JID: JMIR

ARTICLE IN PRESS [mNS;May 16, 2021;9:44]

Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx

www.elsevier.com/locate/jmir
Review Article

Virtual Reality as a Tool for Eliciting Empathetic Behaviour in Carers: An

Integrative Review
Megan Brydon a,∗, Jessica Kimber a, Melissa Sponagle b,c, Jenna MacLaine d, Julie Avery e, Lisa Pyke f
and Robert Gilbert b
a IWK Health Centre, Halifax, Nova Scotia, Canada
b DalhousieUniveristy, Halifax, Nova Scotia, Canada
c CAMRT, Halifax, Nova Scotia, Canada
d Thompson General Hospital, Thompson, Manitoba, Canada
e NSCMIRTP, Halifax, Nova Scotia, Canada
f CADTH, Charlottetown, Prince Edward Island, Canada

Available online xxx

with quasi-experimental designs, and one non-experimental design.

ABSTRACT
Background: Empathy is an essential behavioural competency re-
quired of healthcare providers. It is included in the Canadian National
Competency Profile for Medical Radiation Technologists; supporting
patient-centered care and the development of therapeutic relationships
between carers and care recipients. This review synthesizes evidence
on Virtual Reality (VR) as a tool for eliciting empathetic behaviour in
carers.
Methods: Six Electronic databases (PubMed, EMBASE, PsycInfo,
ERIC, Academic Search Premier and CINAHL) were searched for
studies published from 1997–2020. Studies with MeSH terms “Em-
pathy” and “Virtual Reality”, and conducted on adult carers, were
eligible for inclusion. The Cochrane risk of bias tool guided the
assessment of study quality. Prospero review registration number:
CRD42020210049
Results: Seven studies, with 485 carers, were included in this re-
view. Studies were heterogeneous in terms of interventions and tools
for collecting outcome measures. All seven studies demonstrated VR
could elicit empathetic behaviour in carers. Studies included one ran-
domized controlled trial, three non-randomized controlled trials, two
All studies had a moderate to high risk of bias.
Conclusion: This review suggests that VR may be an appropriate
method for eliciting empathetic behaviours in carers. Future studies
employing appropriately powered multicentere randomized controlled
designs should seek to determine which VR experiences are the most
effective in evoking empathetic behaviours.
ABSTRAIT
Contexte : L’empathie est une compétence comportementale essen-
tielle exigée des prestataires de soins de santé. Elle est incluse dans
le Profil de compétences national pour les technologues en radiation
médicale au Canada; elle soutient les soins centrés sur le patient et
le développement de relations thérapeutiques entre les soignants et
les bénéficiaires de soins. Cette revue fait la synthèse des données
probantes sur la réalité virtuelle (RV) comme outil pour susciter un
comportement empathique chez les soignants.
Méthodologie : Des recherches ont été effectuées dans six bases
de données électroniques (PubMed, EMBASE, PsycInfo, ERIC, Aca-

Ethical approval: Ethical Requirement of Research Ethics Board approval for this project was waived by the institution.
Contributors: All authors contributed to the conception or design of the work, the acquisition, analysis, or interpretation of the data. All authors were involved in
drafting and commenting on the paper and have approved the final version.
Competing Interest: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no financial relationships
with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have
influenced the submitted work.
Funding: This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
∗ Corresponding author: 6 Cherry Drive, Dartmouth B3A2Z2., Nova Scotia, Canada

E-mail address: megan.brydon@iwk.nshealth.ca (M. Brydon).

1939-8654/$ - see front matter © 2021 Published by Elsevier Inc. on behalf of Canadian Association of Medical Radiation Technologists.
https://doi.org/10.1016/j.jmir.2021.04.005

Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
JID: JMIR
ARTICLE IN PRESS
demic Search Premier et CINAHL) pour trouver des études pub-
liées entre 1997 et 2020. Les études comportant les termes MeSH
«Empathie» et «Réalité virtuelle», et menées sur des aidants adultes,
ont été retenues. L’outil Cochrane de gestion des risques de biais a
guidé l’évaluation de la qualité des études. Numéro d’enregistrement
de l’examen Prospero: CRD42020210049.
Résultats : Sept études, portant sur 485 aidants, ont été incluses dans
cette revue. Les études étaient hétérogènes en termes d’interventions
et d’outils de collecte des mesures de résultats. Les sept études ont
démontré que la RV pouvait susciter un comportement empathique
Keywords: Virtual Reality; Empathy; Caregiver; Healthcare
Introduction
Empathy is a multidimensional construct described as:
“An individual’s objective and insightful awareness of the
feelings and behaviour of another person. It should be dis-
tinguished from sympathy, which is usually nonobjective
and noncritical. It includes caring, which is the demonstra-
tion of an awareness of and a concern for the good of others”
[1].
Informally, it is often described as having the capacity to put
oneself in the shoes of another. The two main types of empathy
are cognitive and affective [2,3]. Cognitive empathy is defined
as the capacity to objectively understand the state of mind of
another individual from their perspective, with clear separation
between self and another [2–7]. Affective empathy is defined
as an emotional response where a person not only understands
but also feels and shares the emotions of another [2–4].
Empathy is a behavioural competency required of healthcare
providers and is included in the Canadian National Compe-
tency Profile for Medical Radiation Technologists [7–9]. This
competency is essential to patient-centered care, and crucial
to the development of therapeutic relationships between carers
(healthcare providers, healthcare students, and informal care-
givers such as “parents, spouses, friends, family, clergy, social
workers and fellow patients”) [10], and care recipients [8,11–
14]. A carer’s motivation to care has been described as “based
in and sustained by our human capacity for empathy with oth-
ers” [2,15]. Research has shown empathy affords carers the abil-
ity to provide appropriate supports, increase patient satisfaction
[3,4,7,11,14,16], enhance patient outcomes, resulting in fewer
mistakes, and leading to better overall care [7,11,14,17].
The capacity to provide care may be affected by the type
of empathy a carer develops. High levels of affective empathy
have been associated with increased stress, compassion fatigue,
and decreased overall quality of life for carers [18]. Conversely,
the development of cognitive empathy has been associated
with overall wellbeing and lower stress among carers [6,19].
In a caregiving environment, the development of cognitive
empathy, while limiting the development of affective empathy,
2 M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
[mNS;May 16, 2021;9:44]
chez les soignants. Les études comprenaient un essai contrôlé ran-
domisé, trois essais contrôlés non randomisés, deux avec des con-
ceptions quasi-expérimentales, et une conception non expérimentale.
Toutes les études présentaient un risque de partialité modéré à élevé.
Conclusion : Cette revue suggère que la RV peut être une méth-
ode appropriée pour susciter des comportements empathiques chez les
soignants. De futures études utilisant des plans contrôlés randomisés
multicentriques correctement alimentés devraient chercher à déter-
miner quelles expériences de RV sont les plus efficaces pour évoquer
des comportements empathiques.
may improve care provision while ensuring overall wellbeing
for carers. By limiting affective empathy carers can maintain
emotional distance and limit the potential for compassion
fatigue [16].
Empathy can be elicited through practices that are cen-
tered on establishing connectedness between oneself and others
[2,20]. Recent systematic reviews have investigated the effec-
tiveness of approaches supporting the development of empathy
in health professionals and students. These studies evaluated
the effectiveness of games, standardized patient interactions
(actors), communication skill training, motivational interview-
ing training and role playing in the development of empathy
[7,11]. While many of these approaches are effective in eliciting
empathetic behaviours, simulated experiences where the learner
acts in the role of the individual receiving care appear to be the
most effective [3,11]. However, simulated experiences have lim-
itations that prevent their broader utilization as most require
substantial resources and provide limited opportunities for in-
dependent repeated practice [3,21]. The time and cost associ-
ated with using methods such as standardized patients (SPs) for
learning makes it difficult to introduce a variety of clinical sce-
narios and strategies. Furthermore, such approaches are not al-
ways well suited to providing a secure and safe learning environ-
ment. Currently, there is a need for the development of effective
tools and approaches that are standardizable, low-risk, safe-to-
fail, easily repeatable and could assist in eliciting empathetic
behaviour [3,11,21].
In recent years there has been a growing interest in Vir-
tual Reality (VR) as an approach for eliciting empathetic be-
haviour. VR is defined as “using computer technology to cre-
ate and maintain an environment and project a user’s phys-
ical presence into that environment allowing the user to in-
teract” [22]. In this review, the term VR Experience refers to
the environment, perspective, platform and setting of the in-
tervention. VR Environment refers to the surroundings and
conditions of the VR intervention. VR platform refers to the
software and hardware used to support the VR intervention.
VR platforms can provide participants with an embodied ex-
perience of another or create a practice environment for skill
development. A well-constructed VR experience may include
JID: JMIR
ARTICLE IN PRESS
a variety of elements intended to create a realistic, believable
experience where a participant can relate to, learn from, and
engage in an environment. These might include perceptual il-
lusions (place and plausibility) which provide a strong sense one
is actually within the environment; immersion (embodiment
or ownership) where integrated multisensory stimuli emulate
a real-time first-person perspective; and agency which supports
the illusion of control over one’s actions within the experience
[4]. Collectively, a well-designed VR experience may present
a safe, non-threatening simulated experience and environment
where clinical and behavioural skills such as empathy might be
developed.
VR environments can be either immersive (3D experience
with a virtual interface, VR glasses or a head mount display)
or non-immersive (virtual projectors or computer screens, and
input devices like keyboards, mice, and controllers) [4]. In im-
mersive environments the user has a realistic simulation ex-
periences, complete with sight and sound. VR headsets pro-
vide high-resolution content with a wide field of view and a
stereoscopic 3D effect. Through input tracking, a VR inter-
face can establish an immersive, believable experience. In non-
immersive environments the participant does not have a 3D ex-
perience and can stay aware of and keep control of their physical
surroundings [4].
VR is currently employed in healthcare education to support
a variety of training approaches. Recent systematic reviews have
determined VR to be an effective pedagogical tool, capable of
improving carers knowledge and skill [23,24]. Through inno-
vative tools and approaches, VR allows learners to experience
diverse scenarios and perspectives that are oftentimes difficult to
duplicate through traditional learning approaches. Essentially,
VR can provide an adaptable platform for the development of
learning environments that are standardizable, low risk, safe-to-
fail, easily repeatable, and could assist in eliciting empathetic
behaviour in carers [3,17,21,25].
VR experiences where the carer either embodies another and
their perspective, or works in a virtual practice environment
with virtual patients or persons, may support the eliciting of
empathetic behaviour [17,21,25]. Several studies have evalu-
ated the effectiveness of VR in eliciting empathetic behaviour.
The goal of this integrative review is to synthesize these studies
to determine if VR is an effective tool for eliciting empathetic
behaviour in carers.
Methods
This systematic review was conducted in accordance with
the Preferred Reporting Items for Systematic Reviews and
Meta-analyses (PRISMA) reporting guideline [26]. The pro-
tocol was registered in PROSPERO (CRD42020210049).
Search Strategy
A search of MEDLINE, Embase, CINAHL, ERIC, Aca-
demic Search Premier and PsycInfo databases was conducted
from inception to December 5th , 2020. As this is a rela-
M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
[mNS;May 16, 2021;9:44]
tively new field of research, broad database searches were con-
ducted using the keyword combination (“empathy” [MeSH
Term] OR “empathy” [All Fields]) AND (“virtual reality”
[MeSH Term] OR “virtual reality” [All Fields]). The search was
limited to human studies, with no limits on language or year of
publication. Reference lists of included studies and reviews were
hand searched. All study collaborators conducted the search,
initial title/abstract screening and assessed full-text reports for
eligibility. Study inclusion was determined via consensus.
Inclusion Criteria
All published studies from any setting or country that inves-
tigated the use of VR for eliciting empathetic behaviour in both
formal and informal carers were included. Only those studies
that included tools to measure empathy were eligible for in-
clusion. Studies that did not use a validated tool specifically
designed to measure changes in empathetic behaviour were ex-
cluded.
Data Extraction and Analysis
All study collaborators independently extracted data using a
piloted form which included information on: authors and pub-
lication date, country where the study was conducted, study de-
sign, study population, educational interventions, sample size,
sex, mean age, tool used to measure empathy, time to outcome
measure, the primary outcome (empathy) and statements of
statistical significance. Data from each study collaborator was
collated and final content determined by consensus. A second
template was created to extract data pertaining to the VR ex-
perience (environment, perspective, platform and setting) used
in each included study.
Quality Assessment of the Studies
All study collaborators independently assessed the risk of
bias for each study using the Cochrane Risk-of-Bias 2 table
for randomized controlled trials (RCT) [27,28] and the Risk
of Bias in Non-randomized Studies of Interventions tool [29].
The COREQ tool guided critical appraisal of qualitative stud-
ies [30]. Disagreements during the review process were resolved
through discussion.
Results
Search Results
Of 328 unduplicated records identified, 261 were excluded
following title and abstract screening. Full text of 67 studies
were reviewed and 60 were excluded for the following rea-
sons: 22 studies involved non-carer populations (not specif-
ically identified to be carers e.g. university students, general
public, patients, offenders etc.), 24 did not measure empathy,
five used VR in combination with other learning approaches
and could not be assessed independently, three studies did
3
JID: JMIR
ARTICLE IN PRESS [mNS;May 16, 2021;9:44]

Idenficaon
Records idenfied through Addional records idenfied
database searching through hand search
(n = 398) (n = 2)

Records aer duplicates removed

Screening

(n = 328) Records excluded

following tle and
abstract review
(n = 261)

Arcles Excluded by Full Text

Review (n = 60)
24 did not measure empathy
22 had non-carer
Eligibility

Full-text arcles assessed populaons

for eligibility 5 used VR + addional
(n =67) learning intervenon
3 did not use VR to enhance
empathy
3 were reviews where
included studies did not
meet all inclusion criteria
2 were conference
Included

Studies included in posters/abstracts

integrave review 1 was a study protocol
(n = 7)

Figure 1. Flow chart of literature search and study selection process.

not use VR, three studies were reviews where included stud-
ies did not meet all inclusion criteria, two were abstracts of
conference presentations or editorials, and one result was a
study protocol. Thus, seven studies were included (Figure 1)
[5,6,16,17,21,31,32].
Characteristics of Included Studies
Seven studies were included: one randomized controlled
trial, three non-randomized controlled trials, two quasi-
experimental studies, and one non-experimental study. Studies
were published between 2007-2020 (Table 1).
There were a total of 485 participants across the seven stud-
ies including; 199 adult informal carers, 171 medical students,
81 nursing students, 20 maternal carers, and 14 healthcare pro-
fessionals. Of these, 365 participants underwent a VR experi-
ence and 120 participated as controls.
Four studies were conducted in the United States
[16,21,31,32], one in the United Kingdom [17], one in
Spain [5], and one in The Netherlands [6] (Table 1). Studies
took place in various settings, including teaching labs, clinics,
and a portable simulation unit (Table 2). All studies were at
moderate or high risk of bias (Tables 3, 4).
Virtual Reality Approaches
Descriptions of the VR experiences used in studies included
in this review are provided in Table 2. The duration of the VR
experiences ranged from a single 8-minute session to sessions
lasting 20-25 minutes in duration delivered on two separate
days. Five studies used trademarked VR platforms including:
Digital Animated Avatar (DIANA)[21], Into D’mentia Simu-
lator [6,33], Virtual Dementia Tour (VDT) [17,31,34], and
Neurological Examination Rehearsal Virtual Environment
(NERVE) [16,35], and two studies used researcher-designed
VR experiences [5,32].
Five studies employed immersive VR environments where
participants assumed the role of a care recipient within the
VR environment. Such experiences are intended to give car-
ers an opportunity to gain understanding of what it is like
to have a specific disease or need. In three of these stud-
ies, participants assumed the role of a person with demen-
tia while one study had participants assume the role of a

4 M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx

Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
 JID: JMIR
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,

Table 1
Characteristics of Included Studies.
Author; Year; Study Study Educational Sample Size Male (%) Mean Age Empathy Outcome Time to Outcome Outcomes
Country Design Population Interventions (years) Measurement Tool Measure
Deladisma Multi- 2nd year Intervention: Virtual n = 84 ND ND Novel Immediately Verbal Communication Behaviours: VRP group
et al.; 2007; centered, medical Reality Patient (VRP) Intervention = 51 Partially-validated following responded less empathetically compared to SP group
USA RCT students (non-immersive) Control = 33 Researcher devised intervention (2.16+/-.83 vs 2.75+/- .87, P<0.05).
Control: Standardized tool (verbal and Non-Verbal Communication Behaviours: Level of
M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx

Patient (SP) non-verbal) empathy demonstrated by verbal communication

behaviour was positively correlated with non-verbal
communication behaviours [Eye contact (r = .57, P
.001), level of immersion (r = .56, P .001), head nod
(r = .55, P .001), and body lean (r =.49, P .001)].
VRP group responded with less empathetic
communication behaviours than the SP group (Eye
Contact (2.59 +/- 0.51 vs 2.90+/- .91), head nod

ARTICLE IN PRESS
(1.94 +/- .44 vs 2.78 +/-.79), body lean (1.93 +/-
.58 vs 2.97 +/-.94), immersion level (2.26 +/- .52 vs
3.31 +/-.49)).
Overall: VRP group had lower combined rating of
verbal and non-verbal empathetic communication
behaviours than SP group (3.24 vs 4.29, P<0.05)
Hamilton- Quasi ex- Mothers Intervention: Virtual n = 20 0 39.3 AAPI-2 (Construct Pre- and Empathy (AAPI-2 Construct B) (Cognitive Empathy):
Giachritsis, perimental, Child Embodiment B) & Mind in the immediately Empathy score rose from 8.1 to 9.0 (t = −2.538;
et al; 2018;UK crossover (immersive) with one Eyes Test post-intervention p = 0.02) between the pre- and post-intervention
negative and one regardless of the intervention order.
positive experience Mind in the Eyes Test:
The negative experience improved affective empathy
more so than the positive VR interaction (P=0.018,
95% CI for the coefficient of behaviour 0.19 to 1.97).
Jutten et al.; Non- Adult Intervention: Virtual n = 195 Intervention: Intervention: IRI Pre- and one-week No change in empathy scores were measured between
[40]; randomized Informal Patient Embodiment Intervention 20.7%∗∗ 59.6 +/- 11.9 post-intervention intervention and control.
Netherlands∗ control Caregivers (immersive) plus = 142 Control: Control: 63.8 Small but non-significant increase in cognitive and
trial Didactic Training Control = 53 23.2%∗∗ +/- 11.8 affective empathy following VR:
Control: Didactic IRI Perspective Taking (Cognitive Empathy):
Training Intervention Group: pre-post scores were 17.7 +/- 4.0
and 18.0+/- 3.8
Control Group: pre-post scores were 17.4+/- 4.4 and
17.3 +/- 3.6
Small but non-significant decreased in cognitive and
affective empathy in the control arm:
IRI Empathic Concern (Affective Empathy):

[mNS;May 16, 2021;9:44]

Intervention Group: pre-post scores were 17.8 ± 4.3
and 18.1 ± 4.3
Control group: pre-post scores were 17.8 +/- 3.9 and
17.2 ± 3.8

(continued on next page)

5
 6

JID: JMIR
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,

Table 1 (continued)

Author; Year; Study Study Educational Sample Size Male (%) Mean Age Empathy Outcome Time to Outcome Outcomes
Country Design Population Interventions (years) Measurement Tool Measure

Kimzey et al.; Non- Nursing Intervention: Virtual n = 81 Intervention: 17-21 (78%) IRI Pre- and Up to 5 There was a statistically significant increase in levels of
2019; USA randomized Students Patient Embodiment Intervention = 47 4.6% days cognitive empathy in both control and intervention
M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx

control (immersive) plus Control = 34 Control: post-intervention groups

trial Didactic Training 1.9 % IRI Perspective Taking (Cognitive Empathy):
Control: Didactic Intervention Group: pre-post scores 20.08 and 20.78
Training (p </= 0.05)
Control Group: pre-post scores of 18.33 and 19.78
(p</=0.05)
There was no difference across groups.
IRI Empathic Concern (Affective Empathy): There

ARTICLE IN PRESS
were no statistically significant changes in measures of
affective empathy pre-post intervention for either
group
Kleinsmith Non- 3rd year Intervention: Virtual n = 73 57.5% F: 24.52 ECCS During ECCS (Empathic Communication) (Cognitive
et al.; 2015; randomized medical Reality Patients (VRP) M: 25.52 intervention Empathy∗∗∗ ): Participants expressed higher levels of
USA control students (non-immersive) empathy with the VPs (median score = 4) when
trial and compared to SPs (median score of 2) (Z=-4.18,
Control: Standardized p=.000, r=0.49).
Patients (SP) Empathetic Opportunities: Participants interacting
with VPs missed fewer opportunities to demonstrate
empathy when compared to SP interactions (3% vs
9%)
Raij Quasi ex- 2-4th year Intervention: Virtual n=14 62.5% ND Jefferson Scale of Pre- and Participating as a recipient of their own care provision
et al.;2009; perimental medical social Physician Empathy immediately post significantly increased the level of empathy
USA students, perspective-taking Jefferson Scale of
residents (VSP) with Mixed Physician Empathy (cognitive empathy):
and Reality Human mean empathy scores:
clinicians (MRH) Pre VR intervention (patient role): p = 3.71 +/- 0.72
(Mannequin/physical Post VR intervention (patient role): p = 3.88+/- 0.44
breast F(1,14) = 7.0, p < 0.05)
model)(immersive)
Slater et al.; Non- ex- Healthcare Intervention: Virtual n = 18 16.7% 18–24: 5.6% Four-Component 4-6 Weeks The interactive VDT training enabled an emotive
2018; UK. perimental staff and Patient Embodiment 25–34: 5.6% Model of Empathy (affective), cognitive, moral, and behavioural
informal (immersive) 35–44: 38.9% (semi-structured reflection to occur, enhancing the empathetic state.
caregivers 45–54: 33.3% interviews)
55–65: 16.7%

[mNS;May 16, 2021;9:44]

ND= Not Disclosed.
∗ Some study parameters found in companion publication [40].
∗∗ %M is only reported at the beginning of the study, not for the number of people included in data analysis.
∗∗∗ Level 6 of the ECCS meets this studies definition of affective empathy, although no participants reported this level and the remaining levels are understood to measure cognitive empathy.
JID: JMIR
ARTICLE IN PRESS [mNS;May 16, 2021;9:44]

Table 2
Characteristics of Virtual Reality Experiences.
Author; Year VR Experience (Environment and Perspective) VR Experience (Platform & Setting) Duration of VR
Experience
Deladisma et al.; Environment: Non-Immersive Platform: Digital Animated Avatar (DIANA). Virtual ND
2007 Role: Physician providing care to patients Reality Patient (VRP) projected on wall in examination
presenting with acute abdominal pain room programmed to deliver context specific responses to
participants questions
Setting: Teaching Laboratory
Hamilton- Environment: Immersive Platform: Researcher developed program using head ˜8 minutes per
Giachritsis, et al; Role: Young child (4 years old) separately mounted display (HMD) and full body motion-capture experience
2018 interacting with two mothers (Positive (kind) suit (OptiTrack) to project participant into virtual living
and Negative (angry)) room
Setting: VR Laboratory on University Campus
Jutten et al.; [40] Environment: Immersive Platform: Into D’mentia Simulator, an interactive 25 minutes∗
Role: Person with Dementia stand-alone unit where participants undergo
multi-sensory VR experiences∗
Setting: Portable Simulation Unit
Kimzey et al.; Environment: Immersive Platform: Virtual Dementia Tour (VDT), where 8 minutes
2019 Role: Person with Dementia participants are outfitted with devices (goggles, gloves,
headphones) that alters perception while completing
everyday tasks
Setting: VR Laboratory on University Campus
Kleinsmith et al.; Environment: Non-immersive Platform: Neurological Examination Virtual Environment 40-50 minutes
2015 Role: Physician providing care to patients (NERVE), an online platform (web-browser interface (20-25 minutes per
presenting with cranial nerve injuries where users interact using text-based chat) with VRPs VRP)
Setting: Online (web-based) Clinic
Raij et al.; 2009 Environment: Immersive Platform: Researcher developed using mixed reality 10 minutes
Role: Three scenarios human with tracked HMD (Emagin Z800 HMD) and
1 – physician providing care to patient full-size mannequin with instrumented breast model
presenting with breast cancer combining physical touch with immersive experience
2 – patient perspective (playback of physician Setting: ND
role in scenario 1 as patient A)
3 – physician providing care to a different
patient presenting with breast cancer
Slater et al.; 2018 Environment: Immersive Platform: Virtual Dementia Tour (VDT), where ND
Role: Person with Dementia participants are outfitted with devices (goggles, gloves,
headphones) that alters perception while completing
everyday tasks∗∗
Setting: ND
ND = Not Disclosed.
∗ Some study parameters found in companion publication [40].
∗∗ participants underwent the VR experience prior to this qualitative study.

Table 3
Assessment of Bias in Included Studies using the Cochrane Risk Of Bias Tool.
Bias Domain Author; Year

Deladisma Hamilton-Giachritsis, Jutten Kimzey Kleinsmith Raij et al.; 2009

et al.; 2007 et al; 2018 et al.; 2018 et al.; 2019 et al.; 2015
Random Sequence Generation (selection bias) Moderate Not Completed High High High Not Completed
Allocation Concealment (selection bias) High Not Completed High High High Not Completed
Blinding of Participants and Personnel (performance bias) Moderate High High High High High
Blinding of Outcome Assessment (detection bias) High High High High High High
Incomplete Short-Term Outcome Data Addressed Low Low Low High Low Low
(attrition bias)
Incomplete Long-Term Outcome Data Addressed ND ND ND ND ND ND
(attrition bias)
Selective Reporting (reporting bias) Low Low High Low High Low
Overall Risk of Bias Moderate High High High High High
None of the studies assessed long-term changes in empathy and virtual reality.

M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx 7

Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
JID: JMIR
ARTICLE IN PRESS
Table 4
Assessment of Bias in Included Study Using COREQ.
Section Author; Year
Slater et al.; 2018
Domain 1: Research team and reflexivity Sufficient
Domain 2: Study Design Sufficient
Domain 3: Analysis and Findings Moderately Sufficient
Overall Moderately Sufficient
young child [5,6,17,31]. In one study, the participants assumed
the role of the physician and then the role of care recipient
[32].
Two studies employed non-immersive VR environments
where the participants assumed the role of a care provider in
a simulated care setting (i.e., clinic, office). In these studies par-
ticipants had the opportunity to practice interacting with vir-
tual care recipients. The intention of these experiences was to
develop skills in the delivery of empathetic care in a practice
setting. In these studies, the participants assumed the role of
physicians interviewing patients with either abdominal pain or
cranial nerve damage [16,21].
Of the seven included studies, three acknowledged the
potential for VR’s ability to elicit adverse effects [5,16,17],
however only one reported incidence of distress (physiolog-
ical and psychological upset) [17]. One study demonstrated
lower levels of anxiety in VR versus SP environments [21].
The remaining studies did not comment on the presence or
absence of such occurrences. In only one study participants
described VR as providing a safe-to-fail experience [16]. No
study provided evidence of the cost effectiveness, repeatability,
or accessibility of VR experiences.
Tools Used to Assess Empathy
Two studies used the Interpersonal Reactivity Index (IRI)
to assess change in empathy [6,31], one study employed two
tools, Construct B of the Adult Adolescent Parenting Inventory
(AAPI-2) and the Mind in the Eyes Test [5], one study used the
Empathic Communication Coding System (ECCS) [16], one
study employed the Jefferson Scale of Physician Empathy [32],
one study used the Four-Component Model of Empathy to di-
rect the analysis of interviews [17,36] and a final study used a
partially-validated researcher-developed tool to assess empathy
[21].
Assessment of VR Experience Effectiveness
All included studies demonstrated VR capable in eliciting
an empathetic behaviour in carers (Table 1).
Four of the included studies used a control arm (a stan-
dard approach to eliciting empathetic behaviour) [6,16,21,31].
In two of these, non-randomized controlled studies, VR was
shown to elicit cognitive empathetic behaviours that were statis-
tically greater than or equal to that of the control arm [16,31].
One of these studies also assessed for change in affective em-
pathy but did not see an effect [31]. A third non-randomized
8 M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
[mNS;May 16, 2021;9:44]
controlled study showed a small increase in both cognitive and
affective empathetic behaviours but was not statistically signifi-
cant [6]. The fourth study, an RCT, showed VR capable of elic-
iting an empathetic behaviour but to a lesser degree than that
seen in the control arm [21]. One of these studies [16] demon-
strated VR to be more efficacious in eliciting an empathetic
behaviour when compared to the control.
Three studies did not include a control arm [5,17,32]. Two
of these employed a pre-post test design to assess for change
in empathy [5,32]. Both studies demonstrated a statistically
significant increase in cognitive empathy post VR experience.
A third study employed a qualitative approach and reported
both cognitive and affective empathetic behaviours as a multi-
dimensional phenomenon [17].
Of the seven studies included in this review, none assessed
the long-term effects of VR. The maximum reported follow-up
time, post VR experience was 4-6 weeks (Table 1).
Quality of Reporting for Eligible Studies
Though the body of evidence demonstrated the potential
for VR experiences to elicit empathetic behaviour in carers,
studies included in this review were of moderate to high risk
of bias (Tables 3, 4). The quality of reporting of the studies
included in review were assessed using the highest standard
and have limitations resulting from using quantitative meth-
ods other than an RCT. Six of the included studies used study
designs that provide low levels of evidence and did not em-
ploy randomization [5,6,16,17,31,32], five studies did not use
blinding [5,6,17,31,32], and three did not include a control
arm [5,17,32]. One study used power analysis to determine
sample size [31] and one study with semi-structured interviews
recruited participants until saturation was reached [17]. No
study meeting this integrative review’s inclusion criteria exam-
ined the effects of empathy training beyond six weeks. Poten-
tial adverse effects were only reported in one study [17]. Of
the seven studies, six used a validated tool to assess empathy
[5,6,16,17,31,32] and one used a partially-validated researcher-
developed tool [21].
Discussion
Developing and maintaining empathetic competencies in
carers is essential for the provision of effective care and in im-
proving patient outcomes [3,7]. This integrative review evalu-
ated the use of VR as an approach to elicit empathetic behaviour
in carers. All studies included in this review demonstrated that
VR experiences are capable of eliciting empathetic behaviour in
participants.
Recent systematic reviews have demonstrated VR to be an
effective pedagogical tool for supporting health professionals
and students in the development of knowledge and skill
[23,24]. Specific to the use of VR for learning and eliciting
empathetic behaviour, two recent systematic reviews have syn-
thesized knowledge across a range of environments. A study by
Bearman et al. 2015 examined a variety of simulated learning
JID: JMIR
ARTICLE IN PRESS
experiences developed to teach empathy to health professional
students [11]. This study determined simulation may provide
an effective method for learning empathetic behaviours. Of the
27 studies included, only one pertained to VR experiences [11].
Our study builds on the work of Bearman et al. by providing
a synthesis of studies that examined VR as simulation tool for
eliciting empathetic behaviour in health profession students
and other carer populations. Another recent systematic review
with meta-analysis by Ventura et al. titled “Virtual reality as
a medium to elicit empathy: a meta-analysis” investigated
the ability of VR experiences to elicit empathy in a variety of
settings and populations [3]. The review included seven stud-
ies, three of which were not conducted on carer populations.
Of the four studies that were conducted on carers, two met
inclusion criteria for this review [5,32] (one study did not
define the tool used to assess empathy post VR experience and,
one study combined VR with other interventions) [3]. This
integrative review provides unique understanding of the value
of VR as a tool for eliciting empathetic behaviours specific to
carer populations. However, like the above-mentioned reviews,
our work also noted heterogeneity of study design, study
populations, assessment tools, VR experiences and outcomes
across included studies.
Affective Versus Cognitive Empathy
Several recent studies and reviews have discussed the poten-
tial positive and negative effects associated with eliciting cog-
nitive versus affective empathy. Past studies have demonstrated
approaches eliciting cognitive empathy have led to an altruis-
tic motivation to help [2,4,17]. On the other hand, approaches
eliciting affective empathy have been associated with personal
distress, and an egoistic motivation to help [37,38]. While
several studies included in this review described the potential
negative effects of affective empathy in their literature reviews,
only three studies measured the capacity for VR to elicit both
types of empathy [6,17,31]. Only one study discussed the po-
tential associated risks of VR experiences eliciting affective em-
pathy that had a negative impact on carers [17]. The absence of
discussion in the current literature pertaining to the potential
negative impact of affective empathy is perplexing.
One area for future consideration is whether the type of em-
pathetic behaviour elicited from a VR experience is related to
the VR experience itself or the participant’s interpersonal at-
tributes.
Immersive Versus Non-Immersive VR Experience
Five of the studies included in this review used immersive
VR experiences and two used non-immersive experiences. All
studies, employing immersive VR reported cognitive empathic
behaviours. In each of these studies the participant assumed
the role of a care recipient. Of these, three studies assessed par-
ticipants for affective empathy behaviour. Two showed VR to
elicit affective empathy (although not statistically significant)
M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
[mNS;May 16, 2021;9:44]
[6,17] and one study did not [31]. In non-immersive studies
where participants assumed roles of carers, affective empathy
was not measured [16,21].
Considerations for Learning Environment
Recent studies have highlighted the need to develop effec-
tive tools for eliciting empathetic behaviour that are adaptable
to multiple scenarios, low-risk, safe-to-fail, accessible, easily re-
peatable and cost effective [3,11,21]. The studies included in
this review provided evidence relating to some but not all these
conditions. Our review demonstrates VR’s ability of eliciting
empathetic behaviour across a variety of health conditions (i.e.
dementia, abdominal pain, cranial nerve injury and, breast can-
cer) indicating that it is adaptable to multiple scenarios. While
the collective studies may demonstrate efficacy, low-risk, and
adaptability, more work is needed to appreciate the broader
spectrum of VR benefits.
Biases Related to the Measure of Empathy
Performance bias was a potential source of weakness across
all studies reviewed. Social desirability response bias is a form
of performance bias where there is a tendency for participants
to respond in a way that they believe will be perceived favor-
ably by others [39]. Prior research has specifically identified self-
reported empathy measures as highly susceptible to social de-
sirability bias [39]. This poses a particular challenge in students
where academic standing may be perceived to be contingent on
participants’ emphatic behaviours. This indicates elicited em-
pathetic behaviour might not reflect the actual actions of stu-
dents in clinical practice.
Strengths and Limitations
There was considerable heterogeneity in both empathy as-
sessment tools and VR experiences (environment, perspective,
platform and, settings) employed across included studies. De-
spite these differences, similar outcomes were observed across
all studies. A strength of this integrative review is the inclusion
of a wide spectrum of health professionals and informal carers,
with varying levels and years of experience across a variety of
health conditions, potentially making the findings more gener-
alizable. By using an Integrative Review approach, risk of pub-
lication bias is limited. This review was able to identify several
significant weaknesses of the studies included herein. Most in-
cluded studies are low on the hierarchy of evidence scale and all
included studies lacked methodological rigor. Included studies
did not provide data on whether empathetic behaviours elicited
by VR were sustained over time. Furthermore, no included
study considered the potential transferability of empathy across
varied experiences. This is particularly relevant for Medi-
cal Radiation Technologists (MRTs) who practice in a broad
range of departments and areas, with a highly variable patient
population.
9
JID: JMIR
ARTICLE IN PRESS
Future Studies
Although studies in this review suggest VR may be effec-
tive in eliciting empathetic behaviour in carers, the evidence
based on the research designs employed is very low. Future pri-
mary research studies should employ high order designs that
are better able to control biases. A sufficiently powered, lon-
gitudinal multi-centered randomized controlled trial would be
the most appropriate approach. A multi-centered study (with
a larger number of participants, different geographic locations,
includes a wide range of population groups, and enables com-
parison of results among centers) will improve the generalizabil-
ity of study outcomes. Special effort should be made to control
for social desirability bias. To mitigate performance bias, decep-
tion and blinding of participants and researchers is essential. By
including a longitudinal component, study investigators will
also be able to determine if empathy developed through VR
is sustained over time. When developing longitudinal studies,
care must be taken in the design to account for possible con-
tamination over time, a common challenge with long term be-
havioural studies. Future studies should consider whether em-
pathy training directed at a specific patient population or expe-
rience (e.g. persons with dementia or breast cancer) is transfer-
able to other scenarios. This is relevant for MRTs who care for
a variety of different patient populations daily. Skills learned
through simulation experiences are only valuable if they are
transferable to the real-world setting. Therefore, future studies
should also seek to measure the impact of empathetic behaviour
changes from VR experiences on patient care and patient
outcomes.
Conclusion
This integrative review adds new perspective on the role of
VR as a pedagogical tool for eliciting empathetic behaviour in
carers. Collectively, the included studies suggest that VR may
provide an effective and wide-ranging tool for the learning of
care recipient’s perspectives, allowing participants the opportu-
nity to perceive what it is like to walk in the shoes of another.
Appendix A: Synopsis of included studies
Studies Employing Immersive VR Experiences
A non-randomized controlled study by Kimzey et al. stud-
ied nursing students who assumed the role of a person with
dementia using the Virtual Dementia Tour (VDT) VR plat-
form [31]. This study assessed changes in cognitive and affective
empathy, pre and post VR experience using the IRI tool. Both
VR experience and control groups received an online education
module on dementia prior to the VDT, while only the VR ex-
perience group participated in VDT. Both arms demonstrated
statistically significant increases in cognitive empathy (IRI-PT
scale) post VR experience but did not elicit changes in mea-
sure of affective empathy. The VR experience did not lead to
increased empathy compared to the control (standard teaching
approaches) [31].
10 M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
[mNS;May 16, 2021;9:44]
In a non-randomized controlled study by Jutten et al., infor-
mal carers assumed the role of a person with dementia, using
the Into D’mentia simulator [6]. This study assessed changes
in levels of cognitive and affective empathy, pre and post VR
experience using the IRI tool. Although not statistically signif-
icant, participants in the VR group showed a small increase in
both cognitive and affective empathy post VR experience. In
the control arm of this study (didactic training), a small non-
significant decrease in both forms of empathy was measured
[6].
In a quasi-experimental study by Hamilton et al., mothers,
at low risk for child maltreatment, assumed the role of a young
child and experienced a positive and negative mother using an
investigator-built VR platform [5]. The study assessed changes
in level of empathy, pre and post VR experience using Con-
struct B of the AAPI-2 which measures Parental Empathy To-
wards Children’s’ Needs, and the Mind in the Eyes test. Con-
struct B of the AAPI-2 showed a statistically significant increase
in cognitive empathy following the VR experience. The Mind
in the Eyes tool demonstrated that the negative VR interaction
was associated with a statistically significant increase in affective
empathy compared to the positive VR interaction [5].
In a quasi-experimental study by Raij et al., medical students
underwent a sequence of 3 scenarios in an investigator-built VR
platform [32]. In the first scenario, the subject adopted the role
of the physician caring for a person with breast cancer. The sec-
ond scenario involved the student reliving the first scenario, but
now in the role of the patient. (i.e. the subject interacts with
a recording of themselves as the physician from the first sce-
nario). In the third scenario, participants once again assumed
the role of physician caring for a different person with breast
cancer [32]. This VR approach allowed the participant to ex-
perience their own care provision as a physician and gain insight
on the patient’s perspective of the care they provided. The study
assessed self-reported pre-post VR experience changes in level
of empathy using the Jefferson Physician Empathy Scale. Par-
ticipating as a recipient of their own care provision significantly
increased the level of empathy [32].
In a non-experimental study by Slater et al., healthcare
staff and informal carers who had previously undergone the
VDT experience were evaluated for empathy towards per-
sons with dementia [17]. The study assessed empathy using
semi-structured interviews that were grounded in the Four-
Component Model of empathy (emotive, behavioural, moral
and cognitive) [36]. The interactive VDT training was per-
ceived by participants as useful, providing an emotional oppor-
tunity to "imagine what it is to live with dementia’’ [17].
Studies Employing Non-Immersive VR Experiences
In a randomized controlled study by Deladisma et al.,
[21] medical students assumed the role of a physician inter-
acting with a care recipient with acute abdominal pain using
the Digital Animated Avatar (DIANA) platform. This study
compared DIANA to a control arm using standardized pa-
tients (SPs). Changes in level of empathy were measured using a
novel, partially-validated, researcher-developed tool which in-
tegrated verbal and non-verbal behaviours to assess expressed
JID: JMIR
ARTICLE IN PRESS
empathy. Participants in both arms of the study demonstrated
empathetic behaviours. Participants in the SPs arm demon-
strated statistically significantly higher levels of empathetic be-
haviours when compared to those interacting with virtual pa-
tients [21].
In a non-randomized controlled study, Kleinsmith et al. in-
vestigated medical students’ interactions virtual patients (VPs)
using the Neurological Examination Virtual Environment
(NERVE) VR program compared to SPs [16]. Participants as-
sumed the role of a physician, interacting with 2 SPs and 2 VPs
presenting with cranial nerve injuries. When presented with op-
portunities to demonstrate empathy, students interacting with
VPs missed 3% of opportunities while students interacting with
SPs missed 9%. Empathetic behaviours rated according to the
ECCS demonstrated statistically significant greater empathetic
behaviours with VPs compared to SPs. Authors also demon-
strated a statistically significant positive correlation between
empathetic response length and ECCS score for both VP and
SP empathetic responses, where longer responses are perceived
as more empathetic [16].
References
[1] MeSH Browser [Internet]. Bethesda (MD): U.S. National Library of
Medicine; 2002 - Meta-analysis; [cited 2020 Sept 4]; [about 1 p.]. Avail-
able from: https://www.ncbi.nlm.nih.gov/mesh/?term=empathy.
[2] Maibom H. editor. The routledge handbook of philosophy of empathy. 2017.
Available from. http://ebookcentral.proquest.com/lib/dal/detail.action?
docID=4799867.
[3] Ventura S, Badenes-Ribera L, Herrero R, Cebolla A, Galiana L, Baños R.
Virtual reality as a medium to elicit empathy: a meta-analysis. Cyberpsychol
Behav Soc Netw. 2020;23(10):667–676.
[4] Bertrand P, Guegan J, Robieux L, McCall CA, Zenasni F. Learning em-
pathy through virtual reality: multiple strategies for training empathy-re-
lated abilities using body ownership illusions in embodied virtual reality.
Front Robot AI. 2018;5:26.
[5] Hamilton-Giachritsis C, Banakou D, Garcia Quiroga M, Giachritsis C,
Slater M. Reducing risk and improving maternal perspective-taking and
empathy using virtual embodiment. Sci Rep. 2018;14(1):2975 8.
[6] Jütten LH, Mark RE, Sitskoorn MM. Can the mixed virtual reality sim-
ulator into d’mentia enhance empathy and understanding and decrease
burden in informal dementia caregivers? Dement Geriatr Cogn Dis Extra.
2018;8(3):453–466.
[7] Kiosses VN, Karathanos VT, Tatsioni A. Empathy promoting interven-
tions for health professionals: a systematic review of RCTs. J of Compas-
sionate Health Care. 2016;3(7).
[8] Kerasidou A. Artificial intelligence and the ongoing need for empa-
thy, compassion and trust in healthcare. Bull World Health Organ.
2020;98(4):245–250.
[9] CAMRT. National competency profile for entry-level MRTs in Canada.
2020; [cited 2021 Feb 25]. Available from https://www.camrt.ca/
wp- content/uploads/2020/03/National- Competency- Profile- 2019.pdf .
[10] MeSH Browser [Internet]. Bethesda (MD): U.S. national library of
medicine; 2002 - . Meta-analysis; [cited 2020 Sept 4]; [about 1 p.]. Avail-
able from: https://www.ncbi.nlm.nih.gov/mesh/?term=carer.
[11] Bearman M, Palermo C, Allen LM, Williams B. Learning empa-
thy through simulation: a systematic literature review. Simul Healthc.
2015;10(5):308–319.
[12] Davis MA. A perspective on cultivating clinical empathy. Complement
Ther Clin Pract. 2009;15(2):76–79.
[13] Haley B, Heo S, Wright P, Barone C, Rettiganti M, Anders M. Relation-
ships among active listening, self-awareness, empathy, and patient-cen-
M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005
[mNS;May 16, 2021;9:44]
tered care in associate and baccalaureate degree nursing students. Nurs-
ingPlus Open. 2017;3:11–16.
[14] Halpern J. What is clinical empathy? J Gen Intern Med.
2003;18(8):670–674.
[15] Slote M. The Ethics of Care and Empathy. New York: Routledge; 2017.
[16] Kleinsmith A, Rivera-Gutierrez D, Finney G, Cendan J, Lok B. Under-
standing empathy training with virtual patients. Comput Human Behav.
2015;52:151–158.
[17] Slater P, Hasson F, Gillen P, Gallen A, Parlour R. Virtual simula-
tion training: imaged experience of dementia. Int J Older People Nurs.
2019;14(3):e12243.
[18] Najjar N, Davis LW, Beck-Coon K, Carney Doebbeling C. Compas-
sion fatigue: a review of the research to date and relevance to cancer-care
providers. J Health Psychol. 2009;14(2):267–277.
[19] Lee HS, Brennan PF, Daly BJ. Relationship of empathy to appraisal, de-
pression, life satisfaction, and physical health in informal caregivers of
older adults. Res Nurs Health.. 2001;24(1):44–56.
[20] Verducci S. A moral method? Thoughts on cultivating empathy through
method acting. J Moral Educ. 2000;29(1):87–99.
[21] Deladisma AM, Cohen M, Stevens A, Wagner P, Lok B, Bernard T,
Oxendine C, Schumacher L, Johnsen K, Dickerson R, Raij A, Wells R,
Duerson M, Harper JG, Lind DS. Association for surgical education. Do
medical students respond empathetically to a virtual patient? Am J Surg.
2007;193(6):756–760.
[22] MeSH Browser [Internet]. Bethesda (MD): U.SNational library of
medicine. Meta-analysis. 2002. [cited 2020 Sept 4]; [about 1 p.]. Available
from:. https://www.ncbi.nlm.nih.gov/mesh/?term=virtual+reality.
[23] Kyaw BM, Saxena N, Posadzki P, Vseteckova J, Nikolaou CK, George PP,
Divakar U, Masiello I, Kononowicz AA, Zary N. Tudor Car L. Virtual
reality for health professions education: systematic review and meta-anal-
ysis by the digital health education collaboration. J Med Internet Res.
2019;22(1):e12959 21.
[24] Foronda CL, Fernandez-Burgos M, Nadeau C, Kelley CN, Henry MN.
Virtual simulation in nursing education: a systematic review spanning
1996 to 2018. Simul Healthc.. 2020;15(1):46–54.
[25] Hirt J, Beer T. Use and impact of virtual reality simulation in dementia
care education: a scoping review. Nurse Educ Today. 2020;84.
[26] Moher D, Liberati A, Tetzlaff J, Altman DG, Group The PRISMA.
Preferred reporting items for systematic reviews and meta-analyses: the
PRISMA statement. PLoS Med. 2009;6(7).
[27] Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ,
Welch VA. Cochrane handbook for systematic reviews of interventions
version 6.1 (updated September 2020). Cochrane. 2020. Available from.
www.training.cochrane.org/handbook.
[28] Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing
risk of bias in randomised trials. BMJ. 2019;366:l4898.
[29] Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND,
Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias
in non-randomized studies of interventions. BMJ. 2016;12:i4919
355.
[30] Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qual-
itative research (COREQ): a 32-item checklist for interviews and focus
groups. Int J Qual Health Care. 2007;19(6):349–357.
[31] Kimzey M, Mastel-Smith B, Seale A. effects of dementia-specific educa-
tion for nursing students. Nurse Educator. 2019;44(6):338–341.
[32] Raij A, Kotranza A, Lind DS, Lok B. Virtual experiences for social per-
spective-taking. 2009 IEEE Virtual Reality Conference; 2009:99–102.
[33] Into D’mentia Foundation. Into d’mentia tour. 2018: [Cited 2020 Sept
4]. Available from https://intodmentia.nl/.
[34] Second Wind Dreams. The virtual dementia tourTM . 1997-2019:
[Cited 2020 Sept 4]. Available from: https://www.secondwind.org/
virtual- dementia- tourreg.html.
[35] Cendan J, Lok B. The use of virtual patients in medical school curricula.
Adv Physiol Educ. 2012;36(1):48–53.
[36] Morse JM, Anderson G, Bottorff JL, Yonge O, O’Brien B, Solberg SM,
McIlveen KH. Exploring empathy: a conceptual fit for nursing practice?
Image J Nurs Sch. 1992;24(4):273–280.
11
JID: JMIR
ARTICLE IN PRESS [mNS;May 16, 2021;9:44]

[37] Batson CD, Early S, Salvarani G. Perspective taking: imagining how an-
other feels versus imaging how you would feel. Personality Soc Psychol Bul-
letin. 1997;23(7):751–758.
[38] Batson CD, Lishner DA, Carpenter A, Dulin L, Harjusola-Webb S,
Stocks EL, et al. As you would have them do unto you: does imagining
yourself in the other’s place stimulate moral action? Personal Soc Psychol
Bull. 2003;29(9):1190–1201.
[39] Sassenrath C. Let me show you how nice I am: impression management as
bias in empathic responses. Soc Psychol Personal Sci. 2020;11(6):752–760.
[40] Jütten LH, Mark RE, Maria Janssen BWJ, Rietsema J, Dröes RM, Sit-
skoorn MM. Testing the effectivity of the mixed virtual reality training
Into D’mentia for informal caregivers of people with dementia: proto-
col for a longitudinal, quasi-experimental study. BMJ Open. 2017;7(8)
:e015702.

12 M. Brydon, J. Kimber, M. Sponagle et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx

Please cite this article as: M. Brydon, J. Kimber, M. Sponagle et al., Virtual reality as a tool for eliciting empathetic behaviour in carers: An integrative review,
Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2021.04.005