International Journal of Healthcare Simulation

Introduction

Empathy is the ability to understand and share the feelings of another. In the practice of medicine, empathy in patient–physician communication remains an important skill for all professionals to have to deliver better care for their patients [1]; therefore, medical educators should prioritize uncovering novel educational approaches to enhance empathy among medical students.

Virtual reality (VR) is a powerful tool to build empathy allowing a user to experience what another person is experiencing and in turn, possibly, feel what they are feeling. While the term VR has come to encompass a wide variety of computer-generated audio-visual experiences [2], we are using the term ‘immersive VR’ to delineate the experience of VR via a computer-generated environment, wherein the participant is using a head-mounted display with environmental audio and spatial tracking [3].

Immersion is the level to which the participant becomes involved in the simulation and varying levels of immersion can have varying levels of impact among the participants [4].

Embodied Labs® is an immersive VR software app which creates a realistic environment and scenario for the user to experience how a person with a particular disability lives [5]. Dyer et al. describe medical, nursing and physical therapy students’ increased expression of empathy for older adults with vision and hearing loss or Alzheimer’s disease after using an Embodied Labs immersive VR simulation [6]. During the COVID pandemic Embodied Labs added a new online screen-based VR option which engages the user to interact with a computer to access and respond to the content.

Our pilot study explores learners’ self-reported expression of empathy for older adults with social isolation after experiencing either an immersive or screen-based VR. Our hypothesis is that a greater level of immersion achieved through immersive VR as compared to screen-based VR would invoke a greater level of empathy among medical students.

Innovation

Embodied Labs’® Frank Lab, which focused on social isolation, was selected by the authors to be used for the study as it had a compelling story, especially with imposed isolation that everyone experienced during the COVID pandemic. The HTC Vive® [7] headset was used for the Immersive VR, while a 27-inch Apple iMac [8] with headphones was used for the screen-based VR. Study participants were randomized to either screen-based or immersive VR in a 1:3 ratio, respectively. Pre- and post-surveys were created in Qualtrics® [9] to evaluate the intervention.

Evaluation

The Jefferson Scale of Empathy (JSE) Student (S Version) by Thomas Jefferson University was used to measure empathy. It is a 20-question survey that uses a 7-point Likert scale which provides a score that is a surrogate measure of empathy. Both pre- and post-surveys included JSE as well as various open-ended responses on demographics, extent of prior experience with VR and how immersed they felt during the VR intervention using a 5-point scale (1 = Barely Immersed to 5 = Very Immersed).

Outcomes

Forty-two medical students participated (14% of invited participants), 62% of whom were females. The majority (95.1%) reported a reasonable to more-than-reasonable level of immersion experience and most (95.2%) strongly recommended applying VR into the medical education curriculum. Examining the overall change in all participants’ JSE pre- and post-VR revealed a mean increase of 6.47% (p < 0.001).

A paired t-test analysis on the 32 immersive VR participants’ mean score revealed an increase of 7.76% (p < 0.001). Similarly, for the 10 screen-based VR participants the score change increased by 3.54% (p = 0.049).

A two-sample t -test analysis (Table 1) showed no significant difference between the change in difference in pre–post scores between the two groups (p = 0.142).

Table 1:

Mean JSE score and their change in the study participants

Jefferson score	Overall	Immersive VR	Screen-based VR
Pre-simulation	114.02	113.50	115.70
Post-simulation	121.71	122.31	119.80
Overall change	7.69	8.81	4.10
% Change	6.74	7.76	3.54

The change between the scores for each participant was also calculated and averaged.

A Mann–Whitney U-test comparing the difference in the JSE scores among the different simulation modalities among the subgroups of gender, class group (premedical vs. medical), level of subjective immersion and prior experience with VR demonstrated no statistical significance. Notably, however, the difference between JSE scores among the immersive VR participants who felt less immersed was 3.20 while those who felt more immersed was 9.85. The difference between JSE scores among the immersive VR participants who had no VR experience was 6.00 while those who had VR experience was 12.00.

What’s next?

Our data show that VR simulation, whether immersive or screen-based increases levels of empathy in medical students. There is a 2-fold increase in the difference between pre- and post-simulation JSE scores in the immersive when compared to the screen-based simulation. Whilst not statistically significant, this may be explained in part by the small number of overall participants and our 3:1 modality allocation. For future reference, a crossover study with more participants in each group can further validate these findings.

How might this innovation be relevant in other settings

Immersive VR and screen-based VR are viable options for educators to consider. Our study reveals that learners benefitted from the immersive experience, and empathy scores increased with different levels of immersion, mostly among those with prior experience of VR use, suggesting that access to the technology for wider use may make its use in the educational setting more effective.