Virtual simulation training: Imaged experience of dementia

Abstract

Background and objectives
The need to provide an empathic response to the care of people with dementia has long been advocated. Virtual reality‐based programmes continue to gain momentum across health sectors, becoming an innovative tool that provides staff with the opportunity to experience a dementia‐like experience within a relatively short time frame. The purpose of this study is to explore the impact of an interactive training experience on moral, emotive, behavioural and cognitive elements of empathy.

Research design and methods
A qualitative exploratory design was adopted employing purposive sampling to identify participants, aged over 18 years, who participated in the Virtual Dementia Tour (VDT®) programme. Interviews were conducted over a two‐month period, and qualitative thematic analysis was used to analyse the data.

Results
The four components (moral, emotive, behavioural and cognitive) of empathy were reflected in findings. Overall the interactive training programme was perceived as useful, and emotionally, it provided an opportunity to “imagine what it is to live with dementia,” enabling a cognitive, moral and behavioural reflection to occur, enhancing the empathic state.

Discussion
In this study, the VDT® provides a different way of learning, with participants reporting the emergence of an empathic response. Results suggest that the emotional response laid the foundations to the behavioural or cognitive (objective and subjective) reaction which was underpinned by a moral reaction.

Implications for practice
Virtual reality programmes are one step in the process for healthcare professionals caring empathetically for people with dementia; however, further research is required.

Full text

Int J Older People Nurs. 2019;00:e12243. wileyonlinelibrary.com/journal/opn 
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https://doi.org/10.1111/opn.12243
© 2019 John Wiley & Sons Ltd
Received:26Novembe r2018
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Revised:21M arch2019
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Accepted:15April2 019
DOI : 10.1111/opn.12 243
ORIGINAL ARTICLE
Virtual simulation training: Imaged experience of dementia
Paul Slater FHEA, PhD, MSc, BSc Hons, Lecturer/Statistician1 | Felicity Hasson
PhD, FHEA, MSc, Pg. Dip, BA Hons, Senior Lecturer1 | Patricia Gillen FHEA, PhD, PGD, MSc,
BSc Hons, Lecturer1 | Anne Gallen PhD, MSc, BSc (Hons), ENB, RGN, Director2 |
Randal Parlour PhD, MSc, BSc (Hons), RMN, RGN, Director of Research2
1Institute of Nursing and Health
Research, Ulster University, Belfast, UK
2Nursing/MidwiferyPlanning&
Development at Health Service Executive,
North West, Ballyshannon, Ireland
Correspondence
PaulSlater,InstituteofNursingandHealth
Research, Ulster University, Shore Road
Newtownabbey,Belfast ,Count yAntrim
BT37 0QB, UK.
Email: pf.slater@ulster.ac.uk
Funding information
Health a nd Safet y Executive, N ursing and
Midwife ryPla nning&Developm entUnit
(Nort hwest),Grant /AwardNumber:83233R
Abstract
Background and objectives: The need to provide an empathic response to the care
of people with dementia has long been advocated. Virtual reality‐based programmes
continue to gain momentum across health sectors, becoming an innovative tool that
provides staff with the opportunity to experience a dementia‐like experience within
a relatively short time frame. The purpose of this study is to explore the impact of
an interactive training experience on moral, emotive, behavioural and cognitive ele‐
ments of empathy.
Research design and methods: Aqualitativeexploratorydesignwasadoptedemploy‐
ing purposive sampling to identify participants, aged over 18 years, who participated
in the Virtual Dementia Tour (VDT®) programme. Interviews were conducted over
atwo‐monthperiod,andqualitativethematicanalysiswasusedtoanalysethedata.
Results: The four components (moral, emotive, behavioural and cognitive) of empa‐
thy were reflected in findings. Overall the interactive training programme was per‐
ceived as useful, and emotionally, it provided an opportunity to “imagine what it is to
live with dementia,” enabling a cognitive, moral and behavioural reflection to occur,
enhancing the empathic state.
Discussion: In this study, the VDT® provides a different way of learning, with par‐
ticipants reporting the emergence of an empathic response. Results suggest that the
emotional response laid the foundations to the behavioural or cognitive (objective
and subjective) reaction which was underpinned by a moral reaction.
Implications for practice: Virtual reality programmes are one step in the process for
healthcare professionals caring empathetically for people with dementia; however,
furtherresearchisrequired.
KEYWORDS
caregivers, empathy, healthcare professionals, hospital, Virtual Dementia Tour
1 | INTRODUCTION
Dementia is considered a global health priorit y with projections of the
disease set to increase dramatically across the world (World Health
Organisation, 2012, 2015). International and national policy and re‐
search have h ighlighted th e need to equip h ealthcar e professiona ls
and family caregivers not only with skills and knowledge but also an
empathic understanding of people living with a condition (Department

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of Health , 2010; Jütten et al., 2017; World He alth Organisat ion, 2008).
Research suggests people who are empathetic tend to provide bet ter
careandcanenhance patientsatisfactionandoutcomes(Ahrweiler,
Neumann,Goldblatt,Hahn,&Scheffer,2014;DalSanto,Pohl,Saiani,
&Battistelli,2013;Kim,Kaplowitz,&Johnston,2004).Whilstempa‐
thy has been defined and conceptualised in different ways (Jeffer y,
2016), the central tenet of most definitions refers to the ability to un‐
derstand another person's experiences and feelings (Cunico, Sartori,
Marognolli,&Meneghini,2012;Lemogne,2015).However,research
suggests that empathy is not a singular entity rather it is composed of
differentdimensions (Bylund& Makoul,2002).Informedbyan origi‐
nal review of the nursing literature, and further reinforced in a second
reviewbyReynoldsan dScott(1999),Morseetal.(1992)believedem‐
pathy was comprised of four key components: moral, emotive, behav‐
ioural and cognitive (see Table 1).
Whilst this model is dated, it brings together the four clinically
relevant components that have been empirically demonstrated
(Decety&Jackson,2004;Eisenberg&Eggum,2009).Otherscholars
believed empathy involved two components, cognitive and affective
(Hojat et al., 2009; Wiseman, 2007). Whilst it is unclear the extent
to which the components are interrelate d (Cutclif fe & McKenna,
2005), t he multi‐comp onent model of e mpathy ident ifies two di s‐
tinct areas: empathetic understanding and empathetic action to
emphasise the importance of the cognitive/emotive aspects on the
one hand and the behavioural/action component on the other hand
(Mercer&Reynolds,2002).
Withregardtothepersonwithdementia,thisrequiresgainingan
insight into a “fragmented and confused world which may be chang‐
ing, unpredictable and sometimes frightening” (Cunningham, 2006
citedinDigby&Lee,2016,p53).Compellingevidenceexistswhich
suggests that empathy can improve outcomes for patients, caregiv‐
ersandhealthcareprofessionals(Eversonetal.,2015;Fujimorietal.,
2014;Little,White,Kelly,Everitt,&Mercer,2015;Wijma,Veerbeek,
Prins,Pot,&Willemse,2018).
However, deficits in empathy in current clinical training and prac‐
ticeexist(Chen,Lew,Hershman,&Orlander,2007;Jeffery,2016).For
example, in the United Kingdom (UK), a number ofpublic inquiries
(Francis, 2013; Parliamentary & Health Service Ombudsman, 2015)
suggest severe failings in patient care were attributed to a lack of staff
empathy. Criticism has also been levelled at caregiver training initia‐
tives which lack practicality and transference to daily life (Cheng et al.,
2012; Jütten et al., 2017), with some caregivers finding it difficult to
understand and cope with the changing functioning and behaviour of
theirfamilymemberwithdementia(Veerbeck,Willemse,Prins,&Pot,
2016). Increasingly healthcare providers and caregivers are using vir‐
tual reality (VR) simulation as one approach to enhance empathic un‐
derstandingfor trainingandeducational purposes (Aziz, 2018; Dyer,
Swartzlanfer,& Gugliucci, 2018; Jütten et al., 2017; Elliman, Loizou,
&Loizides,2016;McDougall,2015).VRhasbeenusedforarangeof
conditions,forexample,alcoholism(Metcalf,Rossie,Stokes,Tallman,&
Tanner,2018),multiplesclerosis(Massettietal.,2016),cardiovascular
disease(Silva,Southworth,Raptis,&Sliva,2018)anddementia(Wijma
et al., 2018).
Simulation is a technique to replicate substantial aspects of
real‐world experiences in a fully interactive fashion, often immer‐
sive in nature (Gaba, 20 04). The use of virtual reality simulations
in training has grown due to their advantages over traditional ed‐
ucational methods, enabling trainees to practice procedures in a
safe environment and providing a realistic and memorable expe‐
rience in a cost‐effective manner (Triola et al., 2006). In response,
specific virtual reality programmes for dementia have emerged,
using immersive technology that utilises a perceptual and/or body
ownership illusion which claim to create empathic responses, by
putting the individual at the centre of the imagined experience.
Whilst not exhaustive, three common examples are the Virtual
DementiaExperience™(VDE™),(Alzheimer'sAustraliaVic,2014),
the mySh oes projec t (Adefila , Graham, C louder, Blutea u, & Ball,
2016) and the Vir tual Dementia Tour (VDT®) (Beville, 20 02, 2014)
(see Table 2).
Each focus on the use of virtual reality to increase dementia
awareness through being exposed to the experience of the imagined
What does this research add to existing knowledge
in gerontology?
• This study builds upon the evidence base for the use of
virtual realit y simulation programmes specifically the
Virtual Dementia Tour (VDT®), to help educate health‐
care professionals and carers about the imaged reality
of a person with dementia.
• Numerous studies report virtual reality enhances em‐
pathy generically but this study views empathy as a
multi‐dimensional phenomenon, with emotional, moral,
cognitive and behavioural (communicate) components.
What are the implications of this new knowledge
for nursing care with older people?
• The integration of the Virtual Dementia Tour (VDT®)
provides a different learning opportunity of the imaged
reality of having dementia.
• E xperiencing the imagined realit y of having dementia
andemotionalconsequenceofthatexperiencehelpsto
createanemphaticresponse.Allowing healthcare pro‐
fessionals and carers access to such experiences ena‐
bled a greater sense of understanding, awareness and
reflective caring behaviour towards a person with the
condition.
How could the findings be used to influence policy
or practice or research or education?
• Whilst virtual realit y only represent s the imaged world
of a person with dementia, it offers potential educa‐
tional opportunities upon which to build an emphatic
understanding and potentially the care being delivered.

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world of a person with the condition. Whilst claims suggest that the
programmes enhance empathy, there is a dear th of simulation fidel‐
ity and evaluative evidence of the effectiveness of virtual reality
training and its impact on participants’ sense of empathy. The Irish
National Dementia Strategy (Depar tment of Health, 2014) outlined
a commitment from the government (Department of the Taoiseach,
2016) to provide appropriate training for all those caring for peo‐
ple with Dementia. In 2016, the Health Service Executive (HSE),
North West piloted the VDT programme in North West Ireland
to health and social care staff and family caregivers. This explor‐
ative study aims to investigate the impact of the immersive Virtual
Dementia Tour (VDT®) on empathy of health and social care staf f
and caregivers.
2 | BACKGROUND
VR has bee n described as the “u ltimate empathy mac hine” (Milk,
2015); however, few studies exploring empathy using VR in de‐
mentia identifywhich components it ismeasuring.Forexample, an
evaluationoftheAustralianVDE™programmeDoubeandMcGuire
(2016),adoptingapre‐andpost‐testcontrolquasi‐experimentalde‐
sign, reported that it resulted in statistically significant increases in
empathetic understanding and knowledge of dementia when com‐
pared with classroom training. In an exploratory mixed empirical
evaluationofthemyShoesprogramme,Adefilaetal.(2016)reported
that student and social care professionals (n=55)r epo r ted in c re a se d
awareness, empathy and compassion, confidence and competence
Title Brief description
Virtual dementia
experience™ (VDE™)
(Alzheimer'sAustralia
Vic, 2 014)
Ahighresourceinteractiveenvironmentintendedasanexperiential
learningexercise.Itinvolves10×2.5mprojectionsandusesgam‐
ing technology to draw the person into the imagined lived world of
the person with Dementia
myShoes project (Ball,
Bluteau, Clouder,
Adefila,&Graham,
2015)
The developers used a stereoscopic head‐mounted device and gam‐
ing technology to immerse the wearer into an avatar body, and this
allowed them to make new connec tions with a persona that is not
theirown.Participantsarerequiredtocompleteafewscenarios,
whilstusingathink‐aloudtechnique(Cot ton&Gresty,2007)to
provide immediate access to the thought processes occurring
during immersion and reflect in real time on the experience. The
session concludes with a debriefing exercise, aimed at promoting
interac tivelearning(Rall,Manse,&Howard,2000)
Virtual Dementia Tour
(VDT®) (Beville,
2002, 2014)
Beville (2014) indicates that the VDT® programme mimics the
symptomsoflevel4,moderatedementia.Par ticipantsarenot
briefed about the VDT® process prior to entry. The VDT® process
manipulates both physical and cognitive elements in a standardised
format and timefr ame. It starts by creating the p hysical symptoms
of age, such as the subje ct wearing yellow‐tinted goggles that
mimic the effec ts of eye disease. They also wear gloves and insoles,
which have corn kernels inbuilt creating painful sensations, similar
to pain caused by peripher al ner ve damage. The gloves are de‐
signed to make it diff icult to use your hands, similar to the subject
suffering from arthritis. The cognitive effects of dementia are re‐
created by the use of noise delivered via headphones, which helps
to induce a chaotic mental st ate, similar to what some people with
dementia experience. During the VDT, the subject performs simple
tasks such as pair socks. To enable reflection to occur, subjects
can observe other subjects from an observatory area to consider
the verbal and non‐verbal reactions to the experience. The session
concludes with an oppor tunit y to observe others and then attend a
debriefing exercise
TABLE 1 Virtual reality programmes
for dementia training
Component Definition
Emotive The abilit y to subjectivel y experience and share in another's psychological
state or intrinsic feelings
Moral Aninternalaltruisticforcethatmotivatesthepracticeofempathy
Cognitive Intellectual's ability to identify and understand another's person's feelings
and perspective from an objective stance
Behavioural Communicative response to convey understanding of another's perspective
Source:MercerandReynolds(20 02,pS10)
TABLE 2 Fourcomponentsofempathy

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as measured on a standardised scale. Empathy scores increased by
7.3% immediately af ter simulatio n; confidence ch anged from 4.35
to5.75, competence from 4.36 to 5.84;andcompassionfrom8.48
to9.10.Allchangeswerepositive.QualitativefindingsfromAdefila
et al. (2016) study, suggested that it can have a positive impact on
clinical practice, helping participants think beyond “treatment” to
considering how the person might feel and altering their approach
accordingly.Forexample, oneparticipantrepor tedthatthe virtual
experienceenabledthemtozoneoutandunderstandbettertheser‐
vice user 's world which h ad conseque nces in how the y interact ed
and responded to their needs.
One of the earliest VR simulation programmes for Dementia,
the VDT® programme claims to be a replication of stage four–five
(moderate) dementia, a stage where the person with Dementia may
requireagreaterlevelofcare(Reisberg,Ferris,Leon,&Crook,1982).
The VDT® programme places the par ticipant in the realm of demen‐
tia and provides par ticipants with an imagined “insider's view” of
the condition to help better understand what it is like living with the
condition (Beville, 2014). In a study of the early version of the VDT®
programme, Beville (2002) used a repeated measures research design
with a sample of 146 participants and reported significant increases
in participants’ understanding of the emotional needs of people with
dementia, recognition of the importance of sensitisation to symp‐
toms and understanding of why people with dementia may exhibit
inappropriate behaviour. In addition, Beville (2002) also reported a
decrease in perceptions that people with dementia get the care they
require.
Whilst VR is claimed to enhance empathy, it is unclear what com‐
ponents it affects. This research stems from research undertaken
by Slater, Hasson, and Gillen (2017), that explored the impac t of the
Virtual Dementia Tour (VDT®) on empathy, using a four‐component
model (Morse et al.,1992),among healthand socialcare staff and
carers.
3 | DESIGN AND METHODS
Given the dearth of research exploring the impact of virtual training
onthefou rc om pon en tsofemp at hy, aq ua lit at ivee xpl or atorydes ig n
was adopted.
3.1 | Ethical approval
Priortothe study,ethicalapprovalwasobtainedfromthe Regional
Ethics Committees. Inter views were under taken on a voluntary
basis, and verbal/written consent was recorded before inter views
commenced. A distress and disclosure protocol was adhered to.
Alldata collected were anonymised,anddata were held in accord‐
ance with t he General Data P rotection Regul ation (2018). At the
end of the interviews, all par ticipants were signposted to sources
of support.
3.2 | Sampling frame
Fift y‐two people (both h ealthcare staff and f amily carers) who
had participated in the VDT® programme were recruited from
a Health Service Executive region in Ireland. They were catego‐
rised into six broad disciplinesseeTable 3. From the registration
list, a purposive sample of participants (n=52)wasidentifiedand
screened by the health service provider, according to the following
criteria: attended the VDT® experience; were a health and social
care employee representing hospital, community or voluntary ser‐
vices, or family carers, andaged over eighteen years.All partici‐
pants were posted an information pack, inviting them to take part
inthestudybytheHealth Ser vice Executive. Fromthissampling
frame, eighteen people who were reflective of the disciplines in‐
volvedinthetrainingprogrammetookpart(seeTable3).Allinter‐
views took place within four to six weeks of par ticipating in the
VDT® programme.
3.3 | Data collection
Aninterview schedule, basedon the aims of thestudy andthe four‐
componentmodel(Morseetal.,1992),guidedbythreebroadaspects:
(1) experiences of the VDT® programme (2) the benefits and (3) impact
oftheprogrammeonpractice.Probeswereused toclarify themean‐
ing of responses. A mixture of one‐to‐onef ace‐to‐face (undertaken
in the home and Health Service Executive premises) and telephone
interv iews were condu cted that las ted betwe en 15 and 35 min and
with permission were digitally recorded and supplemented by field
notes. All inter viewswereundert aken bytwo researchers (PF & FH),
Disciplines
Total of participants that took
part (n = 18) No (%)
Front‐linestaff(i.e.,RegisteredNurses,Healthcare
Assistants)
5(28%)
Carers and befrienders 4 (22%)
SeniorManagementincludingSer viceManagersand
Directors of Nur sing
6 (33%)
AlliedHealthProfessionals(AHPs) 1 (6%)
Medical/Psychiatrystaff 1 (6%
Other such as educationalists and Dementia service
managers
1 (6%)
TABLE 3 Disciplines of sample

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SLATER ET AL .
independently from the Health Service Executive. Data were collected
until satu ration occur red. All par ticipants we re asked to complete a 
demographicquestionnaire(i.e.,age,gender,trainingandworkexperi‐
ence) at the end of the inter views.
3.4 | Data analysis
Theinterviewrecordingswereprofessionallytranscribed. Morseet
al.'s (1992) four components of empathy were used as a framework
to analyse participants’ empathic response after taking part in the
VDT® programme.
ThedatawereanalysedusingMayring's(2000)approach,which
isafour‐stagethematicframework.Athematicframeworkwasused
in the initial analysis, and additional codes were added to ensure the
coding framework was comprehensive. After completionofcodes,
the themes and sub‐themes were critically reviewed across all inter‐
views and a coherent set of themes and sub‐themes were adopted
thusenabling comparisons. Pseudonymswereused throughout to
maintain anonymity.
3.5 | Rigour
The Consolidated Criteria for Reporting Qualitative Research
(COREQ)wasusedtoensurequalit yoftheresearchprocess(Tong,
Sainsbury,& Craig,2007), and measurestoensuretrust worthiness
ofthedatawereimplemented(Lincoln&Guba,1985).Forexample,
confirmability and dependability were enhanced by two independ‐
entresearchers(FHandPG)analysingandreviewingthetranscripts.
Credibility was assured by the triangulation of data sources (health‐
care employees and caregivers) and participants’ descriptions of
their own experiences. Transferability was assured by dense de‐
scription of the research analysis and findings and the inclusion of
quotationsinthefindings.
4 | RESULTS
Fromthefifty‐twoparticipantsinvited,eighteenagreedtotakepart,
representingaresponserateof35%.Mostparticipants(seeTable4)
were over thir ty‐five years of age and were “front‐line staff ” (such as
Registered Nurses and healthcare assistants) “senior management”
with a nursing background, with other participant s including unpaid
family carers (n=4),AlliedHealthProfessionals(AHPs)(n = 1) and
medical/psychiatric staff (n = 1).
Experience in working with dementia patient s ranged from two
years to thirty‐five years; average leng th of time was sixteen years.
Almost halfofhealthcareprofessionals(46%)suggestedtheyspent
a little time or less with patients, whilst 31% reported they spent a
moderate amount of time with patients in their role. The findings
of this study (Slater et al., 2017) are presented in accordance with
Morseetal.(1992)fourc ompo ne nt sofem pa thy.Inad di ti onforcon‐
textual reasons, a theme related to prior education experience has
also been reported.
4.1 | Prior education experience
Almost t wo thirds (61.1%) of responde nts had atte nded dement ia
education/training (other than the VDT®) in the previous two years.
Some training had a specific focus on dementia whilst other educa‐
tion stemmed from a small element within their overall professional
curricula which had a theoretical–medical focus on the physical and
biologicaspectsofthedisease.Manyreflectedthattheprofessional
preparationcourseswere inadequateinthepreparationto carefor
someonewithdementia.Asillustrated:
…almost 100% of nursing staff that I work with have
got a very limited understanding of dementia. –
there’s no comprehensive understanding, yet, they
have a continuous attendance of clients with demen‐
tia,yearlong (Par ticipantNo1,RegisteredNurse)
I think there’s a lot of people have never had any for‐
maltraining (ParticipantNo8,HealthcareManager)
4.2 | Emotive component
This theme reported participants’ emotive response, which resulted
in an emotional reaction when entering and participating in the
VDT® programm e. Prior to the VDT® experience, apprehension,
TABLE 4 Demographic characteristics of participants
Category %
Gender
Male 16.7
Female 83.3
Age
18–24 5.6
25–34 5.6
35–44 38.9
45–5 4 33.3
55–65 16.7
Position
Front‐linestaff(i.e.,RegisteredNurses,Healthcare
Assistants)
27. 8
SeniorManagement 33.3
Carers 22.2
AHPs 5.6
Medical/Psychiatrystaff 5.6
Other (i.e., academic) 5.6
Qualification
Degree 23.1
Diploma 30.8
Masters/PhD 38.5
Other (i.e., certificate) 7.7

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uneasiness or fear was expressed by some, attributed to the unfa‐
miliarit y and fear of the unknown with the simulator experience. This
ledthemtoquestiontheirabilitytomanagetheiremotions.
Entering the VDT® experience, all participants commented on
the impact of the devices and environment creating sensory distor‐
tion. This resulted in their physical and mental inabilit y to complete
what they considered to be common day activities, leading to feel‐
ingsoffrustration.Asoneparticipantstated:
You were supposed to match socks, but I couldn’t
find ‐ ver y frustrating, I was determined I had to find
them, but I couldn’t find them. So, you just give up
then. You just leave that and go to something else
 (ParticipantNo3,HealthcareEducator)
Atthe end of the programme, par ticipants were able toobser ve
others in the simulation environment, which allowed for reflection on
learning,behaviourandpracticetooccur.Asillustrated:
…it was like seeing me become a dementia person,
almost immediately. I could see the same character‐
istics of the patients that we would have, develop
immediately…. It gives you an understanding of you
know, when somebody doesn’t want to come with
you, when somebody doesn’t want to get dressed
 (ParticipantNo7,HealthcareManager)
Some participants reflected upon the inappropriate and even bi‐
zarrebehaviourtheyadoptedin directresponsetosensory distor‐
tion attributed to feelings of fear and an overriding desire to keep
safe. This resulted in some deliberately moving slowly, staying com‐
pletely still or staying close to others to shadow or mimic. Others
reported attempting to avoid human cont act instead seeking physi‐
cal surfaces to cling and attempting to physically withdraw from the
environmentleadingthemtowander.Asoneparticipantillustrated:
I couldn’t phy sically move . My whole thi ng was, stay 
still. Stay safe. Don’t move. Just it doesn’t matter what
anybody says to you, just hold your ground. “I was
afraid to move, and somebody brushed up against me
and I could feel myself jumping away from them. So,
I just stood there, literally, with my hands across, up
against my chest and in fists, just ready to defend my‐
selfinaway,butjustnotmoving (ParticipantNo7
HealthcareManager)
ParticipatingintheVDT®experiencewasrepor tedtohavean
emotionalandmentalimpact.Forexample,themisinterpretation
of the sensory environment al cues led some to respond by laugh‐
ing, use in appropria te language and q uestion t heir mental r ea‐
soning abilities, second guessing what they saw, heard and felt.
Feelings of anxiety,fearandacutefeelingsof vulnerability,dis‐
orientation, isolation and powerlessness were widely reported.
As the training progressed,anxiety shifted towardsfeelingsof
frustration, stress and annoyance which was attributed to not
being able to master simple tasks and/or lack of ability to rely
on their everyday senses. In contrast, the ability to complete a
small task created a sense of satisfaction and an achievement for
some.Asoneparticipantreflected:
You feel completely useless …How am I meant to look
for something if I can’t find any thing? So, I started pat‐
ting about and he asked me to find, I think it was blue
sunglasses or something and I felt and felt and felt,
and I realised I’d got glasses and the sense of achieve‐
ment that I felt! Yes, I found them, but they were the
wrongcolour! (ParticipantNo17FamilyCarer)
Despite the physical and psychological upset felt, all participants
considered the experience to be a powerful and effective learning tool.
Unlike traditional dementia training programmes which are theory‐
driven, this experience enabled promotion of a patient's perspective.
Allowingparticipantstoperceivewhatitwasliketo“walkintheshoes
of a person with dementia” which gave it a powerful effective message:
But misidentification, you know, misconstruing, mis‐
understanding, misrepresenting, misperceptions – all
the ‘mis’ and whilst I knew this, and I’ve been preach‐
ing it within my role, I had never really experienced it
 (ParticipantNo1RegisteredNurse).
Of all the training I’ve ever done, having been in that
….it is as close as possible to living in a world with de‐
mentia. It was the most powerful thing that I’ve ever
experienced. It really gave you a completely different
insight (ParticipantNo8,HealthcareManager).
…..because I kept thinking, this is what my daddy is
going to end up like. I found myself fighting back tears.
You often are feeling you’re looking after a stranger.
I think it’s important that the health care professions
see what is there, what it must be like for those people
 (ParticipantNo17,FamilyCarer).
This focus on the person, led all participant s to perceive the VDT®
experience as an effective educational experience and specifically
being superior to traditional educational sessions. However, some psy‐
chological distress was also repor ted, linked to a concern about devel‐
oping dementia and the effects upon a person's emotional, physical
andment alhealth.Ananxiety‐relatedresponsetothefearofdevel op‐
ingdementiacreatedan emotionalfearamongsomeparticipants.As
reflected by one participant:
I would be extremely fearful of ever being diagnosed
with dementia. I suppose one of the things that I came
away with it, from thinking how can we make people

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live longer, better and my initial thing was, if I felt like
that all the time, would I really want to live longer?
 (ParticipantNo7,HealthcareManager).
4.3 | Moral component
The opportunity to reflect on the VDT® experience and their prac‐
tice also highlighted and confirmed their moral responsibilities, both
retrospectively and prospectively. Some participants realised that
they needed to revise their practice to ensure they adopted a per‐
son‐centred approach to ensure they focus on the person not the
condition.
….to be able to look at it maybe not from a nursing per‐
spect ive... but to look at it fr om the patient’s poi nt of view
and be able to think –this is really frightening. That’s not
agitation, that’s responsive behaviour. It can really frame
the way people view a pe rson, a client and ultimately that
frames the care they get and approaches to care that are
taken (Par ticipantNo1,RegisteredNurse).
Andyouthink,howmanyolderpeoplehaveInursed,
I never understood how that impacted on their lives.
You think poor circulation, you’d be thinking, oh their
feet are cold, or give them a nice blanket at night. You
didn’t think they’re in [physical] pain. It didn’t occur to
me at any time during my 40 ‐year career, that there
was actually pain associated. Nobody ever told me
 (ParticipantNo7Healthc areManager).
However, the experience also led to some carers and health‐
care staff to reflect on the care they had delivered in the past and
feel shame and guilt for the way they previously cared for a per‐
son with dementia. This led to some participants recommending
thatpsychologicalsupportbeprovidedtotrainees.Asone carer
explained:
… this particular one person that I spoke to, said “If I’d
have known that, we wouldn’t have maybe done cer‐
tain things.” But she just said, she found it upsetting
because she had – her mother had had dementia. … we
don’t want to upset or traumatise people, as part of the
training, but think we need to be careful, or certainly
aware, that people can come out of it and find it upset‐
tingaswell (ParticipantNo8,HealthcareManager).
4.4 | Cognitive component
The third theme reported on the cognitive response, which was il‐
lustrated by the perceived and actual impact on knowledge, skills,
care and practice.
PriortoenteringtheVDT®programme,manyassociateddemen‐
tia as predominately affecting a person's memory, the programme
helped participants became aware of the other manifestations of
dementia not just memory impairment. The effect on the senses
helped participants to realise why some people with dementia have
issues relating to understanding, judgement, thinking and language.
Asoneparticipantexplained:
I had capacity going into that room. Yes, they took
away my feeling, they gave me things that hurt my
feet, they put, limited my vision and my hearing, but
I didn’t actually lose capacity, but I lost the capacity
to think, because of – and that ’s something that it
taught me, maybe these people that we think don’t
have any capacity, to make a decision, are just so
overwhelmed by all the noise and the stuff that we’re
creating around them. I didn’t lose capacity going into
there, but I acted like somebody who had no capacity
 (ParticipantNo7Healthc areManager)
Participantsalsorepor tedithelpedthemtograspwhysome peo‐
ple with dementia adopt behavioural and psychological responses such
as wandering, feeling aggression and agitation.
This experience enabled many healthcare participants to reflect
ontheirownpractice.Asstated:
…. it made me reflect on lots of interactions that I’d
had. I’d think – oh my goodness – maybe that was
what was going on and this is a better way of doing
things.Atonepointsomebodytriedtofeedmeduring
the thing and you’re like “what the hell are you doing?
What the hell is that?Where is it coming from?And
it was just instantly like – hang on, I’ve seen people
react like this. So yes, it has made me change the way
I think about it and the way I act for people with de‐
mentia (ParticipantNo4,HealthcareEducator)
4.5 | Behavioural component
Findings also indicated behavioural responses among participant s
with reports of feeling more confident to care, being more empa‐
thetic and viewing patients care holistically, and leading to a self‐re‐
ported change in behaviour. Since the programme, several examples
of healthcare staff and carer participants changing their communica‐
tive approach to suit the perceived needs of a person with dementia
werecited.Forexample,providingmoretime,maintainingeyecon‐
tact,listeningandprovidingreassurancewerecited.Asillustrated:
It has slowed me down. Whereas before, James*
doesn’t like being rushed and I would pull on his coat
and pull on his hat and hand him a cup. Now I get
why it’s slow, so it has helped me in that way. Well

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naturally if I calm down and don’t rush him, it’s going
tohelphim (ParticipantNo6,FamilyCarer).
So, I certainly would look at people differently. I’m more
aware of my voice when I speak and getting eye con‐
tact and you know – and telling her what I’m doing, as
opposed to “would you like to go” and taking her hand.
Explaining things to people, because you could hear
thatvoice (ParticipantNo7,HealthcareManager)
Allpar t ic ip ant sr ep ortedtheywerem or ea wa re an dhadagreate r
appreciation of the effect of the environment upon the person with
dementia.Manyrecognisedhowsimplechangesintheenvironment,
both within the hospital and in the home could help enhance the per‐
son‐centred approach, for example, use of colours to differentiate
objects.Participantsalsoreferredtorecognisingandattendingtothe
“little things” that matter, for example, changes in signage, improve‐
ments in food provision and the use of colours would help improve
the care experience.Consequently, some changes tothe environ‐
ment had already been undertaken, as one participant explained:
If you introduce coloured cutlery and crockery, that
they should improve their eating. So, we’ve ac tually
done that in one of the wards since, just to see if it has
anyimpact. (Par ticipantNo8,HealthcareManager).
Overall, participants voiced their enthusiasm for their engagement
withtheexperienceandbelieveditenhancedthequalityofcaredeliv‐
ered.Forst aff,itwasthoughttohaveincreasedawarenessandunder‐
standing of dementia, enhanced communication and confidence, and
lead to staff becoming less judgmental in their management of chal‐
lenging b ehaviour amo ng patient s with demen tia.. For car ers, it was
believed it would increase understanding and ultimately reduce fear,
stress and frustration, helping to inform future care options.
Ultimately, all participants believed the knowledge would chal‐
lenge current care provision, enhancing the client care experience
forthe personwithdementiaandtheirfamily.Anarrayofpotential
clinical care benefits was cited, including a reduction in falls, chest
infections, psychiatric referrals and a reliance on medication.
5 | DISCUSSION AND IMPLICATIONS
The VDT® programme seemed to increase individuals’ understand‐
ing of the imagined experience of dementia and facilitated an emo‐
tive, moral and cognitive impression of empathy according to the
Morse et a l. (1992) framewo rk. This was repo rted to have led to
changes in behaviour. Such findings have been reported in previous
research (Beville, 2002, 2014) and reflect other dementia‐specific
virtualrealityprogrammes(Adefilaetal.,2016;Doube&McGuire,
2016). The distor tion of senses and cognitive functions created by
the VDT® experience among participant s in this study elicited emo‐
tional responses of fear, frustration and helplessness and when the
participants had an opportunity to watch others in the simulator, this
enabled reflective learning to occur which formed a richer under‐
standing of the person with dementia. The importance of reflection
to improve self‐awareness and promote empathic understanding is
key in this process as it allows participant s to become aware of their
own responses, beliefs and biases.
It is this “empathetic understanding” that was reported to have
the most potential to impact on behaviour and communicative prac‐
tice.DigbyandLee(2016)consideredempathyasanessentialcom‐
ponent in compassionate care, and it features as a core element in
person‐centred care (McCormack &McCance, 2017). The findings
from this study support this perspective, as par ticipants were able
to reflect and identify previous work practices where they perceived
they were not person‐centred, identify how the care environment
could be changed to be more dementia‐friendly and felt they were
more confident in working with people with dementia. Upon reflec‐
tion, par ticipants also felt that prior education did not prepare them
to care for some with dementia or the array of symptoms associated
with this condition.
Thecomponentsofempathy(Morseetal.,1992)werereflected
in the resp onse of partici pants of the VDT® progr amme. Emotionall y,
the virtual reality programme provided an oppor tunit y to identify
a source of the “Living with dementia” experience. Participants
reported the subjective sharing of feelings with a person with de‐
mentia and provided evidence of the complexity and cycle of this
response driven by identification. For example, feeling the same
emotions as a person with dementia (i.e., fear, confusion), creating
feelings of distress in response, leading to feelings of compassion.
The cognitive component of empathy was reported by par‐
ticipants adopting what they deemed was a person with demen‐
tia's perspective (or role) to understand the person's thoughts,
or mental state, when sensory deprived. However, Morse et al.
(1992) believed that cognitive empathy was viewed from an objec‐
tive stance in order to be able to look at dementia from the other
person's perspective, yet this undermines the intertwining of the
subjective response that the participant may also experience. In
this study, participants’ own world view of dementia, which was
underpinned by their prior caring experience and training, leads to
acircular response of empathy.At a cognitivelevel, thisledmany
to reflect upon the care they delivered to a person with demen‐
tia, recognising missed opportunities and lack of understanding of
dementia. This cognitive response informed a moral and empathic
reflection, leading to feelings of distress that they were involved in
what they considered sub‐optimal care. The cognitive, moral and
empathic process translated into behavioural (including communi‐
cative) outcomes for participants where they identified changes in
practice they adopted in response. E xamples recognising the power
of touch to connect to people with dementia, the volume and tone
of language, together with the maintenance of eye contact were all
cited as examples.
Whilst the four components of empathy (Morse et al., 1992)
provide a framework upon which to understand the differences in
empathy,howtheyareinterrelated, requiresclarification(Cutcliffe

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&McKenna,2005).Inaddition,empathyisamovingconditionwhich
may be influ enced by different c ognitive, social, e ducational and co n‐
textualdeterminants.Moreover,virtualsimulationtrainingportrays
only an imagined experience of what it is like to live with demen‐
tia for a short time period. Questions regarding how empathy from
virtual realit y simulations can be nurtured and sustained to ensure
caretopeoplewithdementiaisenhancedisalsounclear.Finally,the
reasonswhyempathymachinesarerequiredalsoraisefundamental
questi ons for prac tice. As r aised by Digby a nd Lee (2016), healt h‐
care professionals face a multitude of enablers and barriers to caring
empathetically for people with dementia in hospital, such as lack of
time and resources; therefore, provision of training is only one small
step in the process. Virtual reality therefore represents only a partial
answer to enhancing the care delivered to a person with dementia.
The findings from this study reflect a growing body of evidence
on the utilisation of simulation training across professional groups
(Panetal.,2016;Piotetal.,2018),caregivers(Wijmaetal.,2018)and
across healthandeducationalsettings(McDougall, 2015;Elliman et
al., 2016; Dyer et a l., 2018). VR represent s a movement away from tr a‐
ditional classroom‐based training methods, for dementia care these
tended to be disease focused and failed to address the personhood
behindthesymptoms(Adefilaetal.,2016;Epp,2003).WhilstVRhas
the potential to expand understanding, the evidence base for this ap‐
proachiss tillgrowing.Tor ea li se it sf ullpotential,Eg anan dPot(20 16) 
recommend that VR is not delivered in isolation rather be embedded
into structured services to ensure person‐centred care is delivered.
Moreover in r elation to the V DT®ex perience, t he need to ensure 
the fidelity that such experiences represent the lived experiences of
thosewithmoderateDementiais recommended.Furthermore,lon‐
gitudinal studies measuring the effectiveness and implications of the
VDT®experienceacrosstimeandbetweengroupingsarerequired.
5.1 | Limitations
The limited amount of research on the VDT® experience indicates
an area that is little understood, and as such, this evaluation sought
to provide an insight. However, this is a small‐scale evaluation under‐
taken within one geographic area in Ireland. The findings are based
upon a small sample mainly representing females in their 3 0s and 4 0
occupying professional positions with many repor ting limited contact
withpeoplesuf feringwithdementia.Furthermore,itwasnotexplic‐
itly recorded how many participants may have accessed the VDR®
experience previously. Finally, the viewsof those who declined to
be interviewed may have differed from those reported. These issues
combined may have introduced bias and limited generalisabilit y.
These limitations suggest that the results need to be interpreted
with caution. Future research should focus on recording pre‐ and
postmeasures and assess the long‐term impact of the VDT® experi‐
ence. Whilst the findings add to a growing body of evidence on the
VDT®programme(Beville,2014,2002),furtherresearchisrequired
toconfirm many of the claimsreportedintheliterature (Adefilaet
al.,2016;Beville, 2014;Doube&McGuire,2016)andthedevelop‐
ment of empathy.
6 | CONCLUSION
In this study, the VDT® experience appears to be a learning tool,
which immerses the participant into experiencing the imagined re‐
ality of havingdementiaand emotional consequence of thatexpe‐
rience. Empathy was viewed as a multi‐dimensional phenomenon,
with emotional, moral, cognitive and behavioural (communication)
components.Participants reported the emergence of an empathic
response. This study provides an insight into the different compo‐
nents but calls for further research in this area.
There are several arguments in favour of virtual simulation in
health care such as enabling participants to learn in a simulated risk‐
free environment and perform. However, virtual simulation training
reflects an imaged experience of what it is like to live with demen‐
tia and the lack of evidence exists that it results in demonstrable
behaviour change. In conclusion, virtual reality programmes pro‐
vide additional opportunities to enhance skills and ability to offer
a practical person‐centred approach to developing an awareness of
dementia from the viewpoint of the person.
ACKNOWLEDGEMENTS
The authors wish to convey their sincere gratitude to those who par‐
ticipated in this study. This work was suppor ted by the HSE Nursing
andMidwiferyPlanning&DevelopmentUnit(Nor thwest).
CONFLICT OF INTEREST
We have no conflict of interest to declare.
ORCID
Paul Slater https://orcid.org/0000‐0003‐2318‐0705
Randal Parlour https://orcid.org/0000‐0001‐6893‐609X
REFERENCES
Adefila,A.,Graham,S.,Clouder,L.,Bluteau,P.,&Ball,S.(2016).myshoes‐
the future of experimental dementia training? The Journal of Mental
Health Training, Education and Prac tice, 11( 2), 91–10 1.
Ahrwe iler, F.,Ne umann, M., G oldblat t, H., Hahn, E . G., & Schef fer, C.
(2014). Determinants of physician empathy during medical educa‐
tion:Hypothetical conclusionsfrom an exploratory qualitativesur‐
vey of practicing physicians. BMC Medical Education, 14, 122.
Alzheimer’sAustraliaVic.(2014).VirtualDementiaExperience™.https://
vic.fight demen tia.org.au/vic/about‐us/virtu al‐demen tia‐exper ience
Implications for practice
• Virtual reality is increasingly being used in practice as one
approach to enhance empathic understanding.
• However, there is a lack of simulation fidelity and evaluative
evidence of the effectiveness of virtual reality training and
its impact on participants’ sense of empathy.

10 of 11
|
SLATER ET AL.
Aziz, H. A. (2018). Virtual reality programs applications in health‐
care. Journal of Health & Medical Informatics, 9, 1. https ://doi.
org /10. 4172/2157‐7420.10 00305
Ball, S., Bluteau, P., Clouder, D. L., Adefila, A., & Graham, S. (2015).
MyShoes: An immersivesimulation of dementia. In Proceedings of
the International Conference on e‐Learning, ICEL (pp. 16–23). Nassau,
Bahamas:AcademicConferencesLimited.ISBN:978‐191081025‐5
Beville,P.K.(2002).VirtualDementiaTour®helpssensitivehealthcare
providers. American Journal of Alzheimer’s Disease & Other Dementias,
17(3), 183–190.
Beville, P. K. (2014). Dementia S imulation: Methods and Sys tems for
simulation of cognitive decline. National Nur sing Home: Quality
ImprovementCampaign.https://www.nhqualitycampaign.org/files/
Demen tiaSi mulat ion.pdf.
Bylund,C.L.,&Makoul,G.(2002).Empathiccommunicationandgender
in the physician‐patient encounter. Patient Education Counseling, 48,
20 7–216 .
Chen,D.,Lew,R.,Hershman,W.,&Orlander,J.(2007).Across‐sec tional
measurement of medical student empathy. Journal of General Internal
Medicine, 22(10) , 1434–1438 .
Cheng,S.‐T.,Lau,R.,Emily,P.M.,Mak,E.,Ng,N.,Lam,L.,…Lee,D.(2012).
Abenefit‐findingintervention for familyc aregiversofpersonswit h
Alzheimer disease: Study protocol of a randomized controlled trial.
Trial s., 213,98.https://doi.org/10.1186/1745‐6215‐13‐98
Cotton , D. R. E., & Gr esty, K. A . (2007 ). The rhet oric and re ality of e‐
learning: Using the think‐aloud metho d to evaluate an online re‐
source. Assessment & Evaluation in Higher Education, 2(5),583–600.
Cunico, L ., Sar tori, R ., Marognolli, O., & Meneghini, A. M. (2012).
Developing empathy in nursing students: A cohort longitudinal
stud y. Journal of Clinical Nursing, 21(13–14),2016–2025.
Cunningham,A.(2006).Supportingpeoplewithdementiainacutehospi‐
tal set tings. Nursing Standard, 20(43),51–55.
Cutclif fe,J.R.,&McKenna,H.P.(2005).The essential concepts of nursing:
Building blocks for practice.Edinburgh:Elsevier/ChurchillLivingstone.
DalSanto, L., Pohl,S.,Saiani, L., & Battistelli,A .(2013).Empathy in the
emotional interactions with patients: Is it positive for nur ses too?
Journal of Nursing Education and Practice, 4(2), 74–81.
Decety,J.,&Jackson,P.L.(20 04).Thefunctionalarchitectureofhuman
empathy. Behavioral and Cognitive Neuroscience Reviews, 3( 2) , 71–10 0 .
Depar tment of Health (2010). Equity and excellence: Liberating the NHS.
London:D epar tmentofHealth.
Depar tment of Health (2014). The Irish na tional dementia strategy. Dublin:
Department of Health.
Depar tment of the Taoiseach (2016). A programme for a partnership gov‐
ernment 2011–2016. Dublin: Department of the Taoiseach.
Digby,R .,&Lee,S.(2016).Nurse empathyan dthec are ofpeople wit h
dementia. Australian Journal of Advanced Nursing, 34(1),52–59.
Doube, W., & McGuire, L. (2016). Evaluating a Vir tual Experience for
Training Carers: Can virtual reality technology engender empathetic
understanding of the experience of dementia in carers. Swinburne:
Swinburne University of Technology conference paper.
Dyer,E.,Swartzlanfer,B.J.,&Gugliucci,M.R.(2018).Usingvirtualreality
in medical education to teach empathy. Journal of the Medical Librar y
Association, 106 (4),498–500.
Egan, K . J., & Pot, A. M . (2016). Encouraging i nnovation for ass istive
health technologies in dementia: Barriers, enablers and next steps to
be taken. Journal of the American Medical Directors Association, 17(4),
357–363.
Eisenberg,N .,&Eggum,N.(2009).Empathicresponding:Sympathyand
personal distress. In J. Decety, & I. William (Eds.), The social neuro‐
science of empathy.London:Massachuset tsInstituteofTechnology.
Elliman, J., Loizou, M., & Loizides, F. (2016). Virtual reality simula‐
tion tra ining for stud ent nurse edu cation. Pap er presente d at 8th
International Conference on Games and Vir tual Worlds for Serious‐
Applic ations( VS‐G ames),Barcelona,Spain.
Epp,T.D.(2003).Person‐centreddementia care:Avisiontoberefined.
The Canadian Alzheimer Disease Review, 5(5),14–18.
Everson,N.,Levett‐Jones,T.,Lapkin,S.,Pitt,V.,Vanderriet,P.,Rossiter,R.,
…Jones, D.(2015).Measuringthe impact of a3Dsimulationexperi‐
ence on nursing students’ cultural empathy using a modified version
of the Kiersma‐Chen Empathy Scale. Journal of Clinical Nursing, 24,
2849–2858.
Francis,R. (2013). Repor t of the Mid Staffordshire NHS Foundation Trust
Public Inquiry: Executive Summary.London:TheStationeryOffice.
Fujimori,M.,Shirai, Y.,As ai,M.,Kubota,K.,Katsumata, N., &Uchitomi,
Y. (2014). Effect of communication skills training program for oncol‐
ogists based on patient preferences for communication when re‐
ceiving b ad news: A ran domized cont rolled tria l. Journal of Clinical
Oncology, 32(20), 2166–2172.
Gaba,D.M.(2004).Thefuturevisionofsimulationinhealthcare.BMJ Quality
& Safety, 13(1),00–00.https://doi.org/10.1136/qshc.2004.009878
General Data Protection Regulation (2018). European Commission
Directive 95/46/EC. Brussels: EU.
Hojat, M., Vergare, M. J., Max well, K ., Brainard, G ., Herrine, S. K.,
Isenbe rg, G. A., … G onnella, J. S. ( 2009). The devi l is in the third
year: A longitudinalstudy of erosionofempathy in medical school.
Academic Medicine, 84(9), 1182–1191.
Jeffery, D. (2016). Empathy, sympathy and compassion in healthcare: Is
there a problem? Is there a difference? Does it matter? Journal of the
Royal Societ y of Medicine, 109 (12),446–452.
Jütten,L.H.,Mark,R.E.,MarieJanssen,B.W.J.,Rietsema,J.,Droes,R.
M., & Sit skoom,M. M. (2017). Testing the effectivity of the mixed
virtu al reality training Into D 'mentia for informal caregivers of people
withdementia:Protocolforalongitudinal,quasi‐experiment alstudy.
British Medical Journal Open, 7(8),e015702.https://doi.org/10.1136/
bmjopen‐2016‐015702
Kim,S.S.,Kaplowitz,S., &Johnston,M.V.(2004).The effects ofphysi‐
cian empathy on patient satisfaction and compliance. Evaluation and
the Health Professions, 27(3),237–251.
Lemogne, C. (2015). Empathy and medicine. Bulletin De Academia
Nationale De Medicine, 199(2–3),241–252.
Lincoln,Y.S.,&Guba,G.E.(1985).Naturalistic inquiry.Newbur yPark,CA:
SagePublications.
Little,P.,White,P.,Kelly,J.,Everitt,H.,&Mercer,S.(2015).Randomised
controlled trial of a brief intervention targeting predominantly
non‐verbal communication in general practice consultations. British
Journal of General Practice, 65(635),e351–e356.
Massetti,T.,Trevizan,I.L.,Arab,C.,Favero,F.M.,Riberio‐Papa,D.C.,&
deMell oMont erio,C.B.(2016).V ir tu alr ea lit yi nmult iples clero sis‐A
systematic review. Multiple Sclerosis and Related Disorders, 8, 10 7–112 .
Mayring,P.(20 00).QualitativeContent Analysis[28paragraphs].Social
Research, 1(2), 1–10.
McCormack,B.,&McCance,T.V.(2017).Person‐centred practice in nurs‐
ing and healthcare: Theor y and prac tice (2nd ed.). Chichester: Wiley
Blackwell.
McDougall,E.M.(2015).Simulationineducationforhealthcareprofes‐
sionals. British Columbia Medical Journal, 57(10), 444–448.
Mercer, S. W., & Reyn olds, W. J. (200 2). Empathy an d quality o f care.
British Journal of General Practice, 52 (Suppl 1), 9–12.
Metcalf,M.,Rossie,K.,Stokes,K.,Tallman,C.,&Tanner,B.(2018).Virtual
Reality cue refusal video game for alcohol and cigarette recovery
suppor t: Summative study. JMIR Serious Games, 6(2), e7. https ://doi.
org/10.2196/games.9231
Milk, C. (2015). How virtua l reality can create the ultimate empathy
machine [Internet]. TED: Ideas worth spreading. https ://w ww.ted.
com/talks/ chris_milk_how_virtu al_reali ty_can_create_the_ultim ate_
empat hy_machine
Morse,J.M.,Anderson,G.,Bottorff,J.L.,Yonge,O.,O’Brien,B.,Solberg ,
S.M.,& McIveen,K .H .(1992).Exploring empathy:A conceptual fit
for nursing prac tice? Journal of Nursing Scholarship, 24(4), 273–280.

|
11 of 11
SLATER ET AL .
Pan, X ., Slater, M., Be acco, A., N avarro, X ., Bellid o Rivas, A . I., Swap p,
D., … Delacroix, S. (2016). The responses of medical general prac‐
titioners to unreasonable patient demand for antibiotics––a study
of medical ethics using immersive virtual reality. PLoS ONE, 11(2),
e0146837.
ParliamentaryandHealthServiceOmbudsman(2015).Dying without dig‐
nity.London:PHSO.
Piot, M.‐A ., Dechar tres, A., G uerrier, G., Le mogne, C., L ayat‐Burn, C.,
Fal iss ard ,B .,&Te sni er e ,A .(2 018).Eff ect i ve ne s so fs im ula ti oninpsy ‐
chiatry for initial and continuing training of healthcare professionals:
Protocol forasystematic review.British Medical Journal Open, 8(7),
e0210 12.
Rall, M ., Manse, T., & Howard , S. K. (200 0). Key eleme nts of debrie f‐
ing for simulator training. European Journal of Anaesthesiology, 17(8),
516–517.
Re is b er g ,B . ,F err is, S.H ., deL eon ,M . J. ,& Cro ok, T.(1982).Th egl oba ld e ‐
terioration scale for assessment of primary degenerative Dementia.
American Journal of Psychiatry, 139(9), 113 6–1139.
Reynolds,W.J.,&Scot t,B.(1999).Empathy:Acrucialcomponentofthe
helping relationship. Journal of Psychiatric and Mental Health Nursing,
6(5),363–370.
Silva, J. N . A., Sou thworth , M., Raptis , C., & Sliv a, J. (2018). Emerg ing
applications of virtual reality in cardiovascular medicine. JACC: Basic
to Translational Science, 3(3), 420–430. https ://doi.org /10.1016/j.
jacbts.2017.11.009
Slater, P. F., Hasso n, F.,& G illen, P. (2017). A research evaluation of an
interaction training experience: The Virtual Dementia Tour® (VDT®).
Ballyshannon, Donegal Ireland: Nursing Midwifery Planning and
Development, Health Service Executive.
Tong, A ., Sai ns bur y,P.,& Cra ig ,J.(2007 ). Co nso li dat ed cr i te riafo rr ep o rt‐
ingqualitativeresearch(COREQ):A32‐itemcheck listforinter views
and focus groups. International Journal for Quality in Health Care,
19(6),349–357.
Triola, M., Fel dman, H., K alet, A. L ., Zabar, S., K achur, E. K., Gi llespie,
C., … Lipkin,M. (20 06). A randomized trial of teaching clinical skill
usingvirtualandlivestandardizedpatient s.Journal of General Internal
Medicine, 21, 424–429.
Veerbeck , M., Willems e, B., Prins, M ., & Pot, A. (2016). D evelopment
of a virtual reality‐experience to improve empathy in caregivers
of people with dementia. The Gerontologist, 56(3), 538. ht tps://d oi.
or g/10.109 3/g er on t/gnw16 2. 2172
Wijma, M. E.,Veerbeek,M.A ., Prins,M.,Pot,M.A., & Willemse, M. B.
(2018). A virtual reality intervention to improve the understand‐
ing and empathy for people with dementia in informal caregiver s:
Results of a pilot study. Aging & Mental Health, 22(9) , 1121–1129.
Wiseman,T.(2007). Towarda holisticconceptualizationof empathyfor
nursing practice. Advances in Nursing Science., 30(3), 61–72.
World Heal th Organisation (200 8). Primary care : Putting people f irst in The
World Health report 2008: Primary Health Care, Now more than ever.
Geneva: WHO.
World Health Organisation (2012). Dementia: A public health priority.
Geneva: WHO.
World Health Organisation (2015). Dementia a public health priority.
Geneva: WHO.
How to cite this article:SlaterP,HassonF,GillenP,GallenA ,
ParlourR.Vir tualsimulationtraining:Imagedexperienceof
dementia. Int J Older People Nurs. 2019;e12243. ht t p s : //d oi.
org /10.1111/op n.12243