systematic literature review on virtual reality

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Review article, virtual reality and collaborative learning: a systematic literature review.

• 1 Centre for Education and Learning, Delft University of Technology, Delft, Netherlands
• 2 Leiden Institute of Advanced Computer Science, Leiden University, Leiden, Netherlands
• 3 Interactive Intelligence, Delft University of Technology, Delft, Netherlands

Background: While research on Virtual Reality’s potential for education continues to advance, research on its support for Collaborative Learning is small in scope. With remote collaboration and distance learning becoming increasingly relevant for education (especially since the COVID-19 pandemic), an understanding of Virtual Reality’s potential for Collaborative Learning is of importance. To establish how this immersive technology can support and enhance collaboration between learners, this systematic literature review analyses scientific research on Virtual Reality for Collaborative Learning with the intention to identify 1) skills and competences trained, 2) domains and disciplines addressed, 3) systems used and 4) empirical knowledge established.

Method: Two scientific databases—Scopus and Web of Science—were used for this review. Following the PRISMA method, a total of 139 articles were analyzed. Reliability of this selection process was assessed using five additional coders. A taxonomy was used to classify these articles. Another coder was used to assess the reliability of the primary coder before this taxonomy was applied to the selected articles

Results: Based on the literature reviewed, skills and competences developed are divided into five categories. Educational fields and domains seem interested in Virtual Reality for Collaborative Learning because of a need for innovation, communities and remote socialization and collaboration between learners. Systems primarily use monitor-based Virtual Reality and mouse-and-keyboard controls. A general optimism is visible regarding the use of Virtual Reality to support and enhance Collaborative Learning

Conclusion: Five distinct affordances of Virtual Reality for Collaborative Learning are identified: it 1) is an efficient tool to engage and motivate learners, 2) supports distance learning and remote collaboration, 3) provides multi- and interdisciplinary spaces for both learning and collaborating, 4) helps develop social skills and 5) suits Collaborative Learning-related paradigms and approaches. Overall, the reviewed literature suggests Virtual Reality to be an effective tool for the support and enhancement of Collaborative Learning, though further research is necessary to establish pedagogies.

1 Introduction

Beginning in the 1980s, academia has studied how to support and enhance Collaborative Learning (CL) in educational settings using technology. Referred to as Computer-Supported Collaborative Learning (CSCL), this pedagogical approach stems from social learning, an educational theory revolving around the idea that “new behavior can be acquired through the observation of other people’s behaviors” ( Shi et al., 2019 ) and focusing on social interaction between learners. CSCL’s strength appears to lie in its flexibility: by using characteristics of technology, both distant and face-to-face collaboration, as well as synchronous and asynchronous collaboration between learners, can be supported ( Stahl et al., 2006 ). As such, CSCL has been attributed numerous affordances, including joint information processing, sharing resources and co-construction of knowledge ( Shawky et al., 2014 ; Jeong and Hmelo-Silver, 2016 ).

An on-going development in the field of CSCL is the use of Virtual Reality, a technology that ‘[transports] a person to a reality (i.e., a virtual environment) which he or she is not physically present but feels like he or she is there’ ( Rebelo et al., 2012 ). These virtual environments (VEs) are shared, simulated spaces that allow distributed users to communicate with each other, as well as to participate in joint activities, making them an effective tool for remote collaboration ( Daphne et al., 2000 ). VEs tend to be highly customizable; their visual representation can be realistic (i.e., similar to reality or containing recognizable elements from reality) or abstract (e.g., three-dimensional representations of abstract concepts) depending on their purpose, making VEs adaptable for many different fields and disciplines ( Jackson et al., 1999 ; Joyner et al., 2021 ). Virtual Reality (VR), then, functions as a human-computer interface, allowing users to access these VEs through a variety of hardware, including flat-surface monitors and displays connected to desktop computers, room-sized devices called CAVE systems that project the VE onto its walls and Head-Mounted Displays (HMDs), helmets or headpieces that visualize the VE individually for each eye. In some cases, users inhabit avatars, virtual embodiments that represent their place inside the VE, though in other cases (such as the aforementioned CAVE systems, where users do not have to wear HMDs), no avatars are required for users to detect each other. Like VEs, the visual representation of avatars can be diverse: avatars can provide realistic depictions of users’ real-life appearances, but can also be visualized as something abstract, such as geometric objects or animals. Using these avatars to mediate interactions with each other, users progressively construct a shared understanding of the VE together ( Girvan, 2018 ). Of particular interest is VR’s ability to “immerse” users, providing them a sense of being inside the VE despite its non-physical, digital nature ( Freina and Ott, 2015 ). This immersion may lead to a state of presence, wherein users begin to behave inside the VE as they would in the physical world ( Jensen and Konradsen, 2018 ). Affordances of VR in education include enhancement of experiential learning ( Le et al., 2015 ; Kwon, 2019 ), spatial learning ( Dalgarno and Lee, 2010 ; de Back et al., 2020 ) and motivation and engagement among different types of learners ( Merchant et al., 2014 ; Chavez and Bayona, 2018 ). While research on VR has generally revolved around discovering its potential to support and enhance education, academics appear to agree that the field of educational use of VR lacks pedagogical practices or strategies, with little focus on how the technology should be implemented to reap its benefits ( Cook et al., 2019 ; Smith, 2019 ; Scavarelli et al., 2021 ).

VR technology has already shown potential for the field of CSCL, improving the effectiveness of team behavior, enhancing communication between group members and increasing learning outcome gains ( Le et al., 2015 ; Godin and Pridmore, 2019 ; Zheng et al., 2019 ). What makes the use of Virtual Reality for Collaborative Learning (VRCL) even more appealing for education is its diversity in hardware and, as a result, the different forms it can take depending on the setting. Whether learners interact with the VEs via display monitors, CAVE systems or HMDs, they all seem to produce positive effects such as positive learning gains and outcomes, as well as engagement and motivation for CL ( Abdullah et al., 2019 ; Zheng et al., 2019 ; de Back et al., 2020 ; Tovar et al., 2020 ).

To advance the field of VRCL, as well as to establish its benefits and affordances, several literature reviews have examined research on VRCL. For example, Muhammad Nur Affendy and Ajune Wanis (2019) , aiming to provide an overview of the capabilities of CL through the adoption of collaborative system in AR and VR, review how VEs are used for different types of collaboration (e.g., remote and co-located collaboration), with different VR hardware (e.g., eye tracking) and multiple intended uses (e.g., increasing social engagement and supporting awareness of collaboration among learners). In comparison, Zheng et al. (2019) evaluate VRCL technology affordances by conducting a meta-analysis as well as a qualitative analysis of VRCL prototypes to explore potential learning benefits; Scavarelli et al. (2021) explore a more theoretical side with the intention to produce educational frameworks for future VRCL-related research, discussing how several learning theories (e.g., constructivism, social cognitive theory and connectivism) are reflected in prior research on the potential of VR as well as Augmented Reality (AR) for social learning spaces.

Together, the literature reviews of Muhammad Nur Affendy and Ajune Wanis (2019) , Zheng et al. (2019) ; Scavarelli et al. (2021) describe a general optimism towards VR in educational settings to support collaboration. The reviews outline VRCL’s strengths as 1) its ability to enhance learning outcomes, 2) its potential to facilitate learning, 3) its effectiveness in supporting remote collaboration between learners, as well as experts and novices, 4) its support for interpersonal awareness between collaborating learners and 5) its diversity, both in terms of its customizability (allowing VEs to better suit objectives) as well as its technology. Affordances of VRCL are identified as 1) social interaction (strengthened by VR’s affordances of immersion and presence), 2) resource sharing (strengthened by VR’s ability to present imaginary elements) and 3) knowledge construction (supported by the two prior affordances of VRCL). Furthermore, challenges and gaps related to (research on) VRCL are outlined. First, accessibility should be considered a primary concern according to Scavarelli et al.,; this does not just relate to the technical accessibility of VR when used in education, but more so to the accessibility of social engagement between learners sharing these virtual learning spaces. Second, they recommend to explore the interplay and connectivity between VEs and the real world, as doing so could reveal new learning theories that innovate VRCL. Third, Zheng et al., suggest that research focus on pedagogical strategies involving VRCL, including how to apply VR to educational settings involving collaboration. Fourth, they propose a focus on finding a balance between using VRCL to recreate (or simulate) existing (“real”) situations and creating new situations that would normally be impossible, considering that prior work has primarily been centered on the former and as such misses out on VR’s potential to do the latter.

Considering that remote collaboration and distance learning, especially since the COVID-19 pandemic, are becoming increasingly important for learners, an understanding of VR’s potential for CL could prove beneficial for the field of education. While research on the topic is apparent, studies focusing on VR’s ability to support and enhance CL are still small in scale ( Zheng et al., 2019 ; Scavarelli et al., 2021 ), accentuating the scarcity of knowledge on the topic. This systematic review specifically centers on scientific research on VRCL, with a particular focus on the empirical knowledge that such literature has established. The aim of this paper is to examine in what ways VR supports and enhances CL according to prior research on these topics; to achieve this, it reports on what VRCL is used for in different fields of education, discusses what research has stated regarding VRCL in terms of affordances and benefits for education, describes the characteristics of VRCL that allow these benefits to come to fruition and provides an insight into the technology behind VRCL, as well as how this compares to the state-of-the-art of VR. In doing so, this study intends to identify possible gaps in the field of VRCL research for possible future studies, in addition to highlighting VRCL’s strengths to support current research. To the best of the authors’ knowledge, this study is the first systematic review on the topic of VRCL. As a means to provide the relevant information, this review addresses the following four research questions.

1. What skills and competences have been trained with use of VRCL (and what should a VRCL environment provide to train these)?

2. What domains and disciplines have been addressed (and why)?

3. What systems have been developed and/or established?

4. What empirical knowledge has been established (and with what methods and/or study designs)?

This section discusses the process of collecting the relevant studies for this literature review. In particular, the inclusion and exclusion criteria, databases and methods used are described.

2.1 Identification

The systematic review used two databases: Scopus and Web of Science. The search query contained the following key elements: 1) collaborative interaction, 2) VR, 3) education, training and learning, 4) simulations of a three-dimensional nature, 5) empirical data and 6) the use of a system (application or prototype). As such, the following search string was used in both databases:

[collaboration OR cooperation OR collaborative OR cooperative OR collaborate OR cooperate] [AND] ["virtual reality” OR “mixed reality” OR “extended reality"] [AND] ["3D” OR 3d OR 3-D OR 3-d OR threedimension* OR three-dimension* OR “three dimension*" OR CGI OR “computer generated” OR “computer-generated” OR model* OR construct*] [AND] [evaluat* OR data OR result* OR observ* OR empiric* OR trial* OR experiment* OR significan* OR participant* OR subject*] [AND] [education OR training OR learning OR university OR school OR vocational] [AND] [system* OR prototyp* OR application* OR program*]

To be considered suitable, papers had to meet five specific inclusion criteria. Firstly, an article had to discuss collaborative or cooperative interaction between human users of a virtual, three-dimensional simulation. Secondly, the article had to include and discuss Virtual-, Augmented-, Mixed Reality (MR) or Extended Reality (XR) as a three-dimensional simulation of a physical space or object(s). While this review focuses on VR for CL, mediums such as AR, MR and XR were included in this search for two reasons. On the one hand, definitions for these mediums appear to overlap to such an extent (with some even considering them too vague and ambiguous ( Tovar et al., 2020 )) that ‘pedagogical advantages of either technologies are [considered] comparable’ ( Sims et al., 2022 ). On the other hand, the mediums in question do not always get defined as separate ones, but rather as different points on one spectrum, commonly referred to as the virtuality continuum, in which ‘“reality” lies at one end, and “virtuality” […] at the other, with Mixed Reality […] placed between’ ( Scavarelli et al., 2021 ). As such, the decision was made to include these mediums, so as to ensure that no pedagogical advantages of VR would be excluded. The third inclusion criterium required an article to include an empirical study (i.e., containing qualitative or quantitative data) for it to be considered suitable. For the fourth and fifth criteria, an article had to contain an educational objective or goal (for human entities) and discuss a system used for educational purposes (for human entities) in order to be eligible.

Additionally, studies would be disqualified from the literature review if they 1) only described a patent, 2) only contained a summary (review) of a conference, 3) only consisted of a literature review, 4) were not accessible to the authors of this study, 5) were not available in English, 6) were a duplicate or a version, edition or release of an older study that already had been included or 7) did not specifically state the number of participants of any experiment involved in the study.

The search query resulted in 1,058 publications for Scopus and 845 studies for Web of Science, resulting in a total of 1,608 studies after duplicates were removed. Using the inclusion and exclusion criteria to filter out ineligible articles (initially based on title and abstract, then on full text), this review resulted in 139 articles analyzed. Results and details of the process (which followed the guidelines of the PRISMA method ( Moher et al., 2009 )) can be seen in Figure 1 . Appendix A shows the complete list of all 139 articles.

FIGURE 1 . Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram of the screening process.

To examine reliability of the selection process, five additional coders screened a random sample of 50 studies individually (10 per coder) using the inclusion and exclusion criteria. After comparing and discussing results, inter-rater reliability (between the first coder and the five coders) was calculated using a Kappa-metric, resulting in a moderate level of agreement of 0.77 ( McHugh, 2012 ) (results can be found in Supplementary Table B1 ).

A taxonomy ( Figure 2 ) was created to help classify all 139 articles. With this review’s research questions in mind, three vital topics were established to function as main categories for the coding process: education, system and evaluation (illustrated in column C1 in Figure 2 ). For RQ1 and RQ2, the first category, education, was established to extract information from the articles, concentrating on six classes. Similarly, information necessary to answer RQ3 was collected by coding attributes related to the second category, system, which included eight classes. Focusing the coding on elements related to the third category, evaluation (with five classes), allowed for extraction of relevant information required to answer RQ4. After the relevant categories, classes (visible in column C2 in Figure 2 ) and attributes (visible in column C3 in Figure 2 ) were decided upon, the classification hierarchy in Figure 2 was constructed, partially based on scientific literature ( Bloom et al., 1956 ; Schreiber and Asnerly-Self, 2011 ; Motejlek and Alpay, 2019 ), to provide assistance during the coding process. For an in-depth description of the motivation behind this classification hierarchy, please see Supplementary Appendix C . While the required information for some of these attributes could easily be inferred directly from each study, other attributes required the first coder to deduce which attributes were applicable.

FIGURE 2 . Classification hierarchy used for coding, including percent agreement ( p a ) and Cohen’s kappa (K) between first and second coder on the right.

To assess reliability of the first coder, a second coder classified articles with the taxonomy ( Supplementary Table D1, D2, D3 ). Inter-rater reliability between the two coders for 30 randomly selected studies was 0.60 (with a percent agreement of 0.85), considered a moderate level of agreement ( McHugh, 2012 ). Additionally, Figure 2 shows the inter-rater reliability for each individual class.

3 Descriptive results

In this section, discussion of descriptive results is divided into three sections according to the structure of the taxonomy. An overview of all results (according to the taxonomy) can be found in Figure 3 .

FIGURE 3 . Results of coding of data found in the literature, according to the taxonomy.

3.1 Education

As a first dimension, elements related to education were analyzed. A majority of the selected articles focused on VRCL in tertiary education (i.e., university), discussing possible uses for students. Educators providing support (e.g., scaffolding) for learners proved most prominent, though not all studies discussed this topic. While a wide selection of educational domains were discussed, computer sciences and social sciences were the most popular fields. Most studies specifically focused on synchronous collaboration. Prevalent among learning paradigms and educational approaches were problem-based learning (PBL) and constructivism. The specific results related to this dimension are found in Table 1 .

TABLE 1 . Distribution of Education-related attributes.

In contrast to the high number of articles focusing on tertiary education (64.0%), primary education was central in 10.8% while 5.0% discussed VRCL in secondary education. A small percentage of studies (6.5%) focused on types of learners outside of formal education (e.g., on-the-job training). In relation to the educators, a little over half of the studies reported on educators supporting the learners by providing varying degrees of scaffolding (55.4%). For 20.9% of cases, educators provided presentations and lectures inside the VE, providing a more passive learning experience. On a broader scope, the studies showed a wide variety of educational domains and fields of expertise to which VR was applied. While approximately a quarter of studies reviewed (25.9%) reported use of VRCL for education, specific domains that were often discussed included computer science, robotics, ICT and informatics (12.2%), social sciences (11.5%) medical fields (9.4%) and engineering (8.6%).

Also shown in Table 1 is the appearance of different types of social learning: 62.6% of studies reviewed discussed synchronous (collaborative) interaction, while in comparison a much lower 18.0% discussed asynchronous (cooperative) interaction. For a 10th of the studies, an expert-novice type of social learning was apparent (9.4%). On the topic of educational approaches and learning paradigms, 29.5% of articles did not seem to discuss any specific approaches. Among those that did, constructivism and PBL were featured substantially (33.1% and 41.0%, respectively), while paradigms such as experientialism, situated learning and distributed cognition were discussed less frequently. Other educational approaches, discussed in 35.3% of articles, included self-regulation and shared regulation (e.g., Al-Hatem et al., 2018 ) as well as cognitive apprenticeship (e.g., Bouta and Retalis, 2013 ). Looking at the learning goals and outcomes, the cognitive domain proved to be popular (50.4%), whereas affective and psychomotor domains were featured much less (7.9% and 5.0%, respectively). Other goals and outcomes included general student engagement (discussed in 31.7%) and support of collaboration amongst learners (60.4%).

The second dimension took a closer look at systems used in the studies, including aspects related to the hardware used (e.g., devices, types of control) as well as users’ interaction with VEs (e.g., degree of virtuality, virtual embodiment). A majority of the studies reviewed did not use VR technologies such as HMD-based VR (HMD VR), but instead focused on monitors and displays when discussing VRCL. Most studies chose general purpose controls (e.g., mouse and keyboard) over more advanced hardware such as positional tracking. A majority of studies provided their participants with full-body embodiment (e.g., avatars) and the ability to manipulate virtual objects while inside the VEs. Approximately a quarter of studies used systems for edutainment purposes (i.e., learning by having fun), while system use for training or therapeutic purposes was less common. Table 2 shows these results in detail.

TABLE 2 . Distribution of System-related attributes.

Results showed a clear preference for 3D (non-HMD) simulations, i.e., a virtual simulation of a (physical) environment projected on a surface or display that is not a Head-Mounted Display (and, as such, is considered less immersive): this degree of virtuality was far more prominent in the reviewed studies (78.4%) compared to the lesser implemented AR/MR (16.5%) and HMD VR (7.2%). The hardware used in these studies reflected this: a large amount (89.2%) implemented flat-surface monitors and displays to present VRCL environments. These studies commonly used desktop computer set-ups that included a keyboard, mouse and monitor, though in the case of AR and MR, surface-based mobile devices were often used. When using the system in a larger setting (i.e., larger group size), studies utilized projector-based (but still flat) surfaces to display the VE (e.g., Bower et al., 2017 ). In some cases, several types of these flat-surface displays were being used in different phases of a study (e.g., Nuñez et al., 2008 ). Cases that used CAVE systems (3.6%) included ImmersaDesks, CAVE-like devices that derive from the original CAVE systems. Studies that involved HMD VR used devices like the Oculus Rift and HTC Vive, while studies revolving around AR and MR implemented devices like the HoloLens. Some studies involved multiple devices to compare effects based on the difference (e.g., monitor-based vs HMD VR, as discussed in Vallance et al., 2015 ) while others discussed implementation of HMD VR and AR-related devices as possible future directions without using these in their experiments. With regard to user interaction, studies that implemented general purpose controls used simple computer keyboard and mouse, though some cases also involved video game controllers such as the Nintendo Wiimote and Nunchuck ( Li et al., 2012 ). Apart from the more default specialized controls such as 3DoF and 6DoF controllers or mobile device-based touch screens, studies also discussed a wide variety of other tools in this category, including multi-touch tabletops, haptic feedback devices, Xbox Kinect and gesture-sensing data gloves. While scarce, gaze control and positional tracking (15.1% and 11.5%, respectively) was primarily found in studies that used (mobile-based) AR and HMD VR, though some studies also provided these through devices such as the HoloLens or as part of a CAVE system.

Of the studies examined for this review, 55.4% discussed (self-developed) prototypes, while 44.6% used (pre-existing) applications. The most prominently-mentioned engine for prototypes was Unity, with % (of 77 studies) using it. Concerning the ones that used applications (62 of 139), more than half discussed VE application Second Life (%), while open-source VEs OpenSimulator and Open Wonderland were used in smaller numbers (% and %, respectively). In regard to the intended function of systems used, the majority of articles described a strictly educational one (58.3%) and revolved around implementing these systems in educational contexts as well as using them to facilitate collaborative learning. Studies that used systems to both educate and entertain (22.3%) tended to focus on game-based learning and serious games, though some cases also discussed video games originally not intended for educational purposes (e.g., World of Warcraft ( Kong and Kwok, 2013 ), Minecraft ( Mørch et al., 2019 )). When training purposes were mentioned (17.3%), this often indicated the use of VEs to train specific expertises, such as liver surgery or aircraft inspection. Rare cases where a system was used for therapeutic purposes (just 2.2%) included use of VRCL to teach social skills to patients with autism ( Ke and Lee, 2016 ) or to train physical activities amongst elderly ( Arlati et al., 2019 ).

Motivation behind studies’ choices for the size of collaboration differed between experimental reasons (e.g., a limited number of participants), pedagogical reasons (e.g., using pairs to better stimulate personal social interaction between members compared to larger groups) and reasons related to the systems (e.g., limited hardware availability). Small groups proved to be the most used group size, with 37.4% describing groups of between three and nine members. Pairs were used in 22.3% of studies. Motivations behind pairs included focus on expert-novice interaction and system capabilities (e.g., support for two users maximum). Articles that described larger groups (ten or more members) generally had entire classes of learners interact with system (15.1%).

Apart from a small number of studies that did not provide sufficient information on the matter, virtual embodiment of the users was featured prominently. In cases where physical attributes were virtually represented by (imagery of) tools (18.0%), the VRCL environment was often implemented for specific training of certain expertises. In general, partial virtual embodiment appears in first person, HMD VR (for example, when only the user’s hands are made visible); while scarce (3.6%), studies that displayed partial virtual embodiment provided some interesting examples outside of HMD VR. Examples of partial embodiment included a detailed 3D face to focus on emotional and social expressions ( Cheng and Ye, 2010 ) and using controllable, flat-surfaced rectangles in a 3D environment on which users’ real-life faces were projected via webcam ( Nikolic and Nicholls, 2018 ). Full-body embodiment proved to be the most popular, with 67.6% of studies using systems that provide users complete (full-body) virtual representation. To a degree, the relatively high number of studies that present full-body embodiment can be explained by the systems that were implemented; applications such as Open Simulator and Second Life provide users with customizable avatars, making a full-body virtual embodiment a default feature. In some cases, however, studies specifically examined the effects of virtual embodiment, such as Gerhard et al. (2001) examining possible influences of different avatars on users’ sense of presence. On the topic of user influence on VEs, a little more than half the studies (53.2%) used systems that allowed (some degree of) virtual object manipulation, whereas approximately a quarter of the studies (26.6%) also provided users the tools to manipulate actual content of the VRCL environment. In 16.5% of studies, the system only allowed users to be visibly present inside the VE, while only 3.6% did not provide sufficient information on the matter.

3.3 Evaluation

For the third dimension, the selected articles were analyzed on how they evaluated applying VRCL. Articles frequently concentrated on evaluation of the system(s), with a higher number of them using self-report evaluation methods. Study design of the studies shows a similar result: pre-experimental study design (typically used for preliminary testing of systems) was regularly implemented, with surveys being a popular method of collecting data. While the number of participants was diverse, roughly half of studies reviewed used a sample size between 1 and 25 participants. The majority of articles discussed positive outcomes, whereas only a small amount featured negative results. Detailed results are displayed in Table 3 .

TABLE 3 . Distribution of Evaluation-related attributes.

The majority of studies focused on evaluating a system’s effectiveness when using it in educational settings (71.2%). These studies concentrated on the system’s capacity to support collaboration between learners. Other topics of discussion were student interest in the system and how the system can facilitate learning. Whenever studies examined processes (34.5%), evaluation would be centered around attempts to understand how group interaction materializes in these environments. This included how learners resolve social conflicts ( Cheong et al., 2015 ) and examining how co-presence (e.g., Kong and Kwok, 2013 ) and PBL take shape in VRCL environments. 35.3% of articles discussed learning outcomes after participants interacted with the system. The few situations where the above three attributes did not apply (3.6%) included a study that aimed to develop design guidelines ( Economou et al., 2001 ) and a study primarily interested in the teacher’s role when learners interact with VEs ( Lattemann and Stieglitz, 2012 ).

Most studies collected self-reported data from their participants (85.6%), while over half used behavioral methods to obtain tracking and observational data (59.0%). Articles that reported on knowledge- and/or performance-based assessments (20.9% of studies) often used pre- and post-tests to acquire their data, while only one appeared to use physiological data, tracking participants’ heart rate (0.7%). A notable number of articles (79.9%) implemented pre-experimental design in their studies. Some of these were case studies, applying VEs to educational settings (e.g., Terzidou et al., 2012 ), while others performed pilot studies to establish a first impression of the effects of a system on specific pedagogical situations (e.g., examining how VE-based application OpenSimulator influences Transactive Memory Systems amongst learners ( Kleanthous et al., 2016 )). Quasi-experimental- (13.7%) and true experimental designs (5.8%) were used scarcely, while only 2 out of 139 studies (1.4%) performed an experiment with single-subject design. With respect to non-experimental and descriptive designs, 84.9% of studies implemented a survey-based design, whereas a little over half used observational designs to collect data (56.1%). In some cases, comparative and correlation designs were implemented (7.9% and 15.8%, respectively).

Table 3 also reveals that approximately half of the studies sampled between 1 and 25 participants (53.2%), while around a quarter (26.6%) used a sample size between 26 and 50 participants. For 13.7% of articles, between 51 and 100 participants were used, whereas only 6.5% discussed using more than 100 participants for collecting data. In terms of outcomes, around half of the studies concluded that their system(s) seemed positive and promising (53.2%), while 17.3% draw positive conclusions based on significant outcomes from statistical hypothesis testing. Negative outcomes were scarce, with only 2.2% of the studies reporting negative results. Mixed outcomes were reported for 7.2% of the studies, whereas 20.1% discussed results that were inconclusive, showed no effect or reported outcomes on which positive and negative effects are not applicable.

4 Qualitative results

In general, the literature reviewed for this paper shows a positive attitude towards the use of VR to support and enhance CL. However, the results quickly make it apparent that the methods of applying VR to educational fields to support and enhance CL can vary greatly amongst the studies examined here. In order to acquire a general understanding how these studies have attempted to support and enhance CL using VR, this section will discuss qualitative results established. The rest of this section will be divided into sub-sections, each focusing on discussing results related to one of the four research questions of this literature review.

4.1 Skills and competences trained with VRCL

A number of elements can be identified regarding skills and competences trained with VRCL. Based on the skills and competences discussed in the reviewed literature, five categories were established for this study with the intention to provide a concise overview. These categories, including examples of each category, can be viewed in Table 4 .

TABLE 4 . Skills focused on in the reviewed literature.

For the types of skills and competences shown in Table 4 to be trained effectively, a VRCL environment requires a number of features that support the learners in learning these abilities. Based on the information provided by the reviewed literature, nine required features and design parameters of VRCL can be identified. First, virtual embodiment plays an important role in how learners view themselves and each other inside the VE, impacting learning outcomes and collaborative behavior by providing a sense of awareness and belonging ( Edirisingha et al., 2009 ; McArdle and Bertolotto, 2012 ). Second, efficient communicational tools are essential for effective collaboration: verbal (audio) communication is crucial ( Economou et al., 2001 ; De Pace et al., 2019 ), though additional modalities such as haptic technology can further enhance collaboration ( Moll and Pysander, 2013 ). Third, usability and accessibility should be taken into consideration: VRCL systems should be accessible to all levels of technical skills as differences negatively affect group cohesion and learning between group members (Y. Chang et al., 2016 ; Denoyelles and Kyeong-Ju Seo, 2012 ). Fourth, learners’ perceived usefulness of the VE also affects group cohesion; factors such as awareness, presence and social presence appear to significantly influence this perceived usefulness ( Denoyelles and Kyeong-Ju Seo, 2012 ; Yeh et al., 2012 ). Fifth, the ability to interact with elements inside the VE are considered key: to optimize learning outcomes, learners must have the option to manipulate elements inside the VE (e.g., virtual objects or virtual tools) in a seemingly natural and intuitive way ( Vrellis et al., 2010 ; Bower et al., 2017 ). Sixth, academic efficacy can be achieved if tasks inside the VE are designed around its educational, collaborative objectives, especially when designed for equal input from all learners in a group ( Wang et al., 2014 ; Nisiotis and Kleanthous, 2019 ). Seventh, educators should be ready to provide support, motivation and moderation of collaboration while learners interact inside the VE ( Lattemann and Stieglitz, 2012 ; Bower et al., 2017 ). However, the eighth feature, a level of autonomy, is equally important for each individual learner, not just in terms of independence from the educators, but more importantly from each other, as this allows them to provide different points of views as well as to explore multiple representations, thus improving CL ( Hwang and Hu, 2013 ). Ninth, implementation of VRCL should make sure to primarily support socialization inside the VE, as underestimating the importance of socialization might lead to features of VR obstructing rather than facilitating CL ( Chang et al., 2009 ).

Surprisingly, only a small number of the literature reviewed focused on goals related to the affective domain (7.9%). With some calling VR the “ultimate empathy machine” ( Rueda and Lara, 2020 , p.6), the medium’s ability to induce emotions has been prominently discussed and studied. Not only has VR been shown to indeed be capable of enhancing empathy amongst users ( Herrera et al., 2018 ), with some even arguing it to be more effective than traditional empathy-shaping methods ( Liu, 2020 ), studies have also suggested it to be an effective tool to offer a uniquely different level of understanding ( de la Peña et al., 2010 ). This would suggest that VR’s ability to create a better understanding of different group members’ points of view could in turn support collaboration between learners.

Similarly, even less literature reviewed focused on goals related to the psychomotor domain (5.0%). Prior studies have been positive and hopeful regarding VR to expand the possibilities of physical training ( Pastel et al., 2020 ). Interestingly, technical features such as positional tracking even seem to be effective in predicting psychomotor outcomes ( Moore et al., 2021 ), which could prove useful for domains that specifically focus on expert-novice training in primarily physical tasks (e.g., certain types of engineering). However, positional tracking, not unlike psychomotor outcomes, is only discussed sparingly (11.5%) in the literature reviewed.

An interesting observation in relation to the evaluation methods used in the scientific literature is that only 1 out of 139 articles used physiological measures. As suggested by research, physiological synchrony between group members can serve as an effective indicator for the quality of interpersonal interaction between them (with a higher physiological synchrony correlating with a higher interaction level) ( Liu et al., 2021 ). Furthermore, physiological measurements can be used to identify multiple predictors related to education and training, including the quality of collaboration between group members ( Dich et al., 2018 ). Additionally, visualizing physiological results of each member of a group to the others in real-time during collaboration has shown to have a positive effect on the empathy levels and cohesion of the group, further suggesting how collaboration between learners could benefit from physiological measures ( Tan et al., 2014 ). Considering VR’s visual characteristics as well as research arguing that physical signals such as electroencephalogram (EEG) can conveniently and unobtrusively be tracked during use of HMD VR ( Tremmel et al., 2019 ), future research on VRCL could prove fruitful in terms of training collaborative skills and competences via use of physiological-based information.

4.2 Disciplines focused on regarding VRCL

When looking at the most prominently-featured domains in the literature reviewed (as shown in Figure 4 ), examining what motivated researchers to study VRCL in the field of 1) education, 2) computer science, robotics and informatics and 3) social sciences can provide an understanding of VRCL’s role in these different disciplines.

FIGURE 4 . Results of the educational disciplines focused on in the reviewed literature.

For the field of education, some studies focus on the potential behind VRCL, intending to discover what it can mean for the development of cognitive and technical skills ( Franco and De Deus Lopes, 2009 ). Other studies focus on possible learning gains, examining how knowledge gained in VEs transfers to the real world (i.e., how learners apply outcomes in VEs to situations in actual reality) or attempting to facilitate this transfer by implementing elements of both ( Carron et al., 2013 ). In certain cases, articles specifically examine VEs’ effects on collaboration and how VR can be used to reinforce CL (e.g., Tüzün et al., 2019 ), whereas others aim to determine if existing educational paradigms such as constructivism can be applied to VRCL environments and, if so, how that affects group knowledge gain between learners ( Girvan and Savage, 2010 ). Together, these studies present a general motivation to discover what VRCL can mean for education and where its potential may lie.

For computer science, robotics and informatics, use of VRCL can be summarized in two motivations: 1) innovate these domains and 2) create a learning community. In the first case, researchers intend to utilize the affordances VRCL environments have to offer to further advance fields such as computer science, which have been criticized in the past for using two-dimensional learning platforms and oral-based teaching methods ( Pellas, 2014 ). With VEs, educators can provide learners realistic yet illusionary worlds that are flexible, customizable and even allow for detailed statistics on learners’ performance ( Champsas et al., 2012 ). In the second case, reviewed articles vocalize a desire to use VRCL to provide learners purposeful collaborative activities that create a sense of belonging to a learning community, using aspects such as awareness, presence and different methods of communication to motivate learners in these fields to work together closely ( De Lucia et al., 2009 ).

In similar fashion, social studies appears to be interested in how socialization between learners is manifested inside VRCL (e.g., Edirisingha et al., 2009 ). Some articles go further, studying how VRCL can support socialization: Molka-Danielsen and Brask (2014) suggest that presence, awareness and belonging allow for communication, negotiation and trust between learners, elements deemed necessary for completing collaborative tasks. Other studies focus on specific characteristics of socialization, such as how gender could affect social interaction and group cohesion inside VEs ( Denoyelles and Kyeong-Ju Seo, 2012 ). Collectively, these articles show a desire to understand how elements related to socialization transfer to VRCL, as well as how these environments can sustain and even enhance those elements.

4.3 Systems developed and/or established for VRCL

The results related to systems used show that there is quite a disparity between use of HMD VR and that of non-HMD VR. Almost 80% of systems implemented non-HMD VR, with AR/MR and HMD VR implemented far less frequently (16.5% and 7.2%, respectively, as illustrated in Figure 5 ). Almost 90% of studies described the use of flat-surface monitors and displays, which, when compared to the 10.8% of studies that used HMD devices, further highlights the low use of HMD VR in the literature reviewed (see Figure 6 ).

FIGURE 5 . Results of the degree of virtuality of systems discussed in the reviewed literature.

FIGURE 6 . Results of the hardware used in the reviewed literature.

The lack of representation of HMD VR in these articles is somewhat surprising, considering this type of virtuality and hardware is commonly associated with the medium of VR ( Dixon, 2006 ; Bonner and Reinders, 2018 ; Jing et al., 2018 ). The statement that research into application of VR to the field of education lacks a focus on HMD VR, however, is not uncommon ( Sousa Santos et al., 2009 ; Scavarelli et al., 2021 ), thus begging the question: why is it underrepresented in the reviewed literature?

One possible explanation could be that HMD VR is known to be difficult to apply to educational settings because of its high costs ( Olmos et al., 2018 ). Some of the articles analyzed for this review were published in the late 90s; while HMD VR technology was already available in those times, devices were more expensive and less technologically advanced compared to the technology that is available now ( Mehrfard et al., 2019 ; Wang et al., 2022 ). Furthermore, the technical skills necessary to implement VR properly in educational settings can prove challenging ( Jensen and Konradsen, 2018 ). Since collaboration involves multiple people, difficulties related to accessibility could be more severe when applying VR to a larger group of learners. Another possible reason is the health risks associated with the technology: HMD VR is often connected to motion sickness and cybersickness ( Olmos et al., 2018 ; Yoon et al., 2020 ). A third reason refers to the general lack of pedagogy on the topic of HMD VR: while the medium’s potential for education is often discussed, general guidelines as to how it should be applied efficiently to educational settings ( Cook et al., 2019 ; Zheng et al., 2019 ) as well as an understanding of how learning mechanisms operate inside VR environments ( Smith, 2019 ) are missing. Naturally, the small size of research done on VR and CL exacerbates this lack even further when specifically discussing VRCL. A possible fourth reason that is more closely tied to this particular literature review is that, despite its popularity in research, HMD VR appears to still lack empirical evidence of its educational value ( Sousa Santos et al., 2009 ; Makransky et al., 2019 ; Radianti et al., 2020 ), which, considering this review’s focus on empirically-based knowledge, could explain its scarcity.

The low representation of HMD VR and high representation of non-HMD VR could be related to the ongoing discussion about what defines VR and how it differs from VEs, as discussed in-depth by Girvan, (2018) . Girvan argues that some use terms synonymously with VR and/or VEs, while others use these same terms to classify different types of VEs, thus creating a fragmented understanding of what these are (and what they are not). Girvan’s point is reflected in the reviewed literature of this paper: while some studies identify Second Life as a “virtual environment” or “virtual world” (e.g., Terzidou et al., 2012 ), others refer to it as “virtual reality” (e.g., Sulbaran and Jones, 2012 ). To prevent further confusion with technologies with similar technical features, Girvan suggests to conceptualize VEs as ‘shared, simulated spaces which are inhabited and shaped by their inhabitants, who are represented as avatars [that] mediate our experience of this space as (…) we interact with others, with whom we construct a shared understanding of the world at that time’. VR, then, should be defined as ‘a technical system through which a user or multiple users can experience [such] a simulated environment’ ( Girvan, 2018 ).

Apart from causing a fragmented understanding of the terms in the literature, different interpretations of VR and VEs also lead to HMD VR and non-HMD VR being described as one and the same thing under the moniker of “virtual reality”. Though this may seem a trivial dispute about labels, treating these two types as identical will lead to misconceptions regarding both, as HMD and non-HMD VR contain different benefits and limitations when applied to education. While some studies showed no differences between the two in terms of specific learning outcomes (e.g., spatial- ( Srivastava et al., 2019 ) and language learning (J. Y. Jeong et al., 2018 )), other research highlighted several differences between HMD and non-HMD. Compared to non-HMD, HMD VR has shown to provide a much higher sense of embodiment, which in turn is hypothesized to lead to higher performances, in particular in psychomotor skills ( Juliano et al., 2020 ; Saldana et al., 2020 ). Similarly, HMD VR appeared superior to computer screens in terms of arousal, engagement and motivation in learners ( Makransky and Lilleholt, 2018 ). In contrast, however, Makransky et al. (2019) reported overloads and distractions caused by HMD VR, leading to poorer learning outcomes compared to non-HMD, a sentiment shared by Parong and Mayer (2021) , who described HMD VR to cause high affective and cognitive distractions. Amati and McNeill (2012) even argue that the difference between HMD and non-HMD VR (and in particular how the two are interacted with by users) have severe implications for teaching and practice.

With all of the above in mind, the low representation of HMD VR in the literature examined for this review can be interpreted in two ways. On the one hand, the underutilization underlines that HMD VR is not being used to its full potential and could very well hold much more promise for the field of education and CL. On the other hand, the low use of HMD VR could suggest that implementation of HMD VR in education and/or CL is, in fact, not worth the trouble it brings with it. Whether HMD VR is a benefit or a burden, then, arguably depends on three important elements: 1) the goals (i.e., what skills and/or competences are supposed to be trained), 2) the setting (i.e., the disciplines and fields to which it is applied), and 3) the affordances of VRCL (and to what degree these conform to the goals and setting).

4.4 Empirical knowledge established regarding VRCL

When summarizing the outcomes of the 139 articles, 70% of the studies reviewed displayed a positive attitude towards the application of VRCL to education. While a relatively low number (approximately 25%) presented statistically significant outcomes, this does illustrate a strong optimism amongst those studying VRCL environments in different fields of education as described in prior literature reviews on the topic. This could also explain the high number of studies that deployed pre-experimental study designs: with VRCL being a relatively new addition to the world of CSCL, as well as one that continues to rapidly advance because of the technology behind it, many seem enthusiastic and eager to see what promises VRCL holds when used in different fields and with different types of learners.

Regarding affordances discussed in the reviewed literature, several features are identified. First, VRCL appears an efficient tool to engage learners and to motivate them to study and learn. The ability to customize VRCL environments and their content provides learners more personalized experiences that better suit their personalities and attitudes, thereby enhancing the motivation to learn on both an individual and group level ( Arlati et al., 2019 ). Furthermore, VRCL’s immersive qualities tend to make the experiences more engaging for learners, encouraging them to engage in presentations and demonstrations as well as to communicate and collaborate with each other ( Avanzato, 2018 ).

The second affordance identified VRCL as a great tool for distance learning and remote collaboration. VEs provide a method for learners and educators to work together and collaborate despite distances. In comparison to other media, however, VRCL brings with it a high sense of immediacy (i.e., ‘verbal and non-verbal behaviors that give a sense of reduction of physical and psychological distance between the communicators’), which in turn presents an increased perception of learning ( Edirisingha et al., 2009 ). Additionally, VRCL’s immersive qualities and high presence allow for environments capable of simulating training as preparation for real-life experiences ( Al-Hatem et al., 2018 ) that simultaneously promote active participation and social interaction ( Mystakidis et al., 2017 ) in a setting that feels personal despite distances between learners ( Desai et al., 2017 ). In certain cases, such as education for learners with physical disabilities, learners and educators even considered connectivity to be more accessible and easier than real-life equivalents ( Aydogan and Aras, 2019 ), illustrating that VRCL environments can potentially go beyond simply being a replacement. To effectively support the distance learning and remote collaboration, however, design of the VEs should focus on providing learners a sense of 1) presence, 2) awareness and 3) belonging to the group ( Molka-Danielsen and Brask, 2014 ).

Thirdly, the literature reviewed suggests that VRCL environments are effective spaces to support multi- and interdisciplinary learning and collaboration. The ability to customize VEs, adapting to suit users’ needs, prevents them from being restricted to just a single specific subject field. This in turn allows educators to change the environments to accommodate many different subject fields and topics so as to make sure that learners from different backgrounds can collaborate with each other undisturbed ( Bilyatdinova et al., 2016 ). Moreover, it seems that VRCL environments made some of the literature studies reviewed realize the importance of interdisciplinary collaboration in the learning process ( Franco et al., 2006 ; Nadolny et al., 2013 ).

The fourth affordance identified might be an unsurprising but nonetheless important one: VRCL seems to be a tool for the development of social skills. While identity construction and projection through virtual embodiments can be complex for learners (depending on their technical skills), VRCL is found to facilitate social presence and foster socialization ( Edirisingha et al., 2009 ). VRCL’s customizability allows learners to integrate personal preferences and identity expressions into processes inside the environment (e.g., through their virtual embodiments), in turn mediating identity and norm construction for real-life social settings ( Ke and Lee, 2016 ). Vital social skills, such as the ability to identify and manipulate basic emotional states, can be taught and trained using VEs, improving learners’ socialization, communication skills and emotional intelligence ( López-Faican and Jaen, 2020 ). Learners’ prior experience with VEs, however, should not be underestimated, as a difference in familiarity with VRCL environments has been shown to impact collaboration ( Bluemink et al., 2010 ).

Fifth, VEs appear fitting for CL-related learning paradigms and educational approaches. Some studies specifically focus on examining to what degree VRCL environments are applicable to paradigms such as constructivism, socio-constructivism and constructionism (e.g., Girvan and Savage, 2010 ; Pellas et al., 2013 ; Abdullah et al., 2019 ), concluding that these indeed go well together. Other studies, however, focus on theories and methods commonly associated with these paradigms. In particular, experiential learning and PBL seem appropriate for VRCL environments. VEs allow for safe, consequence-free learning for exploring, experiencing and practicing without any real-life risks ( Cheong et al., 2015 ; Le et al., 2015 ), making it suitable for experiential learning. Moreover, VRCL’s immersive qualities seem to support and even elevate experiential learning strategies such as roleplay and improvisation, providing learners close to real-world experiences in a controlled environment ( Jarmon et al., 2008 ; Ashley et al., 2014 ). In the case of PBL, each individual learner can use different tools inside VRCL environments to illustrate and represent ideas and suggestions to the rest of the group. Considering that VEs seem great tools for conceptual learning because of their customizability and visual nature ( Brna and Aspin, 1998 ; Griol et al., 2014 ), learners can use these features to explain their point of view in ways that they otherwise could not. As a result, learners appear to become more active and effective in sharing ideas, joint problem solving and the co-construction of mental models when working in groups inside VRCL environments ( Rogers, 2011 ; Hwang and Hu, 2013 ).

Returning to the topic of disparity between HMD and non-HMD VR represented in the reviewed literature, as well as both being discussed as one and the same “Virtual Reality”, an important question to ask is whether the affordances identified here are transferable between the two. HMD and non-HMD VR differ in several ways: they are interacted with differently, face different obstacles when applied to education and appear to have different learning outcomes based on different educational settings.

With the definitions of VEs and VR as given by Girvan (2018) as a frame of reference, however, an answer can be given regarding the transferability of these affordances between HMD and non-HMD VR. Both HMD and non-HMD VR should be considered tools, technical systems through which users can virtually enter VEs, i.e., shared simulated spaces in which they can interact with the environment as well as each other. As such, the affordances described in this paper do not revolve around the tools used, but that which they provide access to: the VRCL environments. Simultaneously, which tool is used to access these VRCL environments can in turn affect both the interaction and the outcome of users’ experiences with VEs. For example, HMD VR might offer more effective development of social skills compared to non-HMD VR, considering the former provides a higher sense of embodiment and, in extension, more intuitive and expansive methods of expression. If, however, cognitive learning outcomes are the most important educational objective, non-HMD VR could be a better option, considering HMD VR’s tendency to cause affective and cognitive distractions. This, then, reflects the aforementioned statement regarding HMD VR being a benefit or a burden. While affordances of VRCL environments apply to both HMD and non-HMD VR, the effect of these affordances depend on 1) the goals, 2) the setting and 3) which affordances of VRCL are most vital to the first two elements. As such, the choice between non-HMD VR and HMD VR should be made depending on those three elements.

5 Conclusion and future research

With current research on the topic being scarce while the demand for remote collaboration and distance learning keeps increasing, this literature review intends to study how VR has been (and can be) used to support and enhance CL. To achieve this, it attempts to answer four research questions regarding prior research on VRCL: what skills and competences have been trained with VRCL and what does VRCL provide in these scenarios? To what educational domains has VRCL been applied and why? What systems have been used for VRCL? And what empirical knowledge has been established regarding VRCL?

This paper identifies five types of skills and competences commonly trained with the use of VRCL. Furthermore, a number of features and design principles are identified in terms of what these environments should offer for these skills to be developed. Educational fields and domains appear to be interested in VRCL because of a desire to innovate, to form communities, to support remote collaboration and to enhance socialization skills of learners. In terms of technology, systems used for VRCL-related purposes appear to predominantly focus on monitor-based (non-HMD) VR and mouse-and-keyboard controls, contrasting what VR is commonly associated with (e.g., HMD VR, specialized controls involving gaze control and positional tracking). This study perceives a general optimism present in the literature reviewed regarding the use of VR to support and enhance CL in learners. Additionally, a number of affordances of VRCL are described, though it is of importance to note that these affordances could differ in strength depending on which type of VR (i.e., non-HMD or HMD) is used.

While the literature on VRCL reviewed for this paper is diverse, it suggests that Virtual Reality can be an effective tool for supporting and enhancing Collaborative Learning. This diversity, however, also highlights that pedagogies of VRCL are lacking, with studies showing many different and contrasting approaches to applying VR to their respective fields for the support of CL. In order to see VR become more adopted as an educational tool for collaborative purposes, pedagogies should be clearly structured, highlighting similarities and differences in regards to both the technologies used and the domains they are used in. As such, this paper proposes a number of suggestions for future research. First, the difference between hardware used in the literature reviewed and the state-of-the-art of VR suggests that further examination of differences between non-HMD and HMD VRCL, both in terms of affordances as well as challenges and obstacles, could lead to a better understanding of VRCL’s potential. Second, despite the advantages VR has for development in affective and psychomotor skills, the scientific literature on VRCL shows only minor focus on these domains. This study argues that CL would benefit from both these domains being featured more prominently and as such encourages more research into these matters. Third, this paper suggests that research into VRCL focuses on using study designs and evaluation methods that are less frequently (or barely) featured in the reviewed literature. While the repeated and dominant use of pre-experimental study design is understandably meant to identify the potential behind the technology, the domain of VRCL (and, in extension, research on VR in education) would benefit from more true experimental design. Additionally, considering that the use of physiological data for evaluation methods appears to be unexplored terrain, this paper suggests that future research into VRCL implements these types of methods.

Author contributions

NvM: Main author VvW: Co-author and coder W-PB: Co-author and supervisor MS: Co-author and supervisor. All authors contributed to the article and approved the submitted version.

This project has been funded by the Leiden-Delft-Erasmus Centre for Education and Learning (LDE-CEL).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/frvir.2023.1159905/full#supplementary-material

Supplementary Appendix A | List of all articles included.

Supplementary Appendix B1 | Results of agreement between first author and five additional coders on in- and exclusion criteria.

Supplementary Appendix C | Explanation/motivation behind Taxonomy.

Supplementary Appendix D1 | Results of agreement between first author and coder on use of taxonomy’s first category (Education).

Supplementary Appendix D2 | Results of agreement between first author and coder on use of taxonomy’s second category (System).

Supplementary Appendix D3 | Results of agreement between first author and coder on use of taxonomy’s third category (Evaluation).

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Keywords: virtual reality, collaborative learning, virtual reality education, collaborative virtual environment, virtual reality and collaborative learning, collaborative virtual reality, collaborative virtual reality systems, educational technologies

Citation: van der Meer N, van der Werf V, Brinkman W-P and Specht M (2023) Virtual reality and collaborative learning: a systematic literature review. Front. Virtual Real. 4:1159905. doi: 10.3389/frvir.2023.1159905

Received: 06 February 2023; Accepted: 02 May 2023; Published: 19 May 2023.

Reviewed by:

Copyright © 2023 van der Meer, van der Werf, Brinkman and Specht. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nesse van der Meer, [email protected]

A Systematic Literature Review of Virtual Reality Locomotion Taxonomies

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Surgical planning in virtual reality: a systematic review

Affiliations.

• 1 Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, Berlin, Germany.
• 2 Humboldt Universität zu Berlin, Cluster of Excellence Matters of Activity, Berlin, Germany.
• PMID: 38680654
• PMCID: PMC11043584 (available on 2025-04-25 )
• DOI: 10.1117/1.JMI.11.6.062603

Purpose: Virtual reality (VR) technology has emerged as a promising tool for physicians, offering the ability to assess anatomical data in 3D with visuospatial interaction qualities. The last decade has witnessed a remarkable increase in the number of studies focusing on the application of VR to assess patient-specific image data. This systematic review aims to provide an up-to-date overview of the latest research on VR in the field of surgical planning.

Approach: A comprehensive literature search was conducted based on the preferred reporting items for systematic reviews and meta-analyses covering the period from April 1, 2021 to May 10, 2023. It includes research articles reporting on preoperative surgical planning using patient-specific medical images in virtual reality using head-mounted displays. The review summarizes the current state of research in this field, identifying key findings, technologies, study designs, methods, and potential directions for future research.

Results: The selected studies show a positive impact on surgical decision-making and anatomy understanding compared to other visualization modalities. A substantial number of studies are reporting anecdotal evidence and case-specific outcomes. Notably, surgical planning using VR led to more frequent changes in surgical plans compared to planning with other visualization methods when surgeons reassessed their initial plans. VR demonstrated benefits in reducing planning time and improving spatial localization of pathologies.

Conclusions: Results show that the application of VR for surgical planning is still in an experimental stage but is gradually advancing toward clinical use. The diverse study designs, methodologies, and varying reporting hinder a comprehensive analysis. Some findings lack statistical evidence and rely on subjective assumptions. To strengthen evaluation, future research should focus on refining study designs, improving technical reporting, defining visual and technical proficiency requirements, and enhancing VR software usability and design. Addressing these areas could pave the way for an effective implementation of VR in clinical settings.

Keywords: planning; surgery; systematic review; virtual reality.

© 2024 The Authors.

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• Volume 33, Issue 5
• Equitable and accessible informed healthcare consent process for people with intellectual disability: a systematic literature review
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• http://orcid.org/0000-0002-8498-7329 Manjekah Dunn 1 , 2 ,
• Iva Strnadová 3 , 4 , 5 ,
• Jackie Leach Scully 4 ,
• Jennifer Hansen 3 ,
• Julie Loblinzk 3 , 5 ,
• Skie Sarfaraz 5 ,
• Chloe Molnar 1 ,
• Elizabeth Emma Palmer 1 , 2
• 1 Faculty of Medicine & Health , University of New South Wales , Sydney , New South Wales , Australia
• 2 The Sydney Children's Hospitals Network , Sydney , New South Wales , Australia
• 3 School of Education , University of New South Wales , Sydney , New South Wales , Australia
• 4 Disability Innovation Institute , University of New South Wales , Sydney , New South Wales , Australia
• 5 Self Advocacy Sydney , Sydney , New South Wales , Australia
• Correspondence to Dr Manjekah Dunn, Paediatrics & Child Health, University of New South Wales Medicine & Health, Sydney, New South Wales, Australia; manjekah.dunn{at}unsw.edu.au

Objective To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible.

Data sources Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand-searching three journals.

Eligibility criteria Peer-reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability.

Synthesis of results Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co-researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created.

Results Twenty-three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed-methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals’ attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person-centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3).

Conclusions Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals’ attitudes and lack of education in informed consent with clinician training, the co-production of accessible information resources and further inclusive research into informed consent for people with intellectual disability.

PROSPERO registration CRD42021290548.

• Decision making
• Healthcare quality improvement
• Patient-centred care
• Quality improvement
• Standards of care

Data availability statement

Data are available upon reasonable request. Additional data and materials such as data collection forms, data extraction and analysis templates and QualSyst assessment data can be obtained by contacting the corresponding author.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjqs-2023-016113

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What is already known on this topic

People with intellectual disability are frequently excluded from decision-making processes and not provided equal opportunity for informed consent, despite protections outlined in the United Nations Convention on the Rights of Persons with Disabilities.

People with intellectual disability have the capacity and desire to make informed medical decisions, which can improve their well-being, health satisfaction and health outcomes.

What this review study adds

Health professionals lack adequate training in valid informed consent and making reasonable adjustments for people with intellectual disability, and continue to perpetuate assumptions of incapacity.

Health information provided to people with intellectual disability is often inaccessible and insufficient for them to make informed decisions about healthcare.

The role of support people, systemic constraints, a person-centred approach and ineffective healthcare communication also affect informed consent.

How this review might affect research, practice or policy

Health professionals need additional training on how to provide a valid informed consent process for people with intellectual disability, specifically in using accessible health information, making reasonable adjustments (e.g., longer/multiple appointments, options of a support person attending or not, using plain English), involving the individual in discussions, and communicating effectively with them.

Inclusive research is needed to hear the voices and opinions of people with intellectual disability about healthcare decision-making and about informed consent practices in specific healthcare settings.

Introduction

Approximately 1% of the world’s population have intellectual disability. 1 Intellectual disability is medically defined as a group of neurodevelopmental conditions beginning in childhood, with below average cognitive functioning and adaptive behaviour, including limitations in conceptual, social and practical skills. 2 People with intellectual disability prefer an alternative strength-based definition, reflected in the comment by Robert Strike OAM (Order of Australia Medal): ‘We can learn if the way of teaching matches how the person learns’, 3 reinforcing the importance of providing information tailored to the needs of a person with intellectual disability. A diagnosis of intellectual disability is associated with significant disparities in health outcomes. 4–7 Person-centred decision-making and better communication have been shown to improve patient satisfaction, 8 9 the physician–patient relationship 10 and overall health outcomes 11 for the wider population. Ensuring people with intellectual disability experience informed decision-making and accessible healthcare can help address the ongoing health disparities and facilitate equal access to healthcare.

Bodily autonomy is an individual’s power and agency to make decisions about their own body. 12 Informed consent for healthcare enables a person to practice bodily autonomy and is protected, for example, by the National Safety and Quality Health Service Standards (Australia), 13 Mental Capacity Act (UK) 14 and the Joint Commission Standards (USA). 15 In this article, we define informed consent according to three requirements: (1) the person is provided with information they understand, (2) the decision is free of coercion and (3) the person must have capacity. 16 For informed consent to be valid, this process must be suited to the individual’s needs so that they can understand and communicate effectively. Capacity is the ability to give informed consent for a medical intervention, 17 18 and the Mental Capacity Act outlines that ‘a person must be assumed to have capacity unless it is established that he lacks capacity’ and that incapacity can only be established if ‘all practicable steps’ to support capacity have been attempted without success. 14 These assumptions of capacity are also decision-specific, meaning an individual’s ability to consent can change depending on the situation, the choice itself and other factors. 17

Systemic issues with healthcare delivery systems have resulted in access barriers for people with intellectual disability, 19 despite the disability discrimination legislation in many countries who are signatories to the United Nations (UN) Convention on the Rights of Persons with Disabilities. 20 Patients with intellectual disability are not provided the reasonable adjustments that would enable them to give informed consent for medical procedures or interventions, 21 22 despite evidence that many people with intellectual disability have both the capacity and the desire to make their own healthcare decisions. 21 23

To support people with intellectual disability to make independent health decisions, an equitable and accessible informed consent process is needed. 24 However, current health systems have consistently failed to provide this. 21 25 To address this gap, we must first understand the factors that contribute to inequitable and inaccessible consent. To the best of our knowledge, the only current review of informed consent for people with intellectual disability is an integrative review by Goldsmith et al . 26 Many of the included articles focused on assessment of capacity 27–29 and research consent. 30–32 The review’s conclusion supported the functional approach to assess capacity, with minimal focus on how the informed consent processes can be improved. More recently, there has been a move towards ensuring that the consent process is accessible for all individuals, including elderly patients 33 and people with aphasia. 34 However, there remains a paucity of literature about the informed consent process for people with intellectual disability, with no systematic reviews summarising the factors influencing the healthcare consent process for people with intellectual disability.

To identify barriers to and enablers of the informed healthcare consent process for people with intellectual disability, and to understand how this can be made equitable and accessible.

A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) systematic literature review protocol. 35 The PRISMA 2020 checklist 36 and ENhancing Transparency in REporting the synthesis of Qualitative research (ENTREQ) reporting guidelines were also followed. 37 The full study protocol is included in online supplemental appendix 1 .

Supplemental material

No patients or members of the public were involved in this research for this manuscript.

Search strategy

A search strategy was developed to identify articles about intellectual disability, consent and healthcare interventions, described in online supplemental appendix 2 . Multiple databases were searched for articles published between January 1990 to January 2022 (Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL). These databases include healthcare and psychology databases that best capture relevant literature on this topic, including medical, nursing, social sciences and bioethical literature. The search was limited to studies published from 1990 as understandings of consent have changed since then. 38 39 This yielded 4853 unique papers which were imported into Covidence, a specialised programme for conducting systematic reviews. 40

Study selection

Citation screening by abstract and titles was completed by two independent researchers (MD and EEP). Included articles had to:

Examine the informed consent process for a healthcare intervention for people with intellectual disability.

Have collected more than 50% of its data from relevant stakeholders, including adults with intellectual disability, families or carers of a person with intellectual disability, and professionals who engage with people with intellectual disability.

Report empirical data from primary research methodology.

Be published in a peer-reviewed journal after January 1990.

Be available in English.

Full text screening was completed by two independent researchers (MD and EEP). Articles were excluded if consent was only briefly discussed or if it focused on consent for research, capacity assessment, or participant knowledge or comprehension. Any conflicts were resolved through discussion with an independent third researcher (IS).

Additional studies were identified through an ancestral search and by hand-searching three major journals relevant to intellectual disability research. Journals were selected if they had published more than one included article for this review or in previous literature reviews conducted by the research team.

Quality assessment

Two independent researchers (MD and IS) assessed study quality with the QualSyst tool, 41 which can assess both qualitative and quantitative research papers. After evaluating the distribution of scores, a threshold value of 55% was used, as suggested by QualSyst 41 to exclude poor-quality studies but capture enough studies overall. Any conflicts between the quality assessment scores were resolved by a third researcher (EEP). For mixed-method studies, both qualitative and quantitative quality scores were calculated, and the higher value used.

Data collection

Two independent researchers (MD and JH) reviewed each study and extracted relevant details, including study size, participant demographics, year, country of publication, study design, data analysis and major outcomes reported. Researchers used standardised data collection forms designed, with input from senior researchers with expertise in qualitative research (IS and EEP), to extract data relevant to the review’s research aims. The form was piloted on one study, and a second iteration made based on feedback. These forms captured data on study design, methods, participants, any factors affecting the process of informed consent and study limitations. Data included descriptions and paragraphs outlining key findings, the healthcare context, verbatim participant quotes and any quantitative analyses or statistics. Missing or unclear data were noted.

Data analysis

A pilot literature search showed significant heterogeneity in methodology of studies, limiting the applicability of traditional quantitative analysis (ie, meta-analysis). Instead, inductive thematic analysis was chosen as an alternative methodology 42 43 that has been used in recent systematic reviews examining barriers and enablers of other health processes. 44 45 The six-phase approach described by Braun and Clarke was used. 46 47 A researcher (MD) independently coded the extracted data of each study line-by-line, with subsequent data grouped into pre-existing codes or new concepts when necessary. Codes were reviewed iteratively and grouped into categories, subthemes and themes framed around the research question. Another independent researcher (JH) collated and analysed the data on study demographics, methods and limitations. The themes were reviewed by two senior researchers (EEP and IS).

Qualitative methods of effect size calculations have been described in the literature, 48 49 which was captured in this review by the number of studies that identified each subtheme, with an assigned frequency rating to compare their relative significance. Subthemes were given a frequency rating of A, B, C or D if they were identified by >10, 7–9, 4–6 or <3 articles, respectively. The overall significance of each theme was estimated by the number of studies that mentioned it and the GRADE framework, a stepwise approach to quality assessment using a four-tier rating system. Each study was evaluated for risk of bias, inconsistency, indirectness, imprecision and publication bias. 50 51 Study sensitivity was assessed by counting the number of distinct subthemes included. 52 The quality of findings was designated high, moderate or low depending on the frequency ratings, the QualSyst score and the GRADE scores of studies supporting the finding. Finally, the relative contributions of each study were evaluated by the number of subthemes described, guided by previously reported methods for qualitative reviews. 52

Co-research

The findings were reviewed by two co-researchers with intellectual disability (JL and SS), with over 30 years combined experience as members and employees of a self-advocacy organisation. Guidance on the findings and an easy read summary was produced in line with best-practice inclusive research 53 54 over multiple discussions. Input from two health professional researchers (MD and EEP) provided data triangulation and sense-checking of findings.

Twenty-three articles were identified ( figure 1 ): 14 qualitative, 6 quantitative and 3 mixed-methods. Two papers included the same population of study participants: McCarthy 55 and McCarthy, 56 but had different research questions. Fovargue et al 57 was excluded due to a quality score of 35%. Common quality limitations were a lack of verification procedures to establish credibility and limited researcher reflexivity. No studies were excluded due to language requirements (as all were in English) or age restrictions (all studies had majority adult participants).

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PRISMA 2020 flowchart for the systematic review. 36

Studies were published from 1999 to 2020 and involved participant populations from the UK (n=18), USA (n=3), Sweden (n=1) and Ireland (n=1). Participant numbers ranged from 9 to 604 (median 21), and participants included people with intellectual disability (n=817), health professionals (n=272), carers and support people (n=48), and other professionals that work with people with intellectual disability (n=137, community service agency directors, social workers, administrative staff and care home staff). Ages of participants ranged from 8 to 84 years, though only Aman et al 58 included participants <18 years of age. This study was included as the article states very few children were included. Studies examined consent in different contexts, including contraception and sexual health (6/23 articles), 58–60 medications (5/23 articles), 58–62 emergency healthcare, 63 cervical screening, 64 community referrals, 58–61 65 mental health, 66 hydrotherapy, 64 blood collection 67 and broad decision-making consent without a specific context. 65 68–71 A detailed breakdown of each study is included in online supplemental appendix 3 .

Six major themes were identified from the studies, summarised in figure 2 . An overview of included studies showing study sensitivity, effect size, QualSyst and GRADE scores is given in online supplemental appendix 4 . Studies with higher QualSyst and GRADE scores contributed more to this review’s findings and tended to include more subthemes; specifically, Rogers et al , 66 Sowney and Barr, 63 Höglund and Larsson, 72 and McCarthy 55 and McCarthy. 56 Figure 3 gives the easy read version of theme 1, with the full easy read summary in online supplemental appendix 5 .

Summary of the identified six themes and subthemes.

Theme 1 of the easy read summary.

Theme 1—Health professionals’ attitudes and lack of education about informed consent

Health professionals’ attitudes and practices were frequently (18/21) identified as factors affecting the informed consent process, with substantial evidence supporting this theme. Studies noted the lack of training for health professionals in supporting informed consent for people with intellectual disability, their desire for further education, and stereotypes and discrimination perpetuated by health professionals.

Lack of health professional education on informed consent and disability discrimination legislation

Multiple studies reported inconsistent informed consent practices, for various reasons: some reported that health professionals ‘forgot’ to or ‘did not realise consent was necessary’, 63 73 but inconsistent consent practices were also attributed to healthcare providers’ unfamiliarity with consent guidelines and poor education on this topic. Carlson et al 73 reported that only 44% of general practitioners (GPs) were aware of consent guidelines, and there was the misconception that consent was unnecessary for people with intellectual disability. Similarly, studies of psychologists 66 and nurses 63 found that many were unfamiliar with their obligations to obtain consent, despite the existence of anti-discrimination legislation. People with intellectual disability describe feeling discriminated against by health professionals, reflected in comments such as ‘I can tell, my doctor just thinks I’m stupid – I'm nothing to him’. 74 Poor consent practices by health professionals were observed in Goldsmith et al , 67 while health professionals surveyed by McCarthy 56 were unaware of their responsibility to provide accessible health information to women with intellectual disability. Improving health professional education and training was suggested by multiple studies as a way to remove this barrier. 63 65–67 69 73

Lack of training on best practices for health professions caring for people with intellectual disability

A lack of training in caring for and communicating with people with intellectual disability was also described by midwives, 72 psychologists, 66 nurses, 63 pharmacists 61 and GPs. 56 72 75 Health professionals lacked knowledge about best practice approaches to providing equitable healthcare consent processes through reasonable adjustments such as accessible health information, 56 60 66 longer appointments times, 60 72 simple English 62 67 and flexible approaches to patient needs. 63 72

Health professionals’ stereotyping and assumptions of incapacity

Underlying stereotypes contributed to some health professionals’ (including nurses, 63 GPs 56 and physiotherapists 64 ) belief that people with intellectual disability lack capacity and therefore, do not require opportunities for informed consent. 56 64 In a survey of professionals referring people with intellectual disability to a disability service, the second most common reason for not obtaining consent was ‘patient unable to understand’. 73

Proxy consent as an inappropriate alternative

People with intellectual disability are rarely the final decision-maker in their medical choices, with many health providers seeking proxy consent from carers, support workers and family members, despite its legal invalidity. In McCarthy’s study (2010), 18/23 women with intellectual disability said the decision to start contraception was made by someone else. Many GPs appeared unaware that proxy consent is invalid in the UK. 56 Similar reports came from people with intellectual disability, 55 56 60 64 69 76 health professionals (nurses, doctors, allied health, psychologists), 56 63 64 66 77 support people 64 77 and non-medical professionals, 65 73 and capacity was rarely documented. 56 62 77

Exclusion of people with intellectual disability from decision-making discussions

Studies described instances where health professionals made decisions for their patients with intellectual disability or coerced patients into a choice. 55 72 74 76 77 In Ledger et al 77 , only 62% of women with intellectual disability were involved in the discussion about contraception, and only 38% made the final decision, and others stated in Wiseman and Ferrie 74 : ‘I was not given the opportunity to explore the different options. I was told what one I should take’. Three papers outlined instances where the choices of people with intellectual disability were ignored despite possessing capacity 65 66 69 and when a procedure continued despite them withdrawing consent. 69

Theme 2—Inadequate accessible health information

Lack of accessible health information.

The lack of accessible health information was the most frequently identified subtheme (16/23 studies). Some studies reported that health professionals provided information to carers instead, 60 avoided providing easy read information due to concerns about ‘offending’ patients 75 or only provided verbal information. 56 67 Informed consent was supported when health professionals recognised the importance of providing medical information 64 and when it was provided in an accessible format. 60 Alternative approaches to health information were explored, including virtual reality 68 and in-person education sessions, 59 with varying results. Overall, the need to provide information in different formats tailored to an individual’s communication needs, rather than a ‘one size fits all’ approach, was emphasised by both people with intellectual disability 60 and health professionals. 66

Insufficient information provided

Studies described situations where insufficient information was provided to people with intellectual disability to make informed decisions. For example, some people felt the information from their GP was often too basic to be helpful (Fish et al 60 ) and wanted additional information on consent forms (Rose et al 78 ).

Theme 3—The involvement of support people

Support people (including carers, family members and group home staff) were identified in 11 articles as both enablers of and barriers to informed consent. The antagonistic nature of these findings and lower frequency of subthemes are reflected in the lower quality assessments of evidence.

Support people facilitated communication with health professionals

Some studies reported carers bridging communication barriers with health to support informed consent. 63 64 McCarthy 56 found 21/23 of women with intellectual disability preferred to see doctors with a support person due to perceived benefits: ‘Sometimes I don’t understand it, so they have to explain it to my carer, so they can explain it to me easier’. Most GPs in this study (93%) also agreed that support people aided communication.

Support people helped people with intellectual disability make decisions

By advocating for people with intellectual disability, carers encouraged decision-making, 64 74 provided health information, 74 77 emotional support 76 and assisted with reading or remembering health information. 55 58 76 Some people with intellectual disability explicitly appreciated their support person’s involvement, 60 such as in McCarthy’s 55 study where 18/23 participants felt supported and safer when a support person was involved.

Support people impeded individual autonomy

The study by Wiseman and Ferrie 74 found that while younger participants with intellectual disability felt family members empowered their decision-making, older women felt family members impaired their ability to give informed consent. This was reflected in interviews with carers who questioned the capacity of the person with intellectual disability they supported and stated they would guide them to pick the ‘best choice’ or even over-ride their choices. 64 Studies of psychologists and community service directors described instances where the decision of family or carers was prioritised over the wishes of the person with intellectual disability. 65 66 Some women with intellectual disability in McCarthy’s studies (2010, 2009) 55 56 appeared to have been coerced into using contraception by parental pressures or fear of losing group home support.

Theme 4—Systemic constraints within healthcare systems

Time restraints affect informed consent and accessible healthcare.

Resource limitations create time constraints that impair the consent process and have been identified as a barrier by psychologists, 66 GPs, 56 hospital nurses 63 and community disability workers. 73 Rogers et al 66 highlighted that a personalised approach that could improve informed decision-making is restricted by inflexible medical models. Only two studies described flexible patient-centred approaches to consent. 60 72 A survey of primary care practices in 2007 reported that most did not modify their cervical screening information for patients with intellectual disability because it was not practical. 75

Inflexible models of consent

Both people with intellectual disability 76 and health professionals 66 recognised that consent is traditionally obtained through one-off interactions prior to an intervention. Yet, for people with intellectual disability, consent should ideally be an ongoing process that begins before an appointment and continues between subsequent ones. Other studies have tended to describe one-off interactions where decision-making was not revisited at subsequent appointments. 56 60 72 76

Lack of systemic supports

In one survey, self-advocates highlighted a lack of information on medication for people with intellectual disability and suggested a telephone helpline and a centralised source of information to support consent. 60 Health professionals also want greater systemic support, such as a health professional specialised in intellectual disability care to support other staff, 72 or a pharmacist specifically to help patients with intellectual disability. 61 Studies highlighted a lack of guidelines about healthcare needs of people with intellectual disabilities such as contraceptive counselling 72 or primary care. 75

Theme 5—Person-centred informed consent

Ten studies identified factors related to a person-centred approach to informed consent, grouped below into three subthemes. Health professionals should tailor their practice when obtaining informed consent from people with intellectual disability by considering how these subthemes relate to the individual. Each subtheme was described five times in the literature with a relative frequency rating of ‘C’, contributing to overall lower quality scores.

Previous experience with decision-making

Arscott et al 71 found that the ability of people with intellectual disability to consent changed with their verbal and memory skills and in different clinical vignettes, supporting the view of ‘functional’ capacity specific to the context of the medical decision. Although previous experiences with decision-making did not influence informed consent in this paper, other studies suggest that people with intellectual disability accustomed to independent decision-making were more able to make informed medical decisions, 66 70 and those who live independently were more likely to make independent healthcare decisions. 56 Health professionals should be aware that their patients with intellectual disability will have variable experience with decision-making and provide individualised support to meet their needs.

Variable awareness about healthcare rights

Consent processes should be tailored to the health literacy of patients, including emphasising available choices and the option to refuse treatment. In some studies, medical decisions were not presented to people with intellectual disability as a choice, 64 and people with intellectual disability were not informed of their legal right to accessible health information. 56

Power differences and acquiescence

Acquiescence by people with intellectual disability due to common and repeated experiences of trauma—that is, their tendency to agree with suggestions made by carers and health professionals, often to avoid upsetting others—was identified as an ongoing barrier. In McCarthy’s (2009) interviews with women with intellectual disability, some participants implicitly rejected the idea that they might make their own healthcare decisions: ‘They’re the carers, they have responsibility for me’. Others appeared to have made decisions to appease their carers: ‘I have the jab (contraceptive injection) so I can’t be blamed for getting pregnant’. 55 Two studies highlighted that health professionals need to be mindful of power imbalances when discussing consent with people with intellectual disability to ensure the choices are truly autonomous. 61 66

Theme 6—Effective communication between health professionals and patients

Implementation of reasonable adjustments for verbal and written information.

Simple language was always preferred by people with intellectual disability. 60 67 Other communication aids used in decision-making included repetition, short sentences, models, pictures and easy read brochures. 72 Another reasonable adjustment is providing the opportunity to ask questions, which women with intellectual disability in McCarthy’s (2009) study reported did not occur. 55

Tailored communication methods including non-verbal communication

Midwives noted that continuity of care allows them to develop rapport and understand the communication preferences of people with intellectual disability. 72 This is not always possible; for emergency nurses, the lack of background information about patients with intellectual disability made it challenging to understand their communication preferences. 63 The use of non-verbal communication, such as body language, was noted as underutilised 62 66 and people with intellectual disability supported the use of hearing loops, braille and sign language. 60

To the best of our knowledge, this is the first systematic review investigating the barriers and enablers of the informed consent process for healthcare procedures for people with intellectual disability. The integrative review by Goldsmith et al 26 examined capacity assessment and shares only three articles with this systematic review. 69 71 73 Since the 2000s, there has been a paradigm shift in which capacity is no longer considered a fixed ability that only some individuals possess 38 39 but instead as ‘functional’: a flexible ability that changes over time and in different contexts, 79 reflected in Goldsmith’s review. An individual’s capacity can be supported through various measures, including how information is communicated and how the decision-making process is approached. 18 80 By recognising the barriers and enablers identified in this review, physicians can help ensure the consent process for their patients with intellectual disability is both valid and truly informed. This review has highlighted the problems of inaccessible health information, insufficient clinical education on how to make reasonable adjustments and lack of person-centred trauma-informed care.

Recommendations

Health professionals require training in the informed consent process for people with intellectual disability, particularly in effective and respectful communication, reasonable adjustments and trauma-informed care. Reasonable adjustments include offering longer or multiple appointments, using accessible resources (such as easy read information or shared decision-making tools) and allowing patient choices (such as to record a consultation or involve a support person). Co-researchers reported that many people with intellectual disability prefer to go without a support person because they find it difficult to challenge their decisions and feel ignored if the health professional only talks to the support person. People with intellectual disability also feel they cannot seek second opinions before making medical decisions or feel pressured to provide consent, raising the possibility of coercion. These experiences contribute to healthcare trauma. Co-researchers raised the importance of building rapport with the person with intellectual disability and of making reasonable adjustments, such as actively advocating for the person’s autonomy, clearly stating all options including the choice to refuse treatment, providing opportunities to contribute to discussions and multiple appointments to ask questions and understand information. They felt that without these efforts to support consent, health professionals can reinforce traumatic healthcare experiences for people with intellectual disability. Co-researchers noted instances where choices were made by doctors without discussion and where they were only given a choice after requesting one and expressed concern that these barriers are greater for those with higher support needs.

Co-researchers showed how these experiences contributed to mistrust of health professionals and poorer health outcomes. In one situation, a co-researcher was not informed of a medication’s withdrawal effects, resulting in significant side-effects when it was ceased. Many people with intellectual disability describe a poor relationship with their health professionals, finding it difficult to trust health information provided due to previous traumatic experiences of disrespect, coercion, lack of choice and inadequate support. Many feel they cannot speak up due to the power imbalance and fear of retaliation. Poor consent practices and lack of reasonable adjustments directly harm therapeutic alliances by reducing trust, contribute to healthcare trauma and lead to poorer health outcomes for people with intellectual disability.

Additional education and training for health professionals is urgently needed in the areas of informed consent, reasonable adjustments and effective communication with people with intellectual disability. The experiences of health professionals within the research team confirmed that there is limited training in providing high-quality healthcare for people with intellectual disability, including reasonable adjustments and accessible health information. Co-researchers also suggested that education should be provided to carers and support people to help them better advocate for people with intellectual disability.

Health information should be provided in a multimodal format, including written easy read information. Many countries have regulation protecting the right to accessible health information and communication support to make an informed choice, such as UK’s Accessible Information Standard, 81 and Australia’s Charter of Health Care Rights, 24 yet these are rarely observed. Steps to facilitate this include routinely asking patients about information requirements, system alerts for an individual’s needs or routinely providing reasonable adjustments. 82 Co-researchers agreed that there is a lack of accessible health information, particularly about medications, and that diagrams and illustrations are underutilised. There is a critical need for more inclusive and accessible resources to help health professionals support informed consent in a safe and high-quality health system. These resources should be created through methods of inclusive research, such as co-production, actively involving people with intellectual disability in the planning, creation, and feedback process. 53

Strengths and limitations

This systematic review involved two co-researchers with intellectual disability in sense-checking findings and co-creating the easy read summary. Two co-authors who are health professionals provided additional sense-checking of findings from a different stakeholder perspective. In future research, this could be extended by involving people with intellectual disability in the design and planning of the study as per recommendations for best-practice inclusive research. 53 83

The current literature is limited by low use of inclusive research practices in research involving people with intellectual disability, increasing vulnerability to external biases (eg, inaccessible questionnaires, involvement of carers in data collection, overcompliance or acquiescence and absence of researcher reflexivity). Advisory groups or co-research with people with intellectual disability were only used in five studies. 58 60 68 74 76 Other limitations include unclear selection criteria, low sample sizes, missing data, using gatekeepers in patient selection and predominance of UK-based studies—increasing the risk of bias and reducing transferability. Nine studies (out of 15 involving people with intellectual disability) explicitly excluded those with severe or profound intellectual disability, reflecting a selection bias; only one study specifically focused on people with intellectual disability with higher support needs. Studies were limited to a few healthcare contexts, with a focus on consent about sexual health, contraception and medications.

The heterogeneity and qualitative nature of studies made it challenging to apply traditional meta-analysis. However, to promote consistency in qualitative research, the PRISMA and ENTREQ guidelines were followed. 36 37 Although no meta-analyses occurred, the duplication of study populations in McCarthy 2009 and 2010 likely contributed to increased significance of findings reported in both studies. Most included studies (13/23) were published over 10 years ago, reducing the current relevance of this review’s findings. Nonetheless, the major findings reflect underlying systemic issues within the health system, which are unlikely to have been resolved since the articles were published, as the just-released final report of the Australian Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability highlights. 84 There is an urgent need for more inclusive studies to explore the recommendations and preferences of people with intellectual disability about healthcare choices.

Informed consent processes for people with intellectual disability should include accessible information and reasonable adjustments, be tailored to individuals’ needs and comply with consent and disability legislation. Resources, guidelines and healthcare education are needed and should cover how to involve carers and support people, address systemic healthcare problems, promote a person-centred approach and ensure effective communication. These resources and future research must use principles of inclusive co-production—involving people with intellectual disability at all stages. Additionally, research is needed on people with higher support needs and in specific contexts where informed consent is vital but under-researched, such as cancer screening, palliative care, prenatal and newborn screening, surgical procedures, genetic medicine and advanced therapeutics such as gene-based therapies.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
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• Data supplement 5

Contributors MD, EEP and IS conceived the idea for the systematic review. MD drafted the search strategy which was refined by EEP and IS. MD and EEP completed article screening. MD and IS completed quality assessments of included articles. MD and JH completed data extraction. MD drafted the original manuscript. JL and SS were co-researchers who sense-checked findings and were consulted to formulate dissemination plans. JL and SS co-produced the easy read summary with MD, CM, JH, EEP and IS. MD, JLS, EEP and IS reviewed manuscript wording. All authors critically reviewed the manuscript and approved it for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. MD is the guarantor responsible for the overall content of this manuscript.

Funding This systematic literature review was funded by the National Health & Medical Research Council (NHMRC), Targeted Call for Research (TCR) into Improving health of people with intellectual disability. Research grant title "GeneEQUAL: equitable and accessible genomic healthcare for people with intellectual disability". NHMRC application ID: 2022/GNT2015753.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Linked Articles

• Editorial It is up to healthcare professionals to talk to us in a way that we can understand: informed consent processes in people with an intellectual disability Jonathon Ding Richard Keagan-Bull Irene Tuffrey-Wijne BMJ Quality & Safety 2024; 33 277-279 Published Online First: 30 Jan 2024. doi: 10.1136/bmjqs-2023-016830

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Virtual and augmented reality to develop empathy: a systematic literature review

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• Published: 04 May 2024

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• Jose Lacle-Melendez   ORCID: orcid.org/0009-0000-9573-4194 1 ,
• Sofia Silva-Medina   ORCID: orcid.org/0009-0009-4625-8510 1 &
• Jorge Bacca-Acosta   ORCID: orcid.org/0000-0003-0381-6972 2  

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Recent research suggests that Virtual Reality (VR) and Augmented Reality (AR) as immersive technologies are effective in developing empathy. The main reason behind this assumption is that immersive technologies allow people to experience perspective-taking. However, there is a lack of systematic literature reviews that summarize the current state of research on VR and AR to elicit empathy. This paper reports a systematic literature review of 37 academic papers published between 2007 and 2023. The following categories were analyzed in this review: field of education, data collection instruments, sample size, statistically significant results, technologies used, research design, advantages, limitations, and future research. The main findings of this review provide an overview of the current state of research on immersive technologies to elicit empathy and the future challenges in this field. Some of the main findings involve: VR/AR immersion devices are effective and appealing to participants; the Interpersonal Reactivity Index was found to be the most relevant self-report measure; and larger sample sizes (over 100 participants) are vital in VR/AR-based empathy research to provide a quantitative perspective on participants distribution.

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1 Introduction

The rise of disruptive technologies has redefined patterns of social interaction, showcasing an adaptation in the ways individuals engage with one another. Virtual reality (VR) is a collection of hardware, including computers, head-mounted displays (HMD), and sensors, designed to experience telepresence [ 1 ]. Moreover, VR is also considered a computer system that enables users to create artificial environments in which they can interact, navigate, and immerse themselves in a three-dimensional space [ 2 ]. Augmented Reality (AR) is a technology that allows a real-time combination of virtual objects and real objects so that it seems that the virtual objects are part of the real world [ 3 ]. The main difference between VR and AR is that in VR the participant is completely immersed in a computer-generated visual environment and everything that the participant sees is artificial while in AR the participant sees the real world with some virtual objects superimposed that seem to co-exist in the real world.

VR and AR have emerged as cutting-edge tools that allow users to immerse themselves in simulated environments and experience sensory sensations that simulate real life. Considering this, VR and AR often refers to “enhanced user interfaces.” This encompasses viewing and navigating a 3D environment and interacting with its components in real time. For these creators, the user’s interactive experience in the real world can be received through stimulation of the five human senses (sight, hearing, touch, taste, and smell). In the same line of thought, VR and AR can be an enhancer of prosocial behaviors through empathy, using tools intertwined with current technological developments. In other words, VR enables immersion in a simulated environment like real life, and through interaction with this sensory environment, it can strengthen communication and understanding of others’ perspectives [ 4 ]. In that regard, VR has been considered a medium for perspective-taking [ 5 ]. It allows users of this technology to directly experience feelings and perspectives in a controlled and safe environment. Thus, VR can be understood as a set of computer technologies that provide access to simulated spaces through visual devices, where a person can acquire the sensation of presence, interact within that space and be in the shoes of others.

AR and VR can be used in different contexts for creating empathy and pro-social behaviors [ 6 , 7 ]. From an etymological perspective, empathy can be understood from its Greek root Παθεûv (epathón, to feel) and the prefix εv (an inseparable preposition meaning within). The origin of the term empathy dates back to 1873 when the philosopher Robert Vischer used the German term “Einfühlung” (feeling into) as an expression in art appreciation. Later, the term was used in English in the book “Lectures on the Experimental Psychology of the Thought-processes” in 1909, with a meaning of “feeling oneself into the other, being interpenetrated” [ 8 , p.1].

Empathy can be initially defined as the emotional communication between one person and another, responding assertively within their social environment. Empathy is the ability to identify one’s own emotions and those of others and respond to them constructively [ 9 , p.40]. In other words, the development of these skills not only influences personal well-being but also has a significant impact on various areas of individual adjustment. In simpler terms, it can be understood as the process by which an individual has the ability to understand the feelings of others, allowing them to perceive reality from the other person’s perspective rather than their own. Empathy is usually divided into emotional empathy and cognitive empathy [ 10 ]. One the one hand, emotional empathy means that the person is emotionally moved by a situation. On the other hand, cognitive empathy involves understanding thoughts and the emotion of others and this has been regarded as perspective taking.

It is worth mentioning that applications of VR and AR to develop empathy, while diverse and booming in various fields of study, lack extensive systematic research that reviews data from multiple individual studies to determine a general estimation of the effects of interventions, scope, limitations, variables of interest, and to assess the consistency and variability of results among individual studies. Therefore, it is of methodological importance to conduct a systematic review of current technological trends in various areas and fields of research where VR has been used as a medium for empathy development.

In alignment with this perspective, the present systematic review seeks to comprehensively address 11 research inquiries aimed at elucidating the correlation between exposure to immersive experiences in virtual reality (VR) or augmented reality (AR) and the cultivation of empathy. These 11 research questions have been categorized into four dimensions for the sake of facilitating understanding, organization, and presentation of information. The ensuing research questions steer the course of this review:

Application-domain related research questions

The primary objective of these inquiries is to delineate how AR and VR have been employed to foster empathy across diverse professional domains and to ascertain the prevalence of significant findings in related studies. The relevance of these research questions lies in their capacity to enable researchers to pinpoint specific professional fields wherein AR/VR could potentially be applied to nurture empathy. Additionally, they aid in identifying research lacunae within various professional domains. The consequential significance of results in these studies provides valuable insights for researchers to recognize potential benefits conferred by these immersive technologies.

What are the professional fields of study where virtual reality or augmented reality have been used to promote empathy?

How many studies have reported statistically significant effectiveness percentages in research utilizing virtual reality or augmented reality to foster empathy?

Research questions about methodological aspects

the objective of this set of research questions is to elucidate the methodological intricacies employed in studies investigating the promotion of empathy through AR and VR. The significance of these research questions lies in their capacity to provide insights into the methodologies utilized within the field. This comprehension is instrumental in evaluating the robustness and reliability of findings, fostering a deeper understanding of the research landscape in this domain.

What data collection instruments have been most used in studies utilizing virtual reality or augmented reality to foster empathy?

How many participants or research sample have been used most frequently in studies where virtual reality or augmented reality has been used to foster empathy?

What research design has been predominantly employed in studies where virtual reality or augmented reality has been used to foster empathy?

What percentage of studies have been reported as scientific articles versus conference papers?

Advantages, limitations and future research directions

this set of research queries seeks to elucidate the merits, constraints, and prospective avenues for further investigation as documented in the literature pertaining to the application of AR and VR in empathy development. These inquiries hold significance as their responses encapsulate a concise overview of primary discoveries within the field, the principal constraints and challenges encountered, and the potential avenues for future research endeavors. Exploring these research questions contributes to a comprehensive understanding of the current state of knowledge, facilitating informed discussions on the advancements, challenges, and potential future directions in the domain of AR and VR’s impact on empathy.

What advantages have been described in studies where virtual reality or augmented reality has been used to foster empathy?

What limitations have been reported in studies where virtual reality or augmented reality has been used to foster empathy?

What have been the most frequent recommendations for future research in studies utilizing virtual reality or augmented reality to foster empathy?

Technology-related research questions

this set of questions seeks to ascertain the specific technological hardware and software utilized in studies focused on the utilization of AR and VR in empathy development. The intent behind these questions is to discern the capabilities of particular devices and explore potential avenues for further enhancement, aligning with the imperative for increased research in this domain emphasized by Ventura et al. [ 11 ].

What equipment or technological tools have been used for immersion in virtual or augmented reality in the analyzed studies?

Which software has been used to develop immersive environments in research studies where virtual reality or augmented reality has been used to foster empathy?

In essence, the research team has formulated this set of research questions with the aim of delineating the research landscape concerning empathy development through AR and VR applications. From our standpoint, these research questions serve the purpose of offering a comprehensive survey of studies within this domain, enabling fellow researchers to pinpoint existing gaps in the literature and identify potential avenues for further research.

The rest of this paper is organized as follows: Section 2 describes the related work; Section 3 describes the method followed to conduct the systematic literature review. Section 4 presents the results organized by each research question. Section 5 presents the risk of bias analysis. Section 6 discuss the results obtained in this review. Section 7 describes the limitations of this review. Finally, Section 8 describes the implications of this review for education and training and Section 9 presents the conclusions of this study.

2 Related work

There is a large and growing body of literature that has demonstrated that VR can be effectively utilized as a tool for the development of social and emotional skills, such as empathy. In this context, various studies have investigated the viability of virtual reality in enhancing empathy in individuals. In this section, we present a summary of similar systematic reviews and meta-analysis on VR and empathy and we show how our systematic review extend previous studies in the field and how the systematic review fills a gap in the literature. Table 1 shows a summary of previous studies in the field.

Overall, previous systematic reviews, surveys and meta-analysis on VR and empathy have shown an overview of how VR has been used to create empathy and how some associated factors such as prejudice and intergroup bias might mediate or moderate the influence of VR on empathy. However, the systematic review presented in this article extend previous reviews by updating the research up to 2023 and addressing research questions that have not been addressed in previous reviews. The systematic review presented in this paper holds significant importance in the academic domain as its primary objective is to address aspects that have not been thoroughly explored in other systematic reviews, surveys or meta-analysis such as the ones reported in [ 11 , 12 , 13 ]. Particularly, by providing detailed information, it establishes a solid foundation for future investigations, facilitating the path for researchers who seek to consult tools and technologies utilized within the study’s context, as well as identifying statistically significant impacts on empathy. Moreover, a rigorous examination of limitations encountered in previous research is proposed to establish a critical and reflective framework concerning the current frontiers of knowledge in the field. Considering the above, this systematic literature review contributes to the body of knowledge in the field of VR and AR to develop empathy and is a valuable resource to guide and suggest future research, offering clear and well-founded recommendations that will contribute to the advancement of this field.

The main contribution of this paper is that it summarizes previous research done on the use of VR and AR to develop empathy. This literature review updates previous literature reviews and surveys on VR to develop empathy and, to the best of our knowledge, is the first literature review that also summarizes research on AR to develop empathy.

Following the guidelines outlined by Botella and Zamora [ 22 ], a systematic literature review is structured as follows:

Problem Formulation

Study Search

Study Coding

Analysis and Interpretation

Publication

Figure 1 depicts the PRISMA flow diagram. This diagram was generated based on the PRISMA 2020 statement [ 23 ]. It depicts the process of study identification and selection for the current systematic review. First, a total of 738 records were found after conducting the search. By excluding those published prior to 2007, those written in a language different to English or Spanish, and those different to articles, conference papers or book chapters, the dataset resulted in 636 records. Following the screening process, 58 records were excluded as the key terms (empathy and AR/VR) were merely mentioned in the paper but did not constitute the primary focus. Instances included references to AR and VR technologies without the main topic centering on empathy, or the co-occurrence of empathy, AR, and VR terms without the primary objective of fostering empathy through these technologies. Consequently, 578 records underwent evaluation for eligibility. During this phase, the authors meticulously reviewed the abstracts of each document to confirm its relevance to the designated topic. If the abstract did not provide sufficient clarity regarding the study’s suitability, a comprehensive examination of the full text was undertaken to determine inclusion in the review. Ultimately, 37 studies met the criteria for inclusion. The authors then scrutinized the full text of these 37 articles to extract pertinent information and address the research questions.

PRISMA flowchart and selection of bibliographic material

It should be noted that the three authors of this article were in charge of collecting the articles (identification phase in Fig. 1 ) and the screening process. Then, two of the authors coded the selected articles through a matrix where all the inclusion and exclusion criteria were established. Then the third author also validated the coding process.

Taking into account the aforementioned aspects and the model proposed by Botella and Zamora [ 22 ], the impact of VR and AR to develop empathy was addressed through a systematic literature review of 37 articles retrieved from SCOPUS, using the search string ( TITLE-ABS-KEY ( “virtual reality” ) OR TITLE-ABS-KEY ( “augmented reality” ) ) AND TITLE-ABS-KEY ( “empathy” ). Scopus was selected as the primary database for retrieving studies because it is one of the largest abstracts and citation databases with a high quality of indexed publications. In this systematic review, we did not consider other databases because we had restrictions in accessing other databases such as Web of Science. Other databases such as APA PsycArticles were not included because the pilot searches did not retrieve relevant results for the scope of this systematic review.

In this review, we did not include any other term related to empathy because in the pilot searches before conducting the final search the inclusion of other terms such as prejudice, intergroup, perspective-taking among others restricted the number of results obtained and the results overlapped other existing systematic reviews. In that regard, we decided to maintain a more general search string to collect articles on the topic of VR and AR to develop empathy. In this way, we are able to provide a more general landscape of research instead of a more focused review that might overlap previous reviews.

The inclusion criteria considered in the systematic review were as follows:

Studies conducted between 2007 and 2023. The timeframe was selected and studies before 2007 were not included because the pilot searches conducted prior to the main search for this systematic review showed that the articles before 2007 provided important background and foundations on the use of VR to develop empathy but did not provide insights into the effect of VR to develop empathy due to the maturity of VR before 2007.

Research about the use of virtual reality and/or augmented reality to develop empathy.

Studies written in English or Spanish.

Journal papers, conference papers and book chapters.

Exclusion criteria was:

Studies in languages other than English and Spanish, studies prior to 2007.

Other systematic reviews (these were reported in the related work of this paper), and those that did not involve virtual reality and/or augmented reality as technologies for fostering empathy.

Book reviews, notes, erratum, editorials, letters to the editor, doctoral theses, master’s dissertations, and other non-scientific documents.

The 37 articles were thoroughly read and analyzed by two of the authors and each article was coded according to the categories defined by the researchers to consolidate and answer the research questions. The categories emerged from the research questions. Table 2 shows the 11 research questions grouped into the four dimensions (as presented in the introduction) and each research question has the category that was used to code each study.

Once the analysis categories were defined, they were coded into two groups based on their unit of measurement. On one hand, categories that could be numerically evaluated were included, organizing them into subcategories and tallying the number of identified studies and their respective percentages. This process was carried out using software such as Excel and JASP. On the other hand, categories with nominal characteristics that required interpretation were considered as the second group for coding, thus providing answers to the research questions. It is important to note that the coding matrix design and article consolidation were conducted by two researchers and validated by a third party.

This section in the systematic literature review answers the research questions previously formulated. Through a detailed analysis of the existing scientific literature, relevant data has been collected and subsequently encoded according to the categories defined to be presented in the form of tables and structured subcategories with corresponding percentages. These tools allowed for a clear and comparative visualization of the results, facilitating the understanding of the patterns and trends identified in the research. The percentage analysis provides a deeper understanding of the data distribution and enables significant conclusions to be drawn regarding the research questions. This was achieved by dividing the frequency of each subcategory by the total number of subcategories mentioned and multiplying by 100 to obtain the percentage value. The following sub-section presents the results in detail, offering a comprehensive and rigorous overview of the collected data organized for each research question.

4.1 Application-domain related research questions

4.1.1 what are the professional fields of study where virtual reality or augmented reality have been used to promote empathy.

Table 3 describes the areas where studies on virtual and/or augmented reality have been reported, along with their respective nominal quantity of studies and percentages.

The analysis examined the different areas in which virtual or augmented reality has been used to promote empathy. The results revealed that research has been conducted in fields such as Experimental Psychology, Medicine, Education, Organizational Psychology, Social Psychology, Art, Marketing, and Neuroscience. When looking at the percentages, it was observed that most of the studies focused on Education (29.73%), followed by Experimental psychology (24,32%), and Medicine (16.22%).

4.1.2 How many studies have reported statistically significant effectiveness rates in research where virtual reality or augmented reality has been used to foster empathy?

Table 4 shows the results obtained for studies that have reported statistically significant results, as well as those where, due to the nature of the research, such significance does not apply.

The percentages mentioned address the question regarding the number of studies that have reported statistically significant effectiveness in research using virtual reality or augmented reality to foster empathy. It is noteworthy that 59.46% of the reviewed studies reported statistically significant differences. On the other hand, only 2.70% reported that there were no statistically significant differences.

4.2 Research questions about methodological aspects

4.2.1 what data collection instruments have been most used in studies utilizing virtual reality or augmented reality to foster empathy.

Table 5 shows the data collection instruments used, as well as the number of studies that report them and their respective percentages.

Table 5 reveals valuable information regarding the data collection instruments used in empathy studies. The Interpersonal Reactivity Index (IRI) stands out with a significantly high percentage of 18.75%, indicating its relevance and frequent use in empathy assessment. Furthermore, the results highlight the importance of two research approaches: the Likert-type surveys and interviews, both of which obtained similar percentages around 16,67%. This suggests that these methods are considered significant in measuring and understanding empathy. On the other hand, categories such as Multidimensional empathy scale, Virtual reality quiz, Cognitive and affective empathy test, Jefferson Empathy Scale (JSE) questionnaire presented lower percentages, approximately ranging from 2,08–4,17%. Additionally, other instruments such as questionnaires accounted 14.58%.

4.2.2 How many participants or research sample have been used most frequently in studies where virtual reality or augmented reality has been used to foster empathy?

Table 6 shows the number of participants in virtual reality or augmented reality studies, along with their respective percentages.

The participants were classified into different categories based on sample size. The category with the highest percentage corresponds to studies that included more than 100 participants, representing approximately 35.14% of the total. On the other hand, there were groups with lower representation, such as those with less than 51–75 and cases of 76–100 participants both with a percentage 8,11% and 10,81%, respectively. The intermediate categories show a range where sample size was not applicable due to the type of study,13,51% and, the studies with a range of participants between 25 and 50, accounting 16,22%.

4.2.3 What research design has been predominantly employed in studies where virtual reality or augmented reality has been used to foster empathy?

Table 7 contains the information on the percentages of research design types where virtual reality or augmented reality has been used to foster empathy.

Regarding the methodological design, five different types of research were found in the total number of studies reviewed. In terms of classification by types, experimental studies accounted for a total of 19 studies, representing 51.35% of the total studies reviewed. Following that, descriptive studies accounted for 7 studies, accounting for 18,92%. Qualitative studies accounted for a total of 4 studies, with an equivalent average of 10.81%. Quasi-experimental and mixed methods came next, each comprising 3 studies, and a percentage of 8.11%. Finally, Exploratory methods studies accounted for 1 article representing 2,70%.

4.2.4 What percentage of studies have been reported both as scientific articles and conference papers?

Table 8 shows a summary of the studies reviewed classified according to the typology as journal articles, conference papers or book chapters.

Regarding the analyzed articles that used virtual or augmented reality for empathy enhancement, there is a percentage of 83.78% of studies reported as journal articles, which represents a total of 31 articles from all the reviewed documents. This is followed by 4 conference papers, equivalent to 10.81%, and finally, two book chapter with a percentage value of 5.40%.

4.3 Advantages, limitations and future research directions

4.3.1 what advantages have been described in studies where virtual reality or augmented reality has been used to foster empathy.

Regarding the advantages described in studies where virtual reality or augmented reality has been used to foster empathy, it has been found that statistically significant changes occurred in various empathy-related aspects, increasing participants’ ability to understand others’ perspectives through the alteration of their virtual bodies. This is supported in the study by Wilding et al. [ 4 ], where participants gained a greater understanding of the challenges faced by individuals with disabilities when experiencing frustration within the virtual world.

Furthermore, Fisher [ 24 ] argues that although empathy in virtual reality is not directly established between a user and the subject of a real-life experience, the medium’s capacity to place a body within a new space provides an opportunity for enhanced understanding of others through empathic realities. Additionally, statistical results and user testimonials reveal that the functionalities and elements implemented in the developed application contribute to the promotion of empathy compared to conventional methods of visualization and annotation in 360-degree videos. Findings indicate that experiencing news through a head-mounted display for 360-degree videos resulted in higher self-location and co-presence compared to interacting with the same video on a desktop or reading a textual version. Therefore, the use of virtual reality as a medium to support empathy generation holds promise due to the benefits and advantages it offers.

It is worth noting the significant contributions that VR offers to educational spaces, particularly in terms of additional pedagogical considerations regarding the use of VR in historical education, including incorporating virtual reality into constructivist approaches. According to Castaño & Gonzalez [ 25 ], university students attribute importance to AR and VR in the educational context: it improves academic performance, changes the way of teaching and learning, enables more experimental learning, increases the level of understanding, offers models of relevant experiences, and enhances possibilities for engagement and interaction in the educational context. Furthermore, by generating a highly stimulating space for understanding the reality faced by others, a sense of shared frustration and pain is incorporated within the virtual world, leading participants to gain a greater understanding of the challenges faced by individuals with disabilities, autism, among others.

Parra Vargas et al. [ 26 ] illustrate the potential of a new VR organizational environment combined with machine learning to discriminate empathy dimensions. Additionally, this multi-method approach can increase knowledge about attention and behavior patterns and decision-making processes carried out by workers with different levels of empathy in complex work situations. Furthermore, unlike most assessments that use subjective self-report measures, this method combines neuroscience with VR, attributing greater objectivity and ecological validity to the results.

In summary, the findings suggest that augmented reality (AR) and virtual reality (VR) hold significance in enhancing individuals’ capacity to comprehend others’ perspectives. A primary advantage of AR and VR lies in their capability to immerse individuals in novel environments, fostering a deeper understanding of others’ thoughts and conditions. Additionally, the heightened levels of interaction facilitated by AR and VR surpass the efficacy of 360-degree videos in empathy development. Finally, the integration of artificial intelligence methods with AR and VR technologies introduces novel possibilities for empathy cultivation, as applications can adapt to individual participants, offering more personalized scenarios to enhance empathic experiences.

4.3.2 What limitations have been reported in studies where virtual reality or augmented reality has been used to foster empathy?

Regarding the limitations evidenced in studies where virtual reality or augmented reality has been used to foster empathy, several aspects have been identified. One limitation is the sample size, as in many cases, the total number of participants was not significant enough to establish generalizability of the findings. This lack of a representative sample also reflects limited socio-demographic information, and in some instances, the absence of a control group, pretest and posttest data, and long-term follow-up of the results. Additionally, participants’ unfamiliarity with virtual reality tools was detected, which were often presented in foreign languages or with proprietary licenses that limited their use. Furthermore, difficulties related to the COVID-19 pandemic were reported in studies that started before the preventive isolation measures were implemented. These studies had to change their initially planned methodology, requiring new organization and logistics to carry out the interventions in a timely manner, as mentioned by Villalba [ 27 ].

In terms of the content and format of empathy-building interventions, problems have been identified. Previous studies have shown that people exposed to persuasive messages can experience a psychological reaction, perceiving these messages as a threat to their freedom. As a result, a “boomerang” effect can occur, where the recipient acts in the opposite direction to that advocated by the message. This limitation implies not fully utilizing all emotions, as participants’ responses may be influenced by individual differences or previous experiences with the displayed content, resulting in a poor and somewhat biased understanding of empathy and prosocial moral reasoning.

In line with the issues, inadequate methodologies have been implemented, which in turn present inconveniences. This includes qualitative data being used inappropriately, risking objectivity, and studies that are solely descriptive, making it impossible to compare theory and practice to validate theoretical assumptions. Additionally, studies solely relying on self-reported measures limit researchers’ ability to draw conclusions about how the use of virtual reality devices influenced participants’ behavior, particularly their ability to empathetically communicate with individuals experiencing auditory verbal hallucinations (AVH). Since self-reported measures are based on participants’ subjective perceptions, it cannot be certain if the perceived changes in empathetic communication would translate into empathetic behavior in real life. As mentioned by Libera et al. [ 28 ], researchers face challenges in drawing conclusions about how the use of devices influenced participants’ behavior, especially their ability to empathetically communicate with individuals experiencing AVH. Due to the subjective nature of self-reported measures, it is uncertain whether these perceived changes in empathetic communication would translate into empathetic behavior in real-life situations.

In summary, the limitations identified in the reviewed studies revolve around factors such as small sample sizes, impeding the generalizability of results and the demonstration of genuine effects. The absence of long-term follow-ups and a scarcity of studies employing longitudinal research designs further underscore limitations within the research landscape. These findings align with Ventura et al.‘s [ 11 ] observations. Additionally, the restricted familiarity with augmented reality (AR) and virtual reality (VR) equipment hampers the potential impact of these technologies on empathy, complicating researchers’ efforts to measure their effects. The influence of individual differences on participants’ responses introduces another layer of complexity, potentially leading to unexpected results in the effects of AR and VR. Lastly, the reliance on self-reported measures in some studies introduces a potential source of bias, as these measures may not fully capture participants’ attitudes.

4.3.3 What have been the most frequent recommendations for future research in studies that have used virtual reality or augmented reality to promote empathy?

Regarding the recommendations for future research, one is to conduct longitudinal studies that assess empathy [ 29 ]. In longitudinal studies, the novelty of the technology effect can be controlled and determine the real affordances of VR and AR to develop empathy. Additionally, for upcoming research on virtual tools, empathy, and prosocial moral reasoning, these studies can be conducted with larger sample sizes and implemented in other countries to determine the effect of cultural differences on empathy. It is also emphasized the importance of research that integrates VR embodiment with clinical assessments and patient experiences, as stated by Aya Briñez et al. [ 30 ]. Embodiment is relevant for perspective-taking because the participant can take the body of another person and have a better experience that might increase empathy. Furthermore, future research is needed to explore the use of virtual reality for disability advocacy. On a different note, there were some comments about technical issues, such as interruptions during the presentation due to network problems or getting lost in the virtual world, especially for those who experienced VR for the first time. Li & Kyung Kim [ 31 ] suggest that future work should further examine the distinctions between visual perspectives and perspective-taking in virtual reality.

4.4 Technology-related research questions

4.4.1 what equipment or technological tools have been used for immersion in virtual reality or augmented reality in the analyzed studies.

Table 9 shows the technological means used for immersion in virtual reality environments, along with the number of related studies for this analysis and their respective percentages.

In this research question, the sub-category with the lowest number of studies were “Mobile AR”, “Augmented Reality Cards”, “Oculus Go 360”, “Google Cardboard” and “NVIS nVisor SX111” each accounting for 2.70% of the studies. “360 Immersion Device” is the category with the highest percentage of studies after “Not specified,” representing 18,92% of the total. Moreover, the subcategory “Not specified” has the highest number of studies, accounting for 37.84% of the total. An explanation of this result might be that some of the articles reviewed are theoretical so in the research the authors did not use a particular device.

4.4.2 Which software has been used to develop immersive environments in research studies where virtual reality or augmented reality has been used to foster empathy?

Table 10 shows the software that have been used to build immersive environments in research studies where virtual reality or augmented reality has been used to promote empathy.

Regarding programming languages and software, we found that software developed by Embodiedlabs*, Autopano Video, ImercyVE, AR Foundation, Optitrack Arena Motion, Ataturk, Skybox, Unreal, and AR Core accounted for only 2.5%, with each being the focus of a single study. Unity was used in 6 articles, representing a percentage of 15%. Additionally, it is found that 22 articles did not specify the programming language, or the tool used to develop de immersive experience, accounting for 55%. Finally, the software developed by https://www.embodiedlabs.com is mentioned, which was present in two of the reviewed articles, resulting in a percentage of 5%.

5 Risk of bias analysis

A risk of bias analysis of the selected literature was carried out using the analysis tool proposed by Sterne et al. [ 32 ]. To perform this analysis, both qualitative and quantitative research designs, including experimental, non-experimental, and correlational designs, were considered. This is because these types of designs can be assessed using the tool, and a total of 32 articles were analyzed and the results are shown in Table 11 . In this table, 5 dimensions are assessed by using a group of criterions and finally the overall bias for each study is calculated. Table 11 shows the average score obtained for each dimension for the total of articles analyzed Fig. 2 .

The Table 11 with the case analysis shows the percentage values ​​of the categories or dimensions and the slight biases.

Risk of bias analysis

On one hand, it can be observed that all the dimensions analyzed by the instrument meet or exceed the 74,1% threshold for low risk of bias overall. However, it is relevant to note that the dimensions of randomization, measurement of the outcome, and selection of the reported outcome show a percentage of medium risk or are categorized as ‘some concerns,’ with a maximum of 22,2% for the first, 3,7% and 7,4% for the latter two, respectively. It is important to highlight that only one study, in a single dimension (variation in the intervention), presents a high risk of bias due to a lack of information when assessing research criteria.

In general, a predominantly low risk of bias trend was obtained in the studies analyzed, with at least 74,10% assessed by both the researchers and the instrument’s algorithm. However, the remaining 25,90% of the studies analyzed presented a moderate or high risk of bias. These studies may be more susceptible to systematic errors that could influence the results and conclusions, emphasizing the importance of caution when interpreting these findings and considering potential limitations in the available evidence.

6 Discussion

Although the different bibliographical sources consulted differ slightly in their focus of interest, such as the systematic review by Lee et al. [ 19 ], who explored the design and effectiveness of virtual patient-based medical communication skills training systems through 14 mostly quantitative studies, finding that effective virtual patient systems include well-designed educational interventions, human feedback, and reflection after the activity. Similar results to the systematic review presented in this paper are presented because it confirms that virtual reality increases and improves empathy processes, a result that is also present in the meta-analysis by Ventura et al. [ 14 ] whose main interest is focused on clarifying the existing research on virtual reality as a means to provoke empathy. The results reveal statistically significant positive changes in perspective taking after VR exposure. Likewise, Gerry et al. [ 11 ] investigated the efficacy of VR training for empathy and compassion. These components correspond to three key design characteristics of immersive VR technologies: biofeedback, perspective taking, and simulation, thus demonstrating that empathy can be trained and promoted thanks to different immersive technologies. This is something that is intended to be emphasized throughout this systematic review. Finally, Foxman et al. [ 20 ] propose that empathy is a term that journalists and researchers aspire to show the potential of immersive media for prosocial change, building on fundamental research in the field. However, it is not the only field of interest. Therefore, our systematic review seeks to delve into various areas such as the arts, education, marketing, neurosciences, and other previously mentioned areas in which VR, AR, and empathy are treated as an area of interest. The main purpose of this systematic literature review is to show an overview of the research done in the field of VR and AR to promote empathy. In this section, the results and identified trends are interpreted, the effects and relationships found will be examined, as well as the differences or similarities between subgroups and analyzed variables. Furthermore, these results will be contextualized with the existing literature, allowing for the establishment of connections and significant contributions to the field of study.

6.1 Is AR and VR effective for fostering empathy?

By analyzing current research in the field of AR and VR to develop empathy, the main conclusion is that: It is premature at this early stage to consider VR as a medium that generates empathy over other media such as film, television or photography. This finding is also in line with the findings by Sora-Domenjó [ 33 ]. This finding is also supported by previous research stating that there still a lack of empirical support for the popular claim of VR as the “ultimate empathy machine” [ 34 ]. It is clear from the research that, under certain conditions, alterations in one’s own digital representation of oneself can have a significant impact on how a person behaves in a virtual environment and that also affects their behaviors and attitudes, promoting some of the qualities of empathy. The results also indicate a lack of consensus when considering VR as a narrative medium that provokes empathy due to its immersive qualities. Empathy is a complex phenomenon where cultural and personal implications can affect VR experiences, modulating and differentiating empathy awareness depending on each person.

As shown in this article, some VR experiences designed to elicit empathy could generate negative and counterproductive effects in relation to the outgroup, depending on the subjects and the experimental design. It has been widely demonstrated that empathy in virtual reality films includes, at a minimum, social, cultural, and physical biases that can hinder empathic responses, and that different technical configurations may also be related to these affective responses. The role of interactivity and action in arousing empathy in virtual reality experiences using current technical configurations does not appear to be particularly relevant.

Furthermore, although some results suggest that VR cinematic experiences can modulate emotions and empathy in a short period of time for a specific group of people, the long-term effects of exposure with VR is still unclear, as researchers point out [ 33 ]. Based on the previous effects of mobile and web exposure, one can predict that immersive virtual reality technologies could eventually have similar or even worse results, affecting the same limbic areas involved in sympathetic resonance.

A related comment has been made about the need to consider the “conceptual position of the subject” in relation to the personal narratives developed (especially in VR social films) and the audience. Furthermore, at these stages of VR development, the reflection on the future consequences of using VR is necessary because the impact of VR on society is difficult to predict [ 33 ]. According to Sora-Domenjó [ 33 ], VR experiences could be defined as part of a collective reflection. In that regard, co-design and co-creation methodologies could be effective so that stakeholders can actively participate in the design and development process so that VR experiences can be more effective to develop empathy in certain fields.

6.2 Methodological aspects of studies about AR and VR to develop empathy

It is important to contrast the results considering the findings by Dhar et al. [ 18 ], where it is stated that virtual reality immersion devices are safe, effective, and appealing to participants despite their interdisciplinary variations. From this perspective, it can be confirmed that these findings demonstrate the wide range of areas, especially education and medicine, that have explored the potential of virtual and augmented reality as tools for fostering empathy in a transdisciplinary manner, as evidenced in the Section 4 (Table 3 ). Additionally, the importance of considering multiple data collection instruments in the study of empathy is highlighted, with the IRI report being the most relevant. This result echoes the findings by Mestre Escrivá et al. [ 35 ]: “The Interpersonal Reactivity Index (IRI) (Davis, 1980, 1983) is one of the most widely used self-report measures to assess empathy. It has been applied in different studies to evaluate gender differences in empathic disposition” (p. 255). Furthermore, adapted questionnaires on the use of virtual reality enrich the understanding of this field and have vast potential to be explored as information gathering tools for subsequent social interventions, as presented in Section 4 (Table 5 ). Moreover, this result is in line with the results of the survey of literature by Christofi [ 13 ], who found that most of the research on VR and empathy has used self-reported instruments. An implication of this result might be that future researchers in this field should validate adaptations of the questionnaires to other languages or tailor-made questionnaires to ensure the reliability and validity of the instrument.

Moving on to the population perspective, the reported findings emphasize the need to consider studies with more than 100 participants, as corroborated in Section 4 (Table 6 ). This is relevant as it underscores the importance of sample size, offering a quantitative perspective on how participants are distributed in the context of fostering empathy through the use of virtual reality, as supported by García-García et al. [ 36 ]: “Calculating the number of participants to be included in a study (…) enables researchers to know how many individuals need to be studied to estimate the desired degree of confidence or difference between study groups” (p. 218). A bigger sample size allows researchers to conduct more robust studies that are less sensible to biased, reduce error, and increase precision. According to García-García et al. [ 36 ]. “a study with an insufficient sample size will estimate a parameter with low precision or will be unable to detect differences between groups, leading to erroneous conclusions” (p. 218).

Regarding the technological means for virtual immersion, Useche Rodríguez [ 37 ] pointed out that “360 videos can be used to present audiovisual content aimed at generating empathy in viewers. The research evaluates the effectiveness of the tool developed to support empathy in 360 videos” (p. 8). These technological means encompass a wide range of equipment used in various disciplines, with the most common being 360° video immersion devices and Oculus Rift mixed reality headsets, as evidenced in the Section 4 (Table 9 ). A possible interpretation of this result is that 360° videos are easy to deploy in VR devices, are cheaper to produce and provide more realism when compared to the development of a tailor-made VR or AR experience because VR/AR experiences require the support of software developers, and their development is more time-consuming and expensive. Moreover, in 360° videos the interaction is more limited whereas in VR/AR environments the interaction is higher. Thus, we call for more research studies that involve the development of VR/AR experiences to really exploit the potential of this technologies and uncover the real affordances of the technology to foster empathy.

Another finding in this review of literature deals with the reporting of statistically significant results in research where virtual reality or augmented reality has been used to foster empathy. In total 45.95% of the studies (as shown in Table 4 ) report statistically significant results. This finding is in line with previous research that has found that VR is effective for perspective-taking but there are still some inconclusive results regarding empathy [ 14 ] so further research is needed. Connected to this idea, according to Ordoñez [ 38 ], some of the advantages of VR and AR include “multisensory learning (sight, sound, touch), cognitive improvement, effective combination of physical and virtual worlds, high-quality 3D content and animations in real space, elimination of geographical and temporal limits, content enrichment, and user-friendliness” (p.13). In this literature review, we confirmed that another advantage of VR and AR is that these technologies are effective for developing empathy and this finding contributes to the body of knowledge on the advantages of these technologies.

Experimental research designs have been used in studies of VR and AR to develop empathy (Table 7 ). Experimental research design can be useful to identify the affordances and benefits of VR and AR to foster empathy when compared to other technologies or strategies. Moreover, changes in empathy can be identified by using pre-post tests in experimental research designs. We recommend that, in future studies, researchers use experimental research designs and more robust statistical methods such as Structural Equation Modeling (SEM) to identify some predictors of empathy during VR and AR experiences that are used to foster empathy. Moreover, there is still a lack of research on the features of VR and AR that positively influence empathy and the personal traits that might moderate the factors that influence empathy. Thus, further research is needed in this aspect.

Additionally, it is highlighted that 83.78% of the research has been published in academic journals (31 out of 37 studies reviewed as depicted in Table 8 ) and only 4 studies were published in conference papers and 2 in book chapters. This result shows that most of the research conducted in the field has been peer-reviewed and this ensures the quality of the findings in each paper.

Research has demonstrated the potential of the new organizational context of VR combined with machine learning to distinguish empathy dimensions. Unlike most evaluations that use subjective self-report measures, this approach combines neuroscience with VR, providing greater objectivity and validity to the results. This, in turn, facilitates systematic reviews analyzing the role of these techniques in the importance of immersion in different contexts, as mentioned by Parra Vargas et al. [ 26 ].

6.3 Technological aspects

In this review, we identified some technologies used to create experiences in VR and AR to develop empathy. A remarkable result is that most of the studies analyzed in this review used 360° video in VR headsets. This means that participants were, in most of the cases, passive subjects in the VR experience and therefore the effect on empathy might have been diminished as a result of the lack of interaction with some elements in the experience. However, a positive aspect of using 360° videos is that the VR experience is closer to the reality. Previous research have demonstrated that social presence (which involves the sense of being there in VR) in 360° videos has a positive effect on prosocial behaviors [ 39 ]. In that regard, future studies in which the participants’ sense of presence can be maximized could contribute to a better experience increasing the levels of empathy. Moreover, another feature of VR that can be exploited for developing empathy is embodiment. Previous research has shown that empathy might increase when some features of embodiment are present [ 40 ]. The engagement and sense of presence created by VR experiences might intensify some emotional reactions such as empathy [ 41 ]. According to Ventura et al. [ 14 ], further research should determine if the sense of presence is better than the embodiment or not. The use of other VR headsets or fully immersive VR experiences is still limited so further research on the effect of highly interactive VR experiences (apart from 360° video) might provide more insights into the real effect of VR on empathy. To date, it is unclear which device would be the most effective for presenting VR or AR experiences and this is line with the call for more research stated by Ventura et al. [ 14 ].

Research on AR or Mixed Reality (MR) to develop empathy is still in its infancy. There are few studies that use AR or MR as immersive technologies to create empathy when compared to the number of studies using VR. An interpretation of this result might be that VR as a more immersive technology could be seen as a more powerful to develop empathy when compared to less immersive technologies such as AR or MR. However, further research needs to be conducted to determine the affordances of AR and MR to develop empathy. Mobile AR could be a more affordable way of creating experiences to develop empathy because smartphones are, in general, cheaper than VR headsets and most people own smartphones that can be used to deploy mobile AR apps. Mobile AR can be used to situate experiences in the user’s context to develop empathy in certain physical contexts instead of recreating the entire context in VR.

Regarding the software used to develop immersive experiences to create empathy, most of the studies do not specify the software used and some other studies use general purpose commercial software. In that regard, there are no open source frameworks for designing and developing immersive experiences to create empathy. We call for more research to fill this gap in the literature so that the software allows to configure certain parameters to effectively create the experiences and save time in the development process.

Finally, the combination of VR/AR/MR technologies and artificial intelligence (AI) for training empathy is another field that deserves more research. The possibilities offered by generative AI might provide more personalized and adaptive experiences for empathy development and current research in this aspect is still in its infancy.

6.4 Limitations and future research directions

Finally, we found some limitations in the reviewed studies. First, the sample size was not significant, which affected the generalizability of the findings. In this sense, we suggest that future research consider larger research samples. Stavroulia & Lanitis [ 42 ] conducted a study with 69 participants. On the other hand, regarding the instructions given, some were not given adequately, guaranteeing that the participants understood and complied with them, causing confusion among the participants during the execution of the test. Additionally, in terms of descriptive studies, 9 studies were used (Table 7 ), which received negative criticism since the authors suggest that they reflected deficiencies such as the qualitative use of data, which prevented a comparison between theory and theory. the practice.

However, as a future recommendation, delving into qualitative studies is suggested since this methodology also has valuable theoretical support. According to Quecedo & Castaño [ 43 ], “a qualitative study allows us to know the personal aspect, inner life, perspectives, beliefs, concepts (…) successes and failures, moral struggle, efforts,” which are close and congruent traits when fostering empathy.

7 Limitations of this review

The main limitation of this study is that some papers might have been published in other bibliographic databases such as Web of Science and those papers were not included in this review. The categories considered in this review of literature are not unique. Other categories might be considered in the systematic literature review to obtain more information about the current state of research in the field of VR and AR to develop empathy.

8 Implications for education and training

In the realm of education, it is well-established that basic empathy is a trainable trait rather than an inherent quality [ 44 ]. This implies that individuals do not possess a predetermined amount of empathy at birth but instead develop and acquire this attribute over time. Consequently, the pivotal implication drawn from the review presented in this paper is that virtual reality (VR) emerges as an effective medium for training and fostering empathy across various educational levels, including primary, secondary, and higher education. VR’s unique capabilities allow for intricate and nuanced empathy training programs that surpass the possibilities offered by other technologies [ 45 ]. Such training programs hold significant potential for students, teachers, and society at large, fostering better relationships within the educational community, cultivating prosocial behaviors among students, broadening perspectives, promoting understanding of global inequalities, and contributing to conflict resolution and mediation.

While there exists an expanding body of literature on empathy training within healthcare, medicine, and related disciplines [ 46 ], a noticeable research gap is observed in the training of empathy within other educational domains such as psychology, marketing, and art. Consequently, future research endeavors should concentrate on investigating how empathy can be effectively trained in these diverse fields, exploring the unique variables that influence this trait within specific disciplines.

Within this review, the Empathy Index (IRI) emerged as the most employed instrument for measuring empathy. However, future studies in the realm of education and training should consider validating this instrument within educational contexts or developing new instruments tailored to educational settings. In accordance with Villalba et al.‘s [ 27 ] recommendations, a periodic revision of the IRI instrument is suggested to incorporate current discussions and advancements in empathy research. Additionally, the incorporation of physiological measures and eye-tracking technologies holds promise in offering a more objective assessment of the impact of VR on empathy.

Despite the progress in research on empathy development utilizing augmented reality (AR) and VR, a notable research gap persists in understanding how to effectively train empathy across different educational levels using these technologies. Thus, an additional implication derived from this review is the imperative need for further research dedicated to elucidating mechanisms, frameworks, and methodologies for empathy training across diverse educational levels.

9 Conclusions

This systematic review underscores the potential of VR and AR as effective tools for fostering empathy in various domains. It emphasizes the importance of larger sample sizes, validated questionnaires, and rigorous research designs to advance our understanding of the VR/AR-empathy relationship and shed light on the specific factors and personal traits that influence empathetic experiences in virtual environments. It is important to note that there is a lack of research on the use of AR or MR to develop empathy and this is a gap in the literature that requires more attention. This systematic review presents a comprehensive analysis of the relationship between VR/AR and empathy, yielding significant findings:

VR/AR immersion devices are not only safe but also effective and appealing to participants, corroborating previous research. These results confirm the broad application of VR and AR in fostering empathy, particularly in education and medicine. However, more research is needed to identify the real affordances of VR/AR to develop empathy.

To study empathy, it is crucial to employ multiple data collection instruments, with the IRI report emerging as the most relevant self-report measure. However, we suggest that future research can combine self-reported instruments with more objective measures such as physiological measurements to have more insights into the effect of AR/VR technologies on empathy.

The use of adapted questionnaires tailored to VR/AR enhances the understanding of the field and holds potential as information-gathering tools for social interventions. Future researchers should validate questionnaire adaptations in different languages or develop customized instruments to ensure the reliability and validity of the assessment.

Large sample sizes (over 100 participants) are vital in VR/AR-based empathy research to provide a quantitative perspective on participant distribution. Robust studies with larger sample sizes minimize biases, reduce errors, enhance precision, and facilitates generalizability of results.

Technological means for virtual immersion, such as 360° videos and VR headsets, have gained popularity in fostering empathy across diverse disciplines. While 360° videos offer cost-effective and realistic experiences, VR environments provide higher interaction possibilities. Furthermore, the noticeable absence of research on augmented reality (AR) and mixed reality (MR) for empathy development becomes apparent in the studies scrutinized. Consequently, it is imperative for future research endeavors to delve deeper into and explore the untapped potential of AR or MR experiences in promoting and enhancing empathy.

Approximately 45.95% of the studies reported statistically significant results regarding the effectiveness of VR or AR in fostering empathy. However, the field still lacks conclusive evidence, necessitating further research to gain a comprehensive understanding of the impact of VR/AR/MR on empathy.

VR and AR offer various advantages, including multisensory learning, cognitive improvement, content enrichment, and user-friendliness. This review adds to the body of knowledge by highlighting their effectiveness in developing empathy.

Experimental research designs have commonly been employed in VR/AR empathy studies to identify the affordances and benefits of these technologies. Pre-post tests in experimental designs enable the identification of changes in empathy. Future studies should utilize experimental designs and robust statistical methods, such as Structural Equation Modeling (SEM), to identify predictors of empathy during VR/AR experiences and explore the influential features and personal traits.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Open Access funding provided by Colombia Consortium. This research was funded by COMISIÓN DE REGULACIÓN DE COMUNICACIONES - CRC and MINISTERIO DE CIENCIA, TECNOLOGIA E INNOVACIÓN from Colombia. This article belongs to the products of the research project entitled “Co-creación de narrativas inmersivas sobre migración en Colombia: una propuesta metodológica” presented and approved under the research call 908 from MINCIENCIAS “Nuevo conocimiento, desarrollo tecnológico e innovación para el fortalecimiento de los sectores de TIC, postal y de contenidos audiovisuales”. This study was developed by researchers from Fundación Universitaria Konrad Lorenz.

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Jose Lacle-Melendez & Sofia Silva-Medina

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All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Jose Ignacio Lacle-Melendez and Sofia Vanesa Silva-Medina. The first draft of the manuscript was written by Jose Ignacio Lacle-Melendez and Sofia Vanesa Silva-Medina. Jorge Bacca-Acosta commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Jorge Bacca-Acosta .

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Lacle-Melendez, J., Silva-Medina, S. & Bacca-Acosta, J. Virtual and augmented reality to develop empathy: a systematic literature review. Multimed Tools Appl (2024). https://doi.org/10.1007/s11042-024-19191-y

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Received : 21 July 2023

Revised : 17 February 2024

Accepted : 02 April 2024

Published : 04 May 2024

DOI : https://doi.org/10.1007/s11042-024-19191-y

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