Leveraging virtual humans to effectively prepare learners for stressful interpersonal experiences

A scoping review of emotions and related constructs in simulation-based education research articles

BACKGROUND

While acknowledgement of emotions' importance in simulation-based education is emerging, there are concerns regarding how education researchers understand the concept of emotions for them to deliberately incorporate emotionally charged scenarios into simulation-based education. This concern is highlighted especially in the context of medical education often lacking strong theoretical integration. To map out how current simulation-based education literature conceptualises emotion, we conducted a scoping review on how emotions and closely related constructs (e.g. stress, and emotional intelligence) are conceptualised in simulation-based education articles that feature medical students, residents, and fellows.

METHODS

The scoping review was based on articles published in the last decade identified through database searches (EMBASE and Medline) and hand-searched articles. Data extraction included the constructs featured in the articles, their definitions, instruments used, and the types of emotions captured. Only empirical articles were included (e.g. no review or opinion articles). Data were charted via descriptive analyses.

RESULTS

A total of 141 articles were reviewed. Stress was featured in 88 of the articles, while emotions and emotional intelligence were highlighted in 45 and 34 articles respectively. Conceptualisations of emotions lacked integration of theory. Measurements of emotions mostly relied on self-reports while stress was often measured via physiological and self-report measurements. Negative emotions such as anxiety were sometimes seen as interchangeable with the term stress. No inferences were made about specific emotions of participants from their emotional intelligence.

CONCLUSIONS

Our scoping review illustrates that learners in simulation-based education are most often anxious and fearful. However, this is partially due to medical education prioritising measuring negative emotions. Further theoretical integration when examining emotions and stress may help broaden the scope towards other kinds of emotions and better conceptualisations of their impact. We call for simulation education researchers to reflect on how they understand emotions, and whether their understanding may neglect any specific aspect of affective experiences their simulation participants may have.

Effects of Small Talk With a Crowd of Virtual Humans on Users' Emotional and Behavioral Responses

In this contribution, we empirically investigated the effect of small talk on the users' non-verbal behaviors and emotions when users interacted with a crowd of virtual humans (VHs) with positive behavioral dispositions. Users were tasked with collecting items in a virtual marketplace via natural speech-based dialogue with a crowd of virtual pedestrians and vendors. The users were able to engage in natural speech-based conversation in a predefined corpus of small talk content that covered various commonplace small talk topics such as conversations about the weather, general concerns, and entertainment based on similar real-life situations. For instance, the VHs with the small talk ability would ask the users some simple questions to make small talk or remind the users of their belongings. We conducted a between-subjects empirical evaluation to investigate whether the user behaviors and emotions were different between a small talk condition and a non-small talk condition, and examined gender effects of the participants. We collected objective and subjective measures of the users to analyze users' emotions and social interaction behaviors, when in conversation with VHs that either possessed small-talk capability or not, besides task or goal oriented dialogue capabilities. Our result revealed that the VHs with small talk capability could alter the emotions and non-verbal behaviors of the users. Furthermore, the non-verbal behaviors between female and male participants differed greatly in the presence or absence of small talk.

Effects on Co-Presence of a Virtual Human: A Comparison of Display and Interaction Types

Recently, artificial intelligence (AI)-enabled virtual humans have been widely used in various fields in our everyday lives, such as for museum exhibitions and as information guides. Given the continued technological innovations in extended reality (XR), immersive display devices and interaction methods are evolving to provide a feeling of togetherness with a virtual human, termed co-presence. With regard to such technical developments, one main concern is how to improve the experience through the sense of co-presence as felt by participants. However, virtual human systems still have limited guidelines on effective methods, and there is a lack of research on how to visualize and interact with virtual humans. In this paper, we report a novel method to support a strong sense of co-presence with a virtual human, and we investigated the effects on co-presence with a comparison of display and interaction types. We conducted the experiment according to a specified scenario between the participant and the virtual human, and our experimental study showed that subjects who participated in an immersive 3D display with non-verbal interaction felt the greatest co-presence. Our results are expected to provide guidelines on how to focus on constructing AI-based interactive virtual humans.

Effectiveness of technology-enhanced simulation in teaching digital rectal examination: a systematic review narrative synthesis

Background

Digital rectal examination (DRE) is a challenging examination to learn.

Objective

To synthesise evidence regarding the effectiveness of technology-enhanced simulation (TES) for acquiring DRE skills.

Study selection

EMBASE, Medline, CINAHL, Cochrane, Web of Knowledge (Science and Social Science), Scopus and IEEE Xplore were searched; the last search was performed on 3 April 2019. Included were original research studies evaluating TES to teach DRE. Data were abstracted on methodological quality, participants, instructional design and outcomes; a descriptive synthesis was performed. Quality was assessed using a modified Medical Education Research Study Quality Instrument. The study design domain was modified by scoring the papers based on (1) evaluation of risk of bias for randomised controlled trials, (2) description of participants and (3) assessment of robustness and degree of simulation fidelity of the assessments used to evaluate learning.

Findings

863 articles were screened; 12 were eligible, enrolling 1507 prequalified medical/clinical students and 20 qualified doctors. For skill acquisition, role player was statistically significantly superior to a static manikin (2 studies). For knowledge acquisition, manikin use was significantly superior to role player (1 study); 2 studies showed no difference. For confidence, manikin use was significantly superior to no manikin (4 studies). For comfort, manikin use was significantly superior to no manikin (2 studies). For anxiety, role player was significantly superior to manikin (1 study).

Conclusions

TES training is associated with improved DRE skills and should be used more widely.

The Emotional and Behavioral Impact of Delivering Bad News to Virtual versus Real Standardized Patients: A Pilot Study

Phenomenon: Virtual standardized patients (vSPs) are becoming increasingly common in medical education, though one limitation of vSPs is the artificiality of computer-based simulators. Past research on the use of vSPs has not clearly established whether learners have different emotional responses to real SPs (rSPs) compared with vSPs; however, understanding learners' emotional responses to vSPs is important in providing realistic learning experiences and establishing the validity of this teaching and assessment tool. This study compared the emotional experiences of individuals who interacted with rSPs and vSPs. Approach: Sixty medical students at a medical school in the southeastern United States participated in the study. Participants were randomly assigned to deliver bad news to an rSP or vSP. The vSP for this study used a hybrid intelligence model that allowed a person to "inhabit" the vSP. Salivary cortisol and a self-report measure of mood-the Profile of Mood States, Second Edition (POMS 2)-were gathered before and after delivering the bad news. The SP and 2 independent evaluators rated the behavioral performance of each participant in real and virtual conditions. Participants also rated the performance of the SP. Findings: Participants in both conditions reported increased negative emotionality on the POMS 2 following the SP interaction. There were no significant between-group differences on the POMS 2 or salivary cortisol concentration following the SP interaction. Ratings by the SP and independent evaluators indicated that participants performed similarly on most interpersonal dimensions, except tone of voice. Participants perceived the vSP as less realistic than the rSP. Insights: These results suggest that medical students may have similar emotional and behavioral responses when delivering bad news to a vSP when compared to an rSP. These findings provide support for the continued use of vSPs in training learners to deliver bad news and other communication-based skills and to assess their performance on these tasks.

Artificial Intelligence in Intelligent Tutoring Robots: A Systematic Review and Design Guidelines

This study provides a systematic review of the recent advances in designing the intelligent tutoring robot (ITR) and summarizes the status quo of applying artificial intelligence (AI) techniques. We first analyze the environment of the ITR and propose a relationship model for describing interactions of ITR with the students, the social milieu, and the curriculum. Then, we transform the relationship model into the perception-planning-action model to explore what AI techniques are suitable to be applied in the ITR. This article provides insights on promoting a human-robot teaching-learning process and AI-assisted educational techniques, which illustrates the design guidelines and future research perspectives in intelligent tutoring robots.

Programmable prostate palpation simulator using property-changing pneumatic bladder

The currently available prostate palpation simulators are based on either a physical mock-up or pure virtual simulation. Both cases have their inherent limitations. The former lacks flexibility in presenting abnormalities and scenarios because of the static nature of the mock-up and has usability issues because the prostate model must be replaced in different scenarios. The latter has realism issues, particularly in haptic feedback, because of the very limited performance of haptic hardware and inaccurate haptic simulation. This paper presents a highly flexible and programmable simulator with high haptic fidelity. Our new approach is based on a pneumatic-driven, property-changing, silicone prostate mock-up that can be embedded in a human torso mannequin. The mock-up has seven pneumatically controlled, multi-layered bladder cells to mimic the stiffness, size, and location changes of nodules in the prostate. The size is controlled by inflating the bladder with positive pressure in the chamber, and a hard nodule can be generated using the particle jamming technique; the fine sand in the bladder becomes stiff when it is vacuumed. The programmable valves and system identification process enable us to precisely control the size and stiffness, which results in a simulator that can realistically generate many different diseases without replacing anything. The three most common abnormalities in a prostate are selected for demonstration, and multiple progressive stages of each abnormality are carefully designed based on medical data. A human perception experiment is performed by actual medical professionals and confirms that our simulator exhibits higher realism and usability than do the conventional simulators.

Missing the mark: Current practices in teaching the male urogenital examination to Canadian undergraduate medical students

INTRODUCTION

The urogenital physical examination is an important aspect of patient encounters in various clinical settings. Introductory clinical skills sessions are intended to provide support and alleviate students' anxiety when learning this sensitive exam. The techniques each Canadian medical school uses to guide their students through the initial urogenital examination has not been previously reported.

METHODS

This study surveyed pre-clerkship clinical skills program directors at the main campus of English-speaking Canadian medical schools regarding the curriculum they use to teach the urogenital examination.

RESULTS

A response rate of 100% was achieved, providing information on resources and faculty available to students, as well as the manner in which students were evaluated. Surprisingly, over one-third of the Canadian medical schools surveyed failed to provide a setting in which students perform a urogenital examination on a patient in their pre-clinical years. Additionally, there was no formal evaluation of this skill set reported by almost 50% of Canadian medical schools prior to clinical training years.

CONCLUSIONS

To ensure medical students are confident and accurate in performing a urogenital examination, it is vital they be provided the proper resources, teaching, and training. As we progress towards a competency-based curriculum, it is essential that increased focus be placed on patient encounters in undergraduate training. Further research to quantify students' exposure to the urogenital examination during clinical years would be of interest. Without this commitment by Canadian medical schools, we are doing a disservice not only to the medical students, but also to our patient population.

Effects of Virtual Human Appearance Fidelity on Emotion Contagion in Affective Inter-Personal Simulations

Realistic versus stylized depictions of virtual humans in simulated inter-personal situations and their ability to elicit emotional responses in users has been an open question for artists and researchers alike. We empirically evaluated the effects of near visually realistic vs. non-realistic stylized appearance of virtual humans on the emotional response of participants in a medical virtual reality system that was designed to educate users in recognizing the signs and symptoms of patient deterioration. In a between-subjects experiment protocol, participants interacted with one of three different appearances of a virtual patient, namely visually realistic, cartoon-shaded and charcoal-sketch like conditions in a mixed reality simulation. Emotional impact were measured via a combination of quantitative objective measures were gathered using skin Electrodermal Activity (EDA) sensors, and quantitative subjective measures such as the Differential Emotion Survey (DES IV), Positive and Negative Affect Schedule (PANAS), and Social Presence questionnaire. The emotional states of the participants were analyzed across four distinct time steps during which the medical condition of the virtual patient deteriorated (an emotionally stressful interaction), and were contrasted to a baseline affective state. Objective EDA results showed that in all three conditions, male participants exhibited greater levels of arousal as compared to female participants. We found that negative affect levels were significantly lower in the visually realistic condition, as compared to the stylized appearance conditions. Furthermore, in emotional dimensions of interest-excitement, surprise, anger, fear and guilt participants in all conditions responded similarly. However, in social emotional constructs of shyness, presence, perceived personality, and enjoyment-joy, we found that participants responded differently in the visually realistic condition as compared to the cartoon and sketch conditions. Our study suggests that virtual human appearance can affect not only critical emotional reactions in affective inter-personal training scenarios. but also users' perceptions of personality and social characteristic of the virtual interlocutors.

Teaming Up with Virtual Humans: How Other People Change Our Perceptions of and Behavior with Virtual Teammates

In this paper we present a study exploring whether the physical presence of another human changes how people perceive and behave with virtual teammates. We conducted a study (n = 69) in which nurses worked with a simulated health care team to prepare a patient for surgery. The agency of participants' teammates was varied between conditions; participants either worked with a virtual surgeon and a virtual anesthesiologist, a human confederate playing a surgeon and a virtual anesthesiologist, or a virtual surgeon and a human confederate playing an anesthesiologist. While participants perceived the human confederates to have more social presence (p <; 0.01), participants did not preferentially agree with their human team members. We also observed an interaction effect between agency and behavioral realism. Participants experienced less social presence from the virtual anesthesiologist, whose behavior was less in line with participants' expectations, when a human surgeon was present.

Using a Critical Incident Scenario With Virtual Humans to Assess Educational Needs of Nurses in a Postanesthesia Care Unit

INTRODUCTION

During critical incidents, teamwork failures can compromise patient safety. This study provides evidence that virtual humans can be used in simulated critical incidents to assess the learning needs of health professionals, and provide important information that can inform the development of continuing education programs in patient safety. We explored the effectiveness of information transfer during a devolving medical situation between postanesthesia care unit (PACU) nurses and a virtual attending physician.

METHODS

We designed a three-stage scenario: tutorial, patient transfer, and critical incident. We developed 2 checklists to assess information transfer: Critical Patient Information and Interprofessional Communication Skills. All participants were videotaped; 2 raters reviewed all videos and assessed performance using the checklists.

RESULTS

Participants (n = 43) who completed all 3 stages scored 62.3% correct on critical patient information transfer and 61.6% correct on interprofessional communication skills. Almost 87% missed a fatal drug error. The checklists measured each item on a 1/0 (done/not) calculation. Additionally, no relationship was found between years of nursing experience and performance on either checklist.

DISCUSSION

The PACU nurses in this study did not consistently share critical information with an attending (virtual) physician during a critical incident, and most missed a fatal dosage error. These findings strongly suggest a crucial need for additional structured team training among practicing health care teams, and they demonstrate the utility of using virtual humans to simulate team members.

Effects of virtual human animation on emotion contagion in simulated inter-personal experiences

We empirically examined the impact of virtual human animation on the emotional responses of participants in a medical virtual reality system for education in the signs and symptoms of patient deterioration. Participants were presented with one of two virtual human conditions in a between-subjects experiment, static (non-animated) and dynamic (animated). Our objective measures included the use of psycho-physical Electro Dermal Activity (EDA) sensors, and subjective measures inspired by social psychology research included the Differential Emotions Survey (DES IV) and Positive and Negative Affect Survey (PANAS). We analyzed the quantitative and qualitative measures associated with participants&#146; emotional state at four distinct time-steps in the simulated interpersonal experience as the virtual patient&#146;s medical condition deteriorated. Results suggest that participants in the dynamic condition with animations exhibited a higher sense of co-presence and greater emotional response as compared to participants in the static condition, corresponding to the deterioration in the medical condition of the virtual patient. Negative affect of participants in the dynamic condition increased at a higher rate than for participants in the static condition. The virtual human animations elicited a stronger response in negative emotions such as anguish, fear, and anger as the virtual patient&#146;s medical condition worsened.