Creating Patient Context: Empathy and Attitudes Toward Diabetes Following Virtual Immersion

Abstract

Background:

Pandemic circumstances created challenges for doctor of physical therapy (DPT) students to understand social determinants of health (SDH) in clinical rotations. Instead of canceling clinical rotations, a virtual reality cinema (cine-VR) education series was implemented. The purpose of this project is to describe the effect of this simulated immersion on student empathy and attitudes toward diabetes.

Method:

The DPT students (n=59) participated in 12 cine-VR education modules, completing surveys at three time points as part of coursework. The students completed baseline measures of the Diabetes Attitude Scale–Version 3 (DAS-3) and Jefferson Empathy Scale (JES), and then were immersed in 12 cine-VR modules. One week after module completion, students participated in a class discussion about the modules. The students repeated the JES and DAS-3 scales at postclass and six weeks later. Three subscales from the Presence Questionnaire (PQ) were used to measure the virtual experience.

Results:

Student scores on three DAS-3 subscales significantly improved on posttest: Attitude toward patient autonomy, Mean: 0.75, SD: 0.45; t(58) = 12.742, P < .001; Psychosocial impact of diabetes, Mean: −0.21, SD: 0.41; t(58) = −3.854, P < .001; and Seriousness of type 2 diabetes, Mean: −039, SD: 0.44; t(58) = −6.780, P < .001, with lower scores six weeks later. Student scores increased on the JES and remained high (P < .001). High subscale scores on the PQ demonstrated immersion and involvement in the virtual experience.

Discussion:

These modules can allow for a shared student experience that improves diabetes attitudes, increases empathy, and fosters meaningful classroom discussion. The cine-VR experience is flexible, and modules allow students to engage in aspects of a patient’s life that were not available otherwise.

Introduction/Background

Social determinants of health (SDH) are circumstances over the life course that affect functioning and risks related to health outcomes. Disparities are associated with SDH ¹ and, although health care and disease prevention strategies have improved, health disparities persist and may intensify for people with chronic conditions such as diabetes. ² For example, people with diabetes who are experiencing food insecurity may not have healthier food options and the lack of transportation may prevent them from accessing quality health care. In a scientific review of the impact of SDH on care for the chronic condition of diabetes, interventions addressing SDH improved outcomes. ³ Interventions that addressed SDH for people with low literacy/health numeracy improved diabetes self-management for people with type 2 diabetes ³ and can improve diabetes knowledge and self-care ⁴ To address SDH disparities, another intervention conducted a pilot program providing healthy food, blood glucose monitoring, self-management support, and primary care referrals. Improvements in A1C, fruit and vegetable consumption, increased self-efficacy, and medication adherence were found; ⁵ comparable results were also found in a randomized controlled trial of the intervention. ⁶

Social determinants of health are aspects of the patient context that health professionals may not adequately assess during the clinical encounter, despite being essential components of a patient’s overall health status. ⁷ The need for improved education in SDH and humanistic aspects of health care has been identified as one of the emerging trends critical to the future of health professions education, ⁸ such as physical therapist practice. ⁷ Therefore, health professions students must recognize the importance of integrating SDH into clinical care to achieve favorable outcomes; however, simply discussing SDH may not be sufficient to foster awareness and agency.

Broadening the capacity for empathy is recognized as a mechanism to facilitate connection between students and patients. Social empathy allows “the ability to understand people by perceiving or experiencing their life situations and as a result, gaining insight into structural inequalities and disparities.”^{9 -11} Empathic capacity also enhances therapeutic relationships and patient outcomes ¹² by viewing patients as people, not just medical conditions. ¹³ Amini (2021) argues that minimal understanding of the effects of SDH in dental practice may negatively impact outcomes by causing unconscious bias, and that improving empathy will provide clinicians strategies to mitigate the negative effects of SDH on health. ¹⁴ A similar argument is offered by Yeary et al ¹⁵ stating that improved empathy can overcome unconscious bias that contributes to health care disparities. Peralta et al ¹⁶ offers promising outcomes in describing the effects of an SDH curriculum on empathy levels of medical residents in pediatrics, although data remain unpublished. Because improving empathy in health professions students is challenging, and typically requires exposure to patients in clinical care environments, recent pandemic restrictions necessitated an innovative approach to simulate patient exposure for doctor of physical therapy (DPT) students in lieu of an early clinical rotation.

Wellbery asserts that educational curricula must develop new methods of engaging students in the care of vulnerable groups as the effects of SDH on health disparities and outcomes are increasingly understood. ¹⁷ Virtual reality and simulation have been effective teaching modalities to increase empathy toward older adults across several health professions programs, including physical therapy education.^18,19 Specifically, virtual reality cinema (cine-VR) has been used as an innovative approach to improve diabetes attitudes among health care practitioners and administrators. ²⁰ Virtual reality cinema provides an opportunity to interact with a patient and to observe how the environment is related to the patient’s values and health behaviors. Moreau recommends storytelling as a powerful tool to facilitate student immersion in another’s experience. ²¹ Digital storytelling in health professions education may facilitate development of several skills, such as (1) understanding diversity, oppression, and social justice issues; (2) conceptualizing patient-centered care; (3) caring for underserved populations; and (4) caring for those with chronic health conditions. ²¹ To provide DPT students a meaningful connection with a patient’s lived experience, digital storytelling was implemented using cine-VR modules as an innovative alternative to direct clinical exposure to allow students to envision the effect of SDH on health decisions, improving empathy and attitudes toward the patient experience and needs. ²⁰ This project’s purpose is to describe the effect of the cine-VR virtual immersion on DPT students’ empathy and attitudes toward diabetes.

Methods

Overview

This project received exempt approval from the academic institution’s institutional review board (IRB). A mixed-methods convergence design with qualitative data interpreting the quantitative findings was employed.

Recruitment

Students were recruited from a second semester DPT course, Psychosocial Aspects of Healthcare, designed to provide foundational knowledge and application of the behavioral sciences to clinical practice. Students develop professional identity and role with others to enhance interactions with patients/clients, family, caregivers, and providers. Students also engage in self-assessment and exploration of personal beliefs, biases, and judgments related to human interactions required of a health care professional, identifying critical issues influencing health beliefs and behaviors in the larger contextual framework of practice including SDH.

Students were sent surveys at three time points: baseline, post assessment, and six-weeks after the postsurvey. The first survey asked for permission to use their responses for our study and all students agreed.

Power Analysis

An a priori power analysis using Statulator, ²² an online statistical calculator, estimated need for a total sample size of 34 participants to achieve 80% power at a 5% significance level (P < .05) and to detect an effect size of 0.5 between two pairs.

Cinematic 360° Virtual Reality Simulations

The simulated patient encounter utilized a professionally produced, 360°, virtual reality cinematic (cine-VR) video designed to educate students about diabetes and SDH. Students viewed 12 cine-VR, such as 360° audio and visual simulations, giving the viewer a sense of physical presence in the space, observing interactions between the main character and their primary care physician, pharmacist, family, and community. The cine-VR simulations are described in detail elsewhere.^20,23 The main character is Lula Mae, a 72-year-old woman with type-2 diabetes experiencing the negative effects of SDH on health care access and decisions. Lula Mae is a primary source of support for her extended family; therefore, her own health care needs are deferred to meet the daily needs of the people she loves. Strong subthemes include provider burnout, challenges with managing the health care system, and the importance of compassion in health care. Especially pertinent to DPT students are vignettes that highlight fall risks in the home and a developing foot ulcer, coupled with Lula Mae’s hesitancy to consult her physician.

Measures

Quantitative measures were administered at three time points: baseline, post-cine-VR intervention, and 6 weeks after the initial postassessment.

Diabetes Attitude Scale–Version 3

The Diabetes Attitude Scale–Version 3 (DAS-3) ²⁴ is a 33-item scale that measures diabetes-related attitudes with five discrete subscales: (1) Need for special training (Cronbach’s α=.67), (2) Seriousness of type 2 diabetes (Cronbach’s α=.80), (3) Value of tight glucose control (Cronbach’s α=.72), (4) Psychosocial impact of diabetes (Cronbach’s α=.65), and (5) Attitude toward patient autonomy (Cronbach’s α=.76). Health care professionals are asked to rate their level of agreement on a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The scale demonstrates good internal consistency and high content validity. ²⁴ Sample statements include the following: “People who do not need to take insulin to treat their diabetes have a pretty mild disease”; “Diabetes affects almost every part of a diabetic person’s life”; and “Tight control is too much work.”

Jefferson Empathy Scale

The Jefferson Empathy Scale (JES) is a valid scale used to measure empathy in health professions education. Empathy is conceptualized as “A cognitive (as opposed to affective) attribute that involves an understanding of the inner experiences and perspectives of the patient, combined with a capability to communicate this understanding to the patient.”^25,26 Sample questions include the following: “I try to think like my patients to render better care” and “Empathy is a therapeutic skill without which success in treatment is limited.”

Presence Questionnaire

The 32-item Presence Questionnaire (PQ) ²⁷ was used at postassessment and measures the subjective experience of being in a virtual environment when a person is physically situated in another. It uses a seven-point scale, ranging from 1 (not at all) to 4 to 7 (completely). We used a subset of 15 questions from the questionnaire (Cronbach’s α=.88) and calculated our own internal consistency for each subscale using a reliability analysis. There were three subscales: (1) Involvement, (2) Sensory Fidelity, and (3) Adaptation and Immersion. Involvement measured the participants’ sense of being a part of the environment (Cronbach’s α=.81). Sample questions included the following: “How natural did your interactions with the environment seem?” and “How much did your experiences in the virtual environment seem consistent with your real-world experiences?” Sensory Fidelity measured how well the participant perceived a sensory experience (Cronbach’s α=.72). Sample questions included the following: “How well could you identify sounds?” and “How closely were you able to examine objects?” Adaptation and Immersion measured how well the participant adapted to the immersive environment (Cronbach’s α=.77). Sample questions included the following: “How quickly did you adjust to the virtual environment experience?” and “Was the information provided through different senses in the virtual environment (eg, vision, hearing) consistent?”

Data Collection

The DPT students completed baseline assessments prefaced with informed consent prior to viewing the 12 modules introducing them to their patient, Lula Mae. Baseline assessment included demographic questions, the DAS-3, and the JES. The students viewed all modules, which were 12 individual video lessons, taking about 70 minutes to view. During a subsequent class, students were given time to reflect upon the cine-VR using a clinical narrative process. ²⁸ Students were provided with the link to the post assessments for the three scales, including their identifier, to ensure proper matching. Six weeks after post assessment, students were emailed the final assessment.

Classroom Debriefing

Classroom discussion occurred one week after the reflection exercise and initial post assessment. Discussion was facilitated by the instructor and recorded using Zoom conferencing. Semistructured questions were used to prompt discussion, such as understanding personal stressors for Lula Mae, food insecurity, transportation challenges, paying for prescription medication, understanding and navigating the broader health care system, provider burnout, and comorbidities associated with diabetes. This convenience sample included all students who chose to take part in the discussion.

Data Analysis

Quantitative data

Statistical analyses were completed using SPSS Version 27.0. ²⁹ Baseline and post assessment data were matched using student identifiers. Paired t tests were conducted to determine differences in scales and subscales from baseline to post assessment scores. Repeated measures analysis of variance (ANOVA) determined differences among baseline, post assessment, and six-week assessment data.

Qualitative data

Recorded narrative data were transcribed verbatim, yielding low-inference data. Additional standards of verification were employed to enhance the study’s methodologic rigor. ³⁰ Two coders triangulated data sources during the open coding phase, assisted by use of the software program MAXQDA Version 20.1.1. ³¹ During this process, a project team member who was involved in development of the virtual modules (E.B.) and a project investigator (J.W.) reviewed all transcripts and coded independently. Investigators then examined, compared, expanded, or condensed all codes until saturation was reached and themes were sufficiently categorized. When discrepancies were found, the negative cases were analyzed to determine whether additional codes were needed. Finally, rigor was enhanced by an external audit of the data analysis performed by a project investigator with expertise in qualitative methods, but who had not participated in initial phases of data reduction and analysis (T.C.). The selected quotations best represent the resultant themes from the narrative data.

Quantitative Results

Demographics

All participants were first-year DPT students. Most students were white (82.6%) and female (68.9%). Most of the students were on the urban campus in Omaha (81.5%), versus the rural campus in Kearney (18.5%). In addition, 52.5% of students indicated they had a close friend or family member with diabetes.

Baseline assessments included all 121 students from both campuses. Post assessment included 93 students (76.9% response rate), resulting in 93 matched surveys from baseline to post assessment. The 6-week post survey included 58 (47.9% response rate) matched assessments across all three time points.

Diabetes Attitude Scale–Version 3

Mean and standard deviation scores for the five DAS-3 subscales were calculated (Means are shown in Table 1). Students agreed with Need for special training (Mean: 4.65, SD: 0.32), Seriousness of type 2 diabetes (Mean: 4.04, SD: 0.49), Value of tight glucose control (Mean: 3.88, SD: 0.41), Psychosocial impact of diabetes (Mean: 4.22, SD: 0.44), and Attitude toward patient autonomy (Mean: 3.98, SD: 0.43). After viewing the 12 modules, four of the DAS-3 subscales significantly increased: Seriousness of type 2 diabetes, Mean: 4.32, SD: 0.46; t(59) = −4.936, P < .001, Value of tight glucose control, Mean: 4.01, SD: 0.48; t(59) = −2.547, P = .013, Psychosocial impact of diabetes, Mean: 4.62, SD: 0.39; t(59) = −6.807, P < .001, and Attitude toward patient autonomy, Mean: 4.22, SD: 0.36; t(59) = −5.604, P < .001. No significant change in Need for special training was observed. Results include 59 student responses matched across all three time points. Three domains significantly increased from baseline assessment at the six-week time point: Attitude toward patient autonomy, Mean: 0.75, SD: 0.45; t(58) =12.742, P < .001, Psychosocial impact of diabetes, Mean: −0.21, SD: 0.41; t(58) = −3.854, P < .001, and Seriousness of type 2 diabetes, Mean: −039, SD: 0.44; t(58)= −6.780, P < .001, indicating a sustained effect over time. However, Value of tight glucose control, Mean: 0.92, SD: 0.34; t(58) = 20.764, P < .001, significantly decreased. Need for special training, Mean: 0.05, SD: 0.36; t(58) = 1.158, I = .25, was not significantly different from baseline assessment to 6-week follow-up due to the ceiling effect.

Table 1.

Mean Differences in Diabetes Attitude Scale–Version 3 Subscales Premean and Postmean.

Subscale	Baseline Mean (SD)	Post Mean (SD)	P value
Need for special training	4.65 (0.32)	4.73 (0.38)	.08
Seriousness of type 2 diabetes	4.04 (0.49)	4.32 (0.46)	<.001
Value of tight glucose control	3.88 (0.41)	4.01 (0.48)	.01
Psychosocial impact of diabetes	4.22 (0.44)	4.62 (0.39)	<.001
Attitude toward patient autonomy	3.98 (0.43)	4.22 (0.36)	<.001

Responses were from 1 (strongly disagree) to 5 (strongly agree).

Jefferson Empathy Scale

Students scored moderately high on the JES baseline assessment (Mean: 81.87, SD: 3.93) and higher after viewing the modules, Mean: −080, SD: 4.31; t(59)= −1.437, P < .078.

Six weeks following postassessment, students received the link with the DAS-3 (Figure 1) and JES (Figure 2).

Figure 1.

Differences in DAS-3 subscales at baseline, post assessment, and 6 weeks (n = 59).

Figure 2.

Jefferson Empathy Scale (n = 58) baseline, post assessment, and six weeks.

Repeated measures ANOVA with Greenhouse-Geiser correction determined that JES scores differed significantly among the three time points, F(1.941, 11.682) = 48.796, P < .001. Post hoc analysis with a Bonferroni correction adjustment revealed that JES statistically increased from baseline to post assessment, 5.74 (95% confidence interval [CI]: [4.30, 7.19]), P < .001, from baseline to six weeks, 0.90 (95% CI: [−611, 2.40]), P < .001, and from post assessment to six weeks, −0.90 (95% CI:[ −2.40, 0.61]), P < .001. These data suggest that the cine-VR 12-module simulation had a sustained impact on students’ empathy.

Presence Questionnaire

Following the virtual patient encounter, we observed mean scores ≥5.08 from a maximum score of 7.0, for all three subscales: Involvement (Mean: 5.41, SD: 0.83), Sensory Fidelity (Mean: 5.12, SD: 0.92), and Adaptation and Immersion (Mean: 5.08, SD: 0.64. The high subscale scores demonstrate favorable perceptions of the technology and sense of presence in the cine-VR simulations.

Qualitative Results

Seventeen students actively participated in the focus group discussion. The following themes emerged from data analysis (refer to Table 2 for additional rich quotes):

Table 2.

Representative Quotations from the Classroom Discussion.

Students felt emotionally invested in the patient’s life
“Big thing that stuck out for me and I honestly was kind of emotionally invested into it, but just how rude she was treated at the very beginning by the doctor. I mean he didn’t even give her a chance to speak and just took out his burnout, his frustrations on her and that’s totally not acceptable.” (Student 2)“We got that flashback [simulation] where everyone was first in the relationships, and like I think one [daughter] was pregnant. He [main character’s son] was about to go off and serve [in the war] and that was like when the husband gave the ring thing [ribbons around ring finger to replace the missing wedding band] and that really got me. But I think it really took into perspective the fact how like one unexpected thing can change your life completely. So, like they might have had a really good family dynamic before that and she was saying how they used a garden in all the time and have food all the time and all of that. But now, because you can have just one small thing affect you so wholly and completely you have to keep that in mind, that everyone is probably really struggling with that change.” (Student 8)“Along those lines, it just made me reflect on I was very lucky to grow up in a family that I was provided for healthy, emotional, stable relationships with all my family members and that is not always going to be the case of the patients you treat and it’s very easy to assume your life experience on somebody else. So, I was just very struck by the differences in like the mother-daughter relationship compared to my own mother.” (Student 6)“You know how other scenes brought a tear to your eye or things like that, that transportation scene to me was I could just feel my blood pressure rising. I just felt like holy buckets. You know, it’s like why on Earth would this woman go to her doctor’s appointment? She has so many other things right now to worry about and I was trying to picture myself in that situation and don’t know how I’m going to pay for this and how the heck am I going to be able to get around and do things. She just had layer upon layer and it’s just overwhelming to think about, Oh my God, they want me to check my blood sugar. I’m not even sure how I’m going to pay for this. Just so many layers that that one that one got to me really. Feeling the stress level, I think for her.” (Student 4)
Virtual reality simulations helped students understand the impact of social determinants of health
“I think that leads into the food insecurity that they were experiencing, and Lula Mae not really being able to use that to manage her blood glucose. I remember that there was one scene, I think after the party where she was just like eating a piece of leftover cake because that’s all that there was left.” (Student 5)“I think one of the main ones inhibiting Lula Mae’s access to a doctor was the amount she had to travel to get to the doctor. I know there was the one scene where their car broke down and that was their only car too, so they weren’t able to get there on time and things like that. Just the distance inhibited her ability to access proper medical care.” (Student 12)“It seems like everyone in Lula Mae’s family was very much dependent on her. She was the Center for all this help and so even though again we talked about, you know the large family and so we just can’t assume that they’re going to be able to help with everything. But she does so much and it looked like throughout the experiences she hardly had any time for herself. And I think that’s something that we have to consider is like what is a day look like for Lula Mae? You know she’s taking care of the kids. She’s taking care of her son that had the brain damage. She’s kind of the financial backbone in a sense for when people need money like there’s so many parts. Then the family depends on and so when she is not feeling well, that’s just as it kind of spirals out of control with the family.” (Student 7)“At times you’ll have to drive farther to get to the place you’re going to. Or, as in like a city you’ll be. You can be closer to like a clinic or a doctor’s office in a rural town.You might have to drive 30 miles to get there, so being able to have a reliable mode of transportation is, and there’s not a lot of times like public transportation in rural areas. Either like a bus or something like that, she can’t rely on either.” (Student 13)“Thinking about the quality of food you know, fresh foods don’t last as long. So I mean I think about I’ve never had any struggles getting food, but when I would go camping, I remember I was getting foods that were going to last me for a long time because I was not going to be near a convenience store for a week or so and those foods that I purchased were very unhealthy, but they gave me the calories I needed.But then thinking about that and someone that does have food insecurity, they’re trying to get foods that can carry them through a week or two weeks or a month or something. They’re not thinking about. How can I keep, you know, maybe banana might last a couple days on the table, but it’s going to go bad soon. It’s gonna spoil and so thinking about you know just based off of what works for the family, like how you know and also fresh foods can be a little bit more expensive too. And so that’s another issue.” (Student 7)“I just wanted to bring up to that like in this situation. They had a food bank and they had, you know, people who might need extra access to foods with some nutritional value that that might be in place. But there’s also a stigma of needing to go and get food from a food bank that still might prevent them from going there and getting what they need.” (Student 5)
Students identified areas to improve in future provider-patient interactions
“Eye contact.” (Student 10)“He could have at least acknowledged that she was speaking instead of speaking over her every single time . . . and I don’t know that he ever really even looked at her, just whether or not there was eye contact.” (Student 5)“He also didn’t have a therapeutic tone. I think about that when I interact and practice with my patient interactions. I try to speak very softly and carefully, and kind of calmly and he wasn’t presenting that at all.” (Student 7)“All of his nonverbal communication was just very much on the negative, like pessimistic side towards her.” (Student 14)“Probably anything that has to do with paperwork. For that generation is probably really difficult at this time because there’s so much digitalization you know. Go on the Internet and register. You know, I think that I just after I saw this I just started thinking about how handicapped I would feel if I knew nothing if I didn’t even have the Internet if I didn’t know how to use the Internet. If I didn’t have a computer. You know and I know like in the clinics and not in hospitals that I’ve or the yeah the clinics I frequent, there’s, you know, go on your account. Your account sign in, you know, set up your appointments, all those things. It’s got to be super difficult for the elderly.” (Student 17)“I think a little bit of that goes back to what we did with our medical interview. Just like kind of sitting down with the patient and first like asking them what they know about what’s wrong with them and then ask them what questions they have. I think it’s really important to ask patients, not do you have questions but what questions do you have? like how you work that can open that conversation? And just understanding, what their perspective on their healthcare experiences?” (Student 2)

Feeling of Emotional Investment in Patient’s Life

When reflecting on the cine-VR simulations, many students commented on the emotional impact of their experience, acknowledging their emotional connection with the main character, Lula Mae, and how she was treated by providers and family members.

I was very emotionally invested in this, and I think I was in tears in the first 5 minutes. As we went along, I was just shocked at how her daughter treated her and they were definitely not helping.

Students described intense reactions to simulations that emphasized the barriers Lula Mae faced trying to manage type-2 diabetes. Students expressed feelings of overwhelm, anger, and frustration in watching Lula Mae struggle with these challenges. Students connected to their own family relationships and how similar or different those relationships were in the simulation.

Virtual Reality Simulations Helped Students Recognize Potential Impact of SDH

The cine-VR simulations offered students a glimpse into the home life of Lula Mae. Students observed how SDH interfered with her diabetes self-care. Students readily identified the different aspects of SDH, such as financial insecurity, food insecurity, transportation barriers, medication and supplies cost, and lack of social support:

I think a big one’s economic stability. If I remember right, they’re in Appalachia, right? So, that’s a very low-income part of America and so just being in that area usually the economic problem and then also education, the literacy could be a little bit lower than in other economically stable places.

Regarding lack of social support, students observed that having a large family did not always translate into support.

I was just really surprised that everybody kept saying, “Oh she’s got a big family.

They’ll take care of her.” The pharmacist said it. The mechanic said it. The physician said it. Everybody said the family will help and obviously the family was not helping as much as they thought they were . . . We can’t just assume that family members will take care of our patients for us once they leave the clinic.

Students Identified Areas to Improve in Future Patient-Provider Interactions

The cine-VR series portrayed problematic visits between Lula Mae and her physician and pharmacist through two interactive guided simulations of a private conversation with the provider and a re-creation of Lula Mae’s challenging visits with the physician and pharmacist. The goal was to help students recognize strategies to improve the patient-provider relationship. Students identified eye contact, therapeutic tone of voice, nonverbal communication, and interruption as areas of providers’ communication deficits. In addition, students identified failure of providers to advocate for Lula Mae in negotiating the health care system, especially when there were obvious signs that she needed assistance:

Another thing that kind of surprised me was how the people that were giving her medical care, the pharmacist, and the doctor, weren’t willing to take that extra step of asking why she was late or why have you not filled out these forms in order to get this? Or help with payment and things like that. They weren’t going that extra step in helping her.

Discussion

Principal Findings

This study assessed DPT students’ empathy and attitudes toward diabetes before and after immersion in a 360° cine-VR patient encounter. After viewing the interactive modules, significant differences in empathy levels (JES) and diabetes attitudes in four DAS-3 subscales were found, such as Seriousness of type 2 diabetes (Mean: 4.32, P < .001), Value of tight glucose control (Mean: 4.01, P = .013), Psychosocial impact of diabetes (Mean: 4.62, P < .001), and Attitude toward patient autonomy (Mean: 4.22, P < .001). No significant change in Need for special training was observed.

To determine whether these results lasted beyond the immediate postassessment, DAS-3 and JES were measured at the six-week time point. Significant increases in the subscales Attitude toward patient autonomy (Mean: 0.75, P < .00), Psychosocial impact of diabetes (Mean: −0.21, P < .001), and Seriousness of type 2 diabetes (Mean: −039, P < .001); and significant decreases in the DAS-3 subscale Value of tight control (P < .001) were observed at six weeks, with no significant difference in Need for special training (P = .25). However, significant increases in JES were maintained throughout (P < .001), indicating that the cine-VR 12-modules had a sustained impact on students’ empathy up to six weeks after intervention. Finally, high scores on the PQ indicated a sense of being immersed in technology.

It is possible that concurrent curricular exposure to the pathophysiology of diabetes in a different course may have influenced the student perception of Value of tight control as students received this instruction between postassessment and six-week assessment.

Qualitative analysis provided insight into student learning that stimulated emotional reactions, discerned “patient” context and effect of SDH on health status, and identified provider errors that jeopardized patient-provider interaction. We believe these insights may explain JES scores in students.

Similar to our study’s purpose, research in pediatrics has explored the effect of a curriculum in SDH on empathy levels in residents, and favorable outcomes in dentistry exist when using virtual reality to improve students’ empathy by simulating care for families with language barriers and limited resources. This study, however, is the first to measure empathy and attitudes specific to diabetes in physical therapy students following a virtual reality immersion to facilitate understanding of the influence of SDH on health access and decisions. In addition, implementation of the cine-VR modules in the DPT curriculum addressed several educational needs, such as student engagement in a shared “patient” experience, appreciating multiple perspectives as >60 students were immersed and filtered information differently. Debriefing was a critical reinforcer for communication and perspective in team dynamics. The modules deepened an understanding of SDH by artfully introducing into the context a “real” individual and how she, her providers, family, and community are intertwined in simultaneous navigation of a chronic health condition embedded in complex social circumstances. The cine-VR technology provided a window into areas of a patient’s life that practitioners may not recognize in routine patient care visits, whereas students can better appreciate the patient’s challenge to manage diabetes within her family and community contexts. The immersive technology also allowed a realistic “patient” encounter during a time of clinical disruption owing to COVID-19 restrictions, confirming cine-VR’s utility to enhance flexible learning experiences. In addition, students who participated in this experience independently recalled and applied Lula Mae’s situational factors during a health promotion course two years later in the DPT curriculum (fall, 2022).

Limitations

This is a small study in one DPT course over two years at a Midwestern university with two campuses; thus, there is a selection bias in not expanding to other programs and areas of the country. We note this is a homogeneous sample of DPT students in terms of race/ethnicity and may affect their responses. While identifiable student data were not shared with the instructors, students may have felt the need to respond in a socially desirable way, which could bias results. There was no control group and other classes, and experiences may have affected student responses; therefore, student attitudes may not be solely due to the intervention. The lack of matching data throughout the six-week period is a limitation as only 47.9% of students completed all three surveys.

Conclusions

The cine-VR technology can provide an engaging and enduring learning experience for students, as evidenced in this project focused on diabetes management. Using cine-VR modules as a clinical exposure has the additional advantage of flexibility within the context of a busy student schedule. Although not a substitute for direct patient interaction, these modules may augment the clinical rotation and allow for a shared experience among students that enables in-depth classroom discussion. The cine-VR technology provides realistic engagement with the “patient” context, illustrating effects of SDH on health decisions that prevent management of diabetes. This learning experience could be easily tailored for the education of health professions beyond physical therapists and complex, chronic conditions other than diabetes. Because the effects of SDH and chronicity are multifactorial and require expertise beyond individual professions, this immersive learning experience also offers a dynamic platform for interprofessional learning and a focus on meaningful change in community health promotion and disease prevention initiatives to prevent chronicity. Practitioner attitudes and empathic capacity are fundamental to patient empowerment for self-care.