Our journey began at VR for Empathy Education

How VR could be used as a tool to teach empathy

How it all began…

Empathy education has been our core value and the starting point of all our immersive projects. Empathy as a subject is given special consideration at the Torbay hospital. Our aim is to use immersive experiences in a manner that not only offers students and staff an opportunity to question the role of empathy, but explode, learn, and improve. Empathy for patients and for one another can have positive implications for both patients and healthcare teams. We encourage discussions around empathy by immersing viewers in experiences that allow them to view clinical situations from the patient’s or colleague’s point of view, followed by debriefing sessions conducted by clinical leads.

PatientVR is an invention of Nick Peres (Digital Lead) at Torbay hospital. The app consists of series of 360-degree immersive experiences designed with the goal to teach empathy.

PatientVR empathy intervention

Medical students who go onto their clinical training at the Torbay Horzion Centre have the opportunity to experience the PatientVR platform, which is an empathy VR intervention. The aim of PatientVR is to create a platform from which humanistic skills can be taught effectively through personal reflection and experience. Non-technical skills (such as compassion and empathy) have up until now been difficult to teach in education, as an aside from clinical skills training, where practical skills can be traditionally evaluated and observed, humanistic skills are often just a presumed function among individuals. 

Patients can sometimes be overwhelmed by what is happening around them. The PatientVR concept is about placing doctors, nurses and other frontline staff in the patient’s shoes to understand how, what and why.  The problem PatientVR aims to address is how, as staff of a health service, we can focus on making patients feel better and not simply focus on the treatment alone.  As skilled professionals, medical staff recognise the importance of a good bedside manner, but can forget or become caught up in pressures of a time sensitive system.

Often the positive effect of humanistic skills on a patient’s experience can be witnessed in the small and simple things, like a touch on the shoulder, eye contact or a smile.  On one level, PatientVR looks to highlight the importance of these small elements using the cinematic interface. Beyond this, the unique experience of navigating the patient perspective in different scenarios opens an insight in which the user can look at deeper human factors, such as the appearance of hospital spaces to a patient, the emotive effect the sounds of a room may have, even how staff communication and movement can look to those being treated. Many ‘problems’ can be discovered by simply having this patient perspective that can be replayed and discussed without limitation. PatientVR creates the mechanism from which students and staff can experience this in a safe and self-reflective environment, all vital qualities for effective learning.

PatientVR is currently being deployed on a variety of courses, including Manual Handling and Team Resource and Management(TEREMA).  On the Manual Handling course, the VR intervention is deployed for a segment of the lesson to give participants (consisting of all clinical backgrounds as part of mandatory training) insights into the patient perspective during a bed and hoist transfer, which can be quite frightening. This helps staff realise how they can make the experience more comfortable for the patient. The TEREMA course, which looks primarily at the importance of effective communication in a healthcare setting, deploys the VR intervention (an immersive communication theatre scenario) as part of an exercise to recognise a breakdown of communication and to see the perspective of a worried junior doctor.  In both examples, PatientVR offers an interactive element to the classroom that breaks up text book or PowerPoint learning for all participants to experience, either through the headset, or through a projected image, navigated by a pc mouse). The headsets are centrally controlled from a facilitator’s iPad, allowing the experience to start and finish on all phones/headsets at the same time, helping encourage reactive discussion and feedback.

Traditionally, no such modules have existed within medical schools or hospitals, however, with the development of VR, researchers have began exploring the role of immersive experiences in developing empathy education programmes.

Why empathy education must be a part of healthcare education and training?

Empathy in healthcare is the most crucial element of the physician’s behaviour with direct implications on patient outcomes(Winefield & Chur-Hansen 2000; Sherman & Cramer 2005; del Canale et al. 2012; Peddle et al. 2018). Empathetic healthcare workers often form strong relationships with their patients. Engaging in empathetic behaviours helps in the development of an alliance between the healthcare professional and the patient; a positive alliance has implications on the patient’s motivation to become involved in their care plan(Winefield & Chur-Hansen 2000). From the patient’s point of view, empathy is what makes a ‘good physician'(Carmel & Glick 1996). (Goodchild et al. 2005)found empathy amongst healthcare workers can be used to predict patient satisfaction and the success of consultations. (Abou-Elhamd et al. 2010)have been able to establish that empathy helps physicians in accurately understanding their diabetic patients’ beliefs about their illness, which in turn is associated with better self-care amongst the patients. have found that physicians high in empathy show higher competency in history taking and physical examinations.  (Suchman et al. 1997) have found that physicians high in empathy show higher competency in history taking and physical examinations.  Competent behaviours, as a result of high empathy lead to greater satisfaction amongst patients. Furthermore, (Suchman et al. 1997; Sherman & Cramer 2005) state that physicians high in empathy experience lower malpractice litigations in comparison to those ranking low in empathy. This stresses the importance of teaching empathy skills to medical students, in order to ensure that they are able to practice empathetic communication with patients in the future.

Within the context of patient care, empathy is the physician’s skill to understand what a patient is saying and feeling and in turn communicating this understanding to the patient(Olson 1995). (Fields et al. 2011) have expanded upon Olson’s definition of empathy by focusing on the cognitive attributes that are involved in developing the understanding of patients’ experiences combined with the capacity to communicate the knowledge with an intention to provide help to the patient.

According to (Decety & Jackson 2004) empathy is a naturally occurring subjective experience based upon the psychological inference of observation, memory, knowledge and reasoning (Ickes 1993)about another person’s thoughts and feelings. Given, the subjective and multi-dimensional complex nature of empathy, the measurement of the concept can be elusive (Fields et al. 2011). Not only does this make imparting empathy education a challenging task, but educators are also faced with the issues of effectively measuring the outcomes of the empathy education interventions. As different educators adopt different strategies to teach empathy at medical schools, it has also been noted by (Hojat et al. 2001; Mohammadreza Hojat et al. 2002; Davis & Kimble 2011; Youssef et al. 2014; Hojat 2016) that medical students often become less empathetic as they progress through their education. A systematic review conducted by (Neumann et al. 2011) found that empathy tends to decline the most when students start visiting clinical environments for training. The authors attribute this drop in the empathy to vulnerability, stress and burn out experienced within clinical environments.

Various researchers (Alligood 1992; Nerdrum 1997; M. Hojat et al. 2002; Stepien & Baernstein 2006; Fields et al. 2011; Peddle et al. 2018) recommend incorporating empathy interventions at undergraduate and postgraduate level medical education and training. A number of medical colleges such as the American Medical Association and Medical Board of Australia have also published a variety of formal guidelines and codes of conduct to ensure ethical and effective training. Empathy can be taught through a variety of interventions such as DVD based learning packages, classroom case studies, mannequins, role-playing and virtual reality simulations (Peddle et al. 2018). (Winefield & Chur-Hansen 2000; Kelm et al. 2014)have found that empathy interventions are often taught as part of communication skills course, comprising of didactic sessions, handouts, videotapes, conducting interviews with standardized patients and receiving feedback, and, experiential learning and skills/behaviour workshops. Another commonly used method involves ‘role-playing’ (Chunharas et al. 2013). (Kelm et al. 2014) also found that literature based interventions can be used to teach empathetic behaviours. (Afghani et al. 2011) have used reflective writing to get medical students to write essays from the point of view of a hypothetical or standardized patient. (Peddle et al. 2018)have found that simulation-based education is often effective at helping students in developing their empathy and empathetic behaviours. The researchers further stress that simulated empathy interventions are often viewed as valuable to healthcare education and training.

Empathy interventions can be simulated through various interventions that range from partially immersive to full immersive. At the fully immersive end of the continuum, virtual reality simulators can be found. Virtual Reality (VR) simulators have been touted as the ultimate ’empathy machine’ by (Arora & Milk 2015).

Literature suggests that a number of empathy interventions are utilised across medical colleges, however, (Kelm et al. 2014) have established that these interventions cannot be categorised, which in turn might affect the measurement of their validity. Furthermore, the use of fully immersive simulated virtual reality interventions for the purpose of teaching humanistic skills to medical students is a new concept, as opposed to using similar interventions to teach technical skills, which has a longer history.

Our research on VR for empathy education

Given the current lack of medical education literature on VR empathy interventions, our aim is to build research studies around PatientVR to explore the effects of VR on empathy education for undergraduate students. We will achieve this aim by,

1. Evaluating effects on learning empathy using the VR interventions on undergraduate medical students’ as compared to existing forum theatre based delivery

2. Assessing the feasibility, usability and acceptability of the two VR devices (Samsung Gear VR and Oculus Go) as intervention tools and,

3. Contributing to the overall knowledge on VR based empathy interventions and their role in generating user involvement and immersion.

*All student and patient face-to-face research is currently on hold. We will begin experiments when the COVID-19 situation is under control*

References

Abou-Elhamd KEA, Al-Sultan AI, Rashad UM. 2010. Simulation in ENT medical education. Journal of Laryngology and Otology. 124(3):237–241.

Afghani B, Besimanto S, Amin A, Shapiro J. 2011. Medical students’ perspectives on clinical empathy training. Education for health (Abingdon, England). 24(1):544.

Alligood MR. 1992. Empathy: the importance of recognizing two types. Journal of psychosocial nursing and mental health services [Internet]. 30(3):14–7. http://www.ncbi.nlm.nih.gov/pubmed/1578419

Arora G, Milk C. 2015. Waves of Grace [Internet]. https://with.in/watch/waves-of-grace/

del Canale S, Louis DZ, Maio V, Wang X, Rossi G, Hojat M, Gonnella JS. 2012. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Academic medicine : journal of the Association of American Medical Colleges [Internet]. 87(9):1243–9. http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00001888-201209000-00026

Carmel S, Glick SM. 1996. Compassionate-empathic physicians: Personality traits and social-organizational factors that enhance or inhibit this behavior pattern. Social Science and Medicine. 43(8):1253–1261.

Chunharas A, Hetrakul P, Boonyobol R, Udomkitti T, Tassanapitikul T, Wattanasirichaigoon D. 2013. Medical students themselves as surrogate patients increased satisfaction, confidence, and performance in practicing injection skill. Medical teacher [Internet]. [accessed 2016 Sep 2] 35(4):308–13. http://www.ncbi.nlm.nih.gov/pubmed/23228086

Davis AH, Kimble LP. 2011. Human patient simulation evaluation rubrics for nursing education: Measuring The Essentials of Baccalaureate Education for Professional Nursing Practice. Journal of Nursing Education [Internet]. 50(11):605–611. http://primo-pmtna01.hosted.exlibrisgroup.com/primo_library/libweb/action/display.do?frbrVersion=5&tabs=detailsTab&ct=display&fn=search&doc=TN_proquest901208149&indx=19&recIds=TN_proquest901208149&recIdxs=8&elementId=8&renderMode=poppedOut&displayMode=ful

Decety J, Jackson PL. 2004. The functional architecture of human empathy. BehavCogn NeurosciRev. 3(1534-5823 (Print)):71–100.

Fields SK, Mahan P, Tillman P, Harris J, Maxwell K, Hojat M. 2011. Measuring empathy in healthcare profession students using the Jefferson Scale of Physician Empathy: health provider–student version. Journal of interprofessional care. 25(August 2010):287–293.

Goodchild CE, Skinner TC, Parkin T. 2005. The value of empathy in dietetic consultations. A pilot study to investigate its effect on satisfaction, autonomy and agreement. Journal of Human Nutrition and Dietetics. 18(3):181–185.

Hojat M. 2016. Empathy in health professions education and patient care. Empathy in Health Professions Education and Patient Care [Internet].:1–450. https://www.scopus.com/inward/record.uri?eid=2-s2.0-84979158417&partnerID=40&md5=50ea59cb7d616bfa2f9f68f232dc310d

Hojat M., Gonnella JS, Mangione S, Nasca TJ, Veloski JJ, Erdmann JB, Callahan CA, Magee M. 2002. Empathy in medical students as related to academic performance, clinical competence and gender. Medical Education. 36(6):522–527.

Hojat Mohammadreza, Gonnella JS, Nasca TJ, Mangione S, Veloksi JJ, Magee M. 2002. The Jefferson Scale of Physician Empathy: further psychometric data and differences by gender and specialty at item level. Academic medicine : journal of the Association of American Medical Colleges. 77:S58–S60.

Hojat M, Mangione S, Nasca TJ, Cohen MJM, Gonnella JS, Erdmann JB, Veloski J, Magee M. 2001. The Jefferson Scale of Physician Empathy: Development and Preliminary Psychometric Data. Educational and Psychological Measurement. 61(2):349–365.

Ickes W. 1993. Empathic Accuracy. Journal of Personality [Internet]. 61(4):587. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=9406220194&site=ehost-live

Kelm Z, Womer J, Walter JK, Feudtner C. 2014. Interventions to cultivate physician empathy: a systematic review. BMC medical education [Internet]. 14(1):219. http://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-14-219

Nerdrum P. 1997. Maintenance of the effect of training in communication skills: A controlled follow-up study of level of communicated empathy. British Journal of Social Work [Internet]. 27(5):705–722. http://bjsw.oxfordjournals.org/cgi/doi/10.1093/oxfordjournals.bjsw.a011261

Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, Haramati A, Scheffer C. 2011. Empathy Decline and Its Reasons: A Systematic Review of Studies With Medical Students and Residents. Acad Med [Internet]. 86(8):996–1009. http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00001888-201108000-00024

Olson JK. 1995. Relationships Between Nurse???Expressed Empathy, Patient???Perceived Empathy and Patient Distress. Image: the Journal of Nursing Scholarship. 27(4):317–322.

Peddle M, Bearman M, Radomski N, McKenna L, Nestel D. 2018. What non-technical skills competencies are addressed by Australian standards documents for health professionals who work in secondary and tertiary clinical settings? A qualitative comparative analysis. BMJ Open.

Sherman JJ, Cramer A. 2005. Measurement of changes in empathy during dental school. Journal of dental education. 69(3):338–345.

Stepien KA, Baernstein A. 2006. Educating for empathy: A review. Journal of General Internal Medicine. 21(5):524–530.

Suchman A, Markakis K, Beckman H, Frankel R. 1997. A Model of Empathic Communication in the Medical Interview. Journal of the American Medical Association [Internet]. 277(8):678–682. https://www.forcedo.org/wp-content/uploads/2014/03/A-model-of-Empathic-Communication.pdf

Winefield HR, Chur-Hansen A. 2000. Evaluating the outcome of communication skill teaching for entry-level medical students: Does knowledge of empathy increase? Medical Education. 34(2):90–94.

Youssef FF, Nunes P, Sa B, Williams S. 2014. An exploration of changes in cognitive and emotional empathy among medical students in the Caribbean. International journal of medical education [Internet]. 5:185–92. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4216728&tool=pmcentrez&rendertype=abstract

Authors: Payal Ghatnekar and Nick Peres