Social presence, or the feeling of being there with a “real” person, is a crucial component of interactions that take place in virtual reality. This paper reviews the concept, antecedents, and implications of social presence, with a focus on the literature regarding the predictors of social presence. The article begins by exploring the concept of social presence, distinguishing it from two other dimensions of presence—telepresence and self-presence. After establishing the definition of social presence, the article offers a systematic review of 222 separate findings identified from 150 studies that investigate the factors (i.e., immersive qualities, contextual differences, and individual psychological traits) that predict social presence. Finally, the paper discusses the implications of heightened social presence and when it does and does not enhance one’s experience in a virtual environment.

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A Systematic Review of Social Presence: Definition, Antecedents, and Implications.

Background: Blended learning, which combines face-to-face learning and e-learning, has grown rapidly to be commonly used in education. Nevertheless, the effectiveness of this learning approach has not been completely quantitatively synthesized and evaluated using knowledge outcomes in health education.
Objective: The aim of this study was to assess the effectiveness of blended learning compared to that of traditional learning in health education.
Methods: We performed a systematic review of blended learning in health education in MEDLINE from January 1990 to July 2019. We independently selected studies, extracted data, assessed risk of bias, and compared overall blended learning versus traditional learning, offline blended learning versus traditional learning, online blended learning versus traditional learning, digital blended learning versus traditional learning, computer-aided instruction blended learning versus traditional learning, and virtual patient blended learning versus traditional learning. All pooled analyses were based on random-effect models, and the I2 statistic was used to quantify heterogeneity across studies.
Results: A total of 56 studies (N=9943 participants) assessing several types of learning support in blended learning met our inclusion criteria; 3 studies investigated offline support, 7 studies investigated digital support, 34 studies investigated online support, 8 studies investigated computer-assisted instruction support, and 5 studies used virtual patient support for blended learning. The pooled analysis comparing all blended learning to traditional learning showed significantly better knowledge outcomes for blended learning (standardized mean difference 1.07, 95% CI 0.85 to 1.28, I2=94.3%). Similar results were observed for online (standardized mean difference 0.73, 95% CI 0.60 to 0.86, I2=94.9%), computer-assisted instruction (standardized mean difference 1.13, 95% CI 0.47 to 1.79, I2=78.0%), and virtual patient (standardized mean difference 0.62, 95% CI 0.18 to 1.06, I2=78.4%) learning support, but results for offline learning support (standardized mean difference 0.08, 95% CI –0.63 to 0.79, I2=87.9%) and digital learning support (standardized mean difference 0.04, 95% CI –0.45 to 0.52, I2=93.4%) were not significant.
Conclusions: From this review, blended learning demonstrated consistently better effects on knowledge outcomes when compared with traditional learning in health education. Further studies are needed to confirm these results and to explore the utility of different design variants of blended learning.

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Blended Learning Compared to Traditional Learning in Medical Education: Systematic Review and Meta-Analysis.

This article surveys the area of computational empathy, analysing different ways by which artificial agents can simulate and trigger empathy in their interactions with humans. Empathic agents can be seen as agents that have the capacity to place themselves into the position of a user’s or another agent’s emotional situation and respond appropriately. We also survey artificial agents that, by their design and behaviour, can lead users to respond emotionally as if they were experiencing the agent’s situation. In the course of this survey, we present the research conducted to date on empathic agents in light of the principles and mechanisms of empathy found in humans. We end by discussing some of the main challenges that this exciting area will be facing in the future.

Empathy in Virtual Agents and Robots: A Survey

Background: Virtual patients are interactive digital simulations of clinical scenarios for the purpose of health professions education. There is no current collated evidence on the effectiveness of ...

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Virtual Patient Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration

Background Empathy and compassion are vital components of health care quality; however, physicians frequently miss opportunities for empathy and compassion in patient care. Despite evidence that empathy and compassion training can be effective, the specific behaviors that should be taught remain unclear. We synthesized the biomedical literature on empathy and compassion training in medical education to find the specific curricula components (skills and behaviors) demonstrated to be effective. Methods We searched CENTRAL, MEDLINE, EMBASE, and CINAHL using a previously published comprehensive search strategy. We screened reference lists of the articles meeting inclusion criteria to identify additional studies for potential inclusion. Study inclusion criteria were: (1) intervention arm in which subjects underwent an educational curriculum aimed at enhancing empathy and/or compassion; (2) clearly defined control arm in which subjects did not receive the curriculum; (3) curriculum was tested on physicians (or physicians-in-training); and (4) outcome measure assessing the effect of the curriculum on physician empathy and/or compassion. We performed a qualitative analysis to collate and tabulate effects of tested curricula according to recommended methodology from the Cochrane Handbook. We used the Cochrane Collaboration’s tool for assessing risk of bias. Results Fifty-two studies (total n = 5,316) met inclusion criteria. Most (75%) studies found that the tested curricula improved physician empathy and/or compassion on at least one outcome measure. We identified the following key behaviors to be effective: (1) sitting (versus standing) during the interview; (2) detecting patients’ non-verbal cues of emotion; (3) recognizing and responding to opportunities for compassion; (4) non-verbal communication of caring (e.g. eye contact); and (5) verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perception of physician empathy and/or compassion. Conclusion Evidence suggests that training can enhance physician empathy and compassion. Training curricula should incorporate the specific behaviors identified in this report.

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Curricula for empathy and compassion training in medical education: A systematic review

IntroductionPhysician empathy is a complex phenomenon known to improve illness outcomes; however, few tools are available for deliberate practice of empathy. We used a virtual patient (VP) to teach empathic communication to first-year medical students. We then evaluated students’ verbal empathy in a

Using Virtual Patients to Teach Empathy: A Randomized Controlled Study to Enhance Medical Students' Empathic Communication.

We are preparing learners to work in complex environments, interacting with other professionals while caring for patients. Communicating effectively within a team is urgent because lapses in teamwork and communication are the leading causes of errors and patient harm. The results of collaborations between disciplines such as computer science/engineering and health sciences education have been described. In scripted and technically driven scenarios, these collaborations often complement each other, and as such, descriptions and results appear in the journals of multiple disciplines well beyond health professions education.

The Role for Virtual Patients in the Future of Medical Education.

A comparison of speaking up behavior during conflict with real and virtual humans

Researchers have created mixed-reality humans (MRHs) and applied them to critical team training. MRHs are embodied conversational agents with virtual and physical components that inhabit the user's space. In this research, MRHs role-played members of an operating-room team. Studies examined how MRH components affected social presence (the user's sense of &#x0022;being there&#x0022; with an embodied conversational agent) and the training of communication skills for medical teams.

Mixed-Reality Humans for Team Training

We conducted a study which investigated if we could overcome challenges associated with interpersonal communication skills training by building a virtual human with back story. Eighteen students interacted with a virtual human who provided back story, and seventeen students interacted with the same virtual human who did not provide back story. Back story was achieved through the use of cutscenes which played throughout the virtual human interaction. Cutscenes were created with The Sims 3 and depicted short moments that occurred in the virtual human’s life. We found medical students who interacted with a virtual human with a back story, when interacting with a standardized patient, were perceived by the standardized patient as more empathetic compared to the students who interacted with the virtual human without a back story. The results have practical implications for building virtual human experiences to train interpersonal skills. Providing back story appears to be an effective method to overcome challenges associated with training interpersonal skills with virtual humans.

Andrew Cordar

Papers

Using Virtual Patients to Teach Empathy: A Randomized Controlled Study to Enhance Medical Students' Empathic Communication.

The Role for Virtual Patients in the Future of Medical Education.

A comparison of speaking up behavior during conflict with real and virtual humans

Mixed-Reality Humans for Team Training

Building Virtual Humans with Back Stories: Training Interpersonal Communication Skills in Medical Students