed legally.
Software and hardware vendors need help in understanding the metaverse frontier to create the products, programs, and devices that will meet the user’s current needs and current state of the metaverse with an eye to the future. As with any digital platform, malicious activity, and attacks that breach security will be an ever-present threat that could cause ethical issues, loss of data and information, invasion of privacy, harassment, and intentional human rights infringements to name a few. With the metaverse capabilities, users might suffer risks of physical harm from the prolonged use of wearable technologies, especially HMDs or headsets during their immersive activities. As with any socially interactive space, there are risks of emotional and psychosocial harm whether intentional or unintentional.
When dealing with a new frontier, everyone must be vigilant to maintain access and equity. Since the metaverse is presenting us with an enormous evolution of the Internet, issues with interoperability and scalability must be recognized and addressed. For the metaverse to be viable, the ability must exist to exchange, use, and share data and information on a grand scale and be able to handle the expanding volume and workload. Artificial intelligence (AI) agents will need to be enhanced to improve and personalize the user experience by providing meaningful just-in-time assistance or information. Infrastructure improvements must be made to ensure reliable and persistent availability. There must be a secure system in place to be able to make payments for services or products in the metaverse. Blockchain and cryptocurrency technology must be implemented where blockchain is a digital ledger that overcomes the weaknesses of centralized data storage by providing a secure means to create, own and monetize decentralized digital assets. Cryptocurrency is a method of digital payment using blockchain technology.
The weaknesses and threats in the metaverse become challenges that must be eliminated such as confidentiality issues, interoperability problems, privacy invasion, security breaches, faulty navigation, and seamless transitioning between the real world and the virtual or digital world as needed. There are many challenges to address as the metaverse evolves. It is important to keep an eye to the future while being grounded in the present while striving to have the metaverse approach real world exchanges, the seamless and concurrent interactions gained through presence, interfaces, and connections. As the metaverse mimics the real world, it can elicit or cause real emotions and feelings as people are immersed and present in their digital experiences. As more nurses and nurse informaticists learn about, research, and experience the metaverse, they must realize the impact they can have in shaping this new frontier for the improvement of patient outcomes, enhancing their professional development as well as advancing the nursing profession. Nurses and nurse informaticists must educate other nurses, patients, and the healthcare team on how to leverage the benefits of the metaverse. Nurse informaticists must assess the impact of this new frontier on their own practice setting while helping other nurses and healthcare team members understand the technologies, functionality, and capabilities of the metaverse so they can enhance their practices and support their patients.
It is imperative to determine how the nursing informatics specialty will influence and be affected by the metaverse. As the metaverse envelope is pushed, it continues to create the cutting edge of this frontier. Everyone must always be vigilant against security and privacy issues as well as access and entry equity and persistence. It is every professional’s responsibility to access, enter and navigate this new evolution of the Internet so they can harness its potential for the benefit of the patients under their care. Nurse informaticists and nurses must recognize and address the challenges as they arise during the evolution of the metaverse frontier.
The metaverse is not just a new trend or an improvement in existing technology. It is a paradigm shift in content consumption, that nurses and nurse informaticists can help lead. The metaverse is emerging as an immersive technology with enormous potential for optimizing patient care across the entire healthcare continuum. The authors encourage everyone to join as participants in new paradigms that will disrupt and influence the future of healthcare, as well as professional and personal lives. Nurses and other healthcare professionals must participate so our practice settings, patients and our profession have a place at the table. The metaverse is composed of many different elements in which the users’ input and creativity is essential. It is believed that the future does not depend on the developers as much as the users who can shape every facet of this new Internet frontier. There will be ongoing challenges and issues that must be addressed since there will be many new shifting dimensions of the metaverse. By anticipating and preparing to mitigate potential pitfalls and creating a patient centered collaborative setting, healthcare providers in the metaverse will generate better expectations for this immersive and unparalleled frontier as they engage their constituents and colleagues to improve healthcare delivery.
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Mr. McGonigle is currently associated with Whitemouse Productions as a virtual innovative immersive teaching learning experiences solutions architect. He has over 7 years of experience in teaching and learning modalities within virtual worlds, artificial intelligence (AI), and virtual reality (VR). He has led learner support initiatives for students interacting with branching logic and AI powered standardized patients, as well as VR experiences. Mr. McGonigle applies his strong business foundation and technological expertise to enable the students to focus on their core competencies, ensuring future success. He led the development of a public metaverse space and continues to innovate and enhance the learner experience.
Dee McGonigle PhD, RN, FAAN, ANEF
Dee McGonigle is the director of Immersive Learning experiences (ILX) at Adtalem. Dr. McGonigle has over 44 years of experience in teaching/learning including nursing informatics, serious gaming, simulation, and virtual immersive learning with realities, especially virtual reality (VR). She is a Fellow in both American Academy of Nursing and NLN Academy of Nursing Education and co-authored four textbooks including one on virtual simulation. Dr. McGonigle has been active in exploring and investigating the metaverse concept and her team launched the first public metaverse space for Adtalem Global Education. She is currently exploring and developing in the private space of this metaverse to develop immersive learning strategies for veterinary science, social determinants of health, and interprofessional education.