VR interventions aimed to induce empathy: a scoping review

Abstract

To assess the methods and outcomes of virtual reality (VR), interventions aimed at inducing empathy and to evaluate if VR could be used in this manner for disability support worker (DSW) training, as well as highlight areas for future research. The authors conducted a scoping review of studies that used VR interventions to induce empathy in participants. We searched three databases for articles published between 1960 and 2021 using “virtual reality” and “empathy” as key terms. The search yielded 707 articles, and 44 were reviewed. VR interventions largely resulted in enhanced empathy skills for participants. Most studies agreed that VR’s ability to facilitate perspective-taking was key to inducing empathy for participants. Samples were often limited to the context of healthcare, medicine, and education. This literature provides preliminary evidence for the technology’s efficacy for inducing empathy. Identified research gaps relate to limited studies done, study quality and design, best practice intervention characteristics, populations and outcomes of interest, including lack of transfer and data across real-world settings.

1 Introduction

More than one billion people worldwide experience some form of disability that impacts their daily lives (Lollar and Chamie 2020). Each person will uniquely experience the effects of disability, owing to the underlying cause of the disability, the environment in which the person lives, and resources made available to them (World Health Organization and World Bank 2011)

Historically, disability support work has been based on a paternalistic system where people with disability were considered a passive subject, receiving care designed in a general way for disabled people, deprived of considering the person's individual needs, preferences, and characteristics (Wardana and Dewi 2017). As the disability support service sector has evolved in Australia, with the view that a more inclusive client decision-making approach offers better outcomes, along with other factors, such as population growth, life expectancy increase, technology, and changing social expectations, policies and training practices have struggled to keep up (Commonwealth of Australia 2020; Koritsas 2022; Wark et al. 2014).

Although studies on disability have stated the need for advancements in support training that facilitates personalised disability support, governments and organisations around the world continue to report that there is a lack of knowledge and understanding of people with disability in the support sector (Commonwealth of Australia 2020; Van Mierlo et al. 2012; World Health Organization and World Bank 2011). Perhaps, one way to close the “knowledge and understanding” gap is to turn to VR as a training intervention that could be designed to induce empathy in the user (trainee).

Several studies have reported empathy as a key characteristic of providing quality support to people with disability (Jorgensen et al. 2009; Koritsas 2022; Lee and Brennan 1999). A key factor as to why empathy is considered an important characteristic for support workers is because it facilitates the ability to imagine oneself in the shoes of another, which helps the support worker to construct and deliver a more meaningful and beneficial support environment (Lee and Brennan 1999). However, it has been reported that the ability and likelihood to empathise with others greatly depends on a person’s personality type (Dymond 1950). For that reason, VR’s unique ability to allow a user to experience immersive perspective-taking, irrespective of their personality type, may prove to be an effective training intervention that can bridge the gap between support workers who are sensitive to cues as to how others are feeling, and those who are not. Technology also provides an opportunity to customise the VR experience to the individual learner, giving us even greater scope for training across different personality types.

Whilst VR has been defined as the “ultimate empathy machine” (Milk 2015), some researchers have argued that there is limited empirical evidence to support this claim, as well as a lack of quality research that considers pre-existing biases and attitudes that may affect the results of different types of VR empathy interventions (Herrera et al. 2018). Moreover, the evidence that does exist, supporting VR as an effective empathy enhancing intervention, is largely the result of participants self-reporting their VR experiences to researchers (Gugliucci 2019; Swartzlander et al. 2017). This can be problematic if a variety of interfering factors, such as an individual’s ability to articulate their thoughts, or the respondent has reported what they think others would expect them to feel, rather than how they felt, have not been considered (Stueber 2019). Nevertheless, in the field of empathy assessment, whilst there are different approaches to measuring empathy, the self-reporting method continues to be the most popular approach in use today (Gilet et al. 2013; Ilgunaite et al. 2017; Lawrence et al. 2004).

Even though some studies concerning VR as an empathy inducing intervention have indicated that different kinds of VR experiences can increase empathy, a study by Martingano et al. (2021) performed a subgroup analyses that revealed that VR as an empathy inducing instrument was no more effective than traditional empathy enhancing methods like reading or imagining another person’s experience. Moreover, the researchers also discovered that the more immersive and interactive VR experiences were no more effective than those delivered by cheaper devices like cardboard headsets (Martingano et al. 2021). Similarly, Herrera et al. (2018); conducted a study to compare the short and long-term effects of a VR perspective-taking task against a traditional perspective-taking task, focused on inducing empathetic responses towards the homeless. The researchers found that the self-report empathy measures for any of the perspective-taking tasks in their study did not differ between conditions (Herrera et al. 2018). Nevertheless, the researchers did report a noticeably higher number of participants in the VR condition who signed a petition supporting affordable housing for the homeless, compared to participants in the less immersive and traditional conditions (Herrera et al. 2018).

One of the few studies involving informal caregivers as participants used a VR intervention called ‘Through the D'mentia Lens’ (TDL) that allowed users to experience what living with dementia might be like (Wijma et al. 2018). Thirty-five caregivers completed the pre-test and post-test and reported that TDL provided them with greater insight into how a person with dementia may experience situations (Wijma et al. 2018). TDL consisted of a virtual reality simulation movie and e-course that was graded 8.03 out of 10 and 7.66, respectively, for ‘acceptability’ by participants, with a significant reported improvement in empathy, confidence in supporting, and positive interactions with the person who had dementia (Wijma et al. 2018). Likewise, a study by Jütten et al. (2017) also used informal caregivers as participants to assess whether a mixed VR dementia simulator training called ‘Into D’mentia’ increased their empathy and understanding of dementia. The researchers used an intervention group (n = 145) and a control group (n = 56) and found that whilst the intervention group improved understanding of dementia over time, there were no significant differences between the two groups concerning empathy, sense of competence, and relationship quality (Jütten et al. 2017).

A study by Hargrove et al. (2020) considered the theory of ‘psychological proximity’, a theory that suggests that individuals will typically empathise easier with others who more closely resemble themselves, explored how effective VR is compared to traditional physical embodiment at increasing the ostensible closeness. In the VR group, the participants follow a 13-year-old Ethiopian girl for nine minutes as she gathers water and discusses the burden that collecting water has on her life. In the embodied activity group, participants physically carried two one-gallon water jugs through a building that was temperature-controlled to add warmth for 10 min. The findings of this study suggest that the VR experience was no more effective at inducing empathy and donations than the physical embodied experience (Hargrove et al. 2020). Moreover, it was identified by the researchers that the physical embodied group donated more than their VR peers, however not significantly higher (Hargrove et al. 2020). In addition, Sulpizio et al. (2015), found that females scored higher than the males relating to empathic concern, whereas Martingano et al. (2021) reported that gender played no significant moderating factor.

Indeed, findings on VR as an effective intervention to improve empathy range from it having no effect to having significant influence and also differing depending on the type of study done and the method used (Herrera et al. 2018; McEvoy et al. 2016; Steinfeld 2020). In addition, it has been reported that there is limited empirical evidence to support VR as an effective empathy inducing intervention (Herrera et al. 2018), and this appears to be even more so in the field of disability support work training.

The current review extends knowledge in the field of disability support work training, and the use of VR technology as an empathy enhancement tool, regardless of the context or discipline by evaluating a broader range of studies using a scoping review (Arksey and O'Malley 2005). Moreover, rather than being limited to studies focused on either ‘situational empathy’ (empathic reactions in a specific situation), or ‘dispositional empathy’ (empathy that is understood as a person’s persistent character trait) (Stueber 2019); we reviewed all studies that aimed to use virtual reality (digital) intervention to improve empathy. This includes using scenarios designed to simulate real-world situations that allow the participant to see what it is like in someone else’s shoes in an immersive and interactive manner.

2 Objectives

This scoping review aimed to assess the methods and outcomes of virtual reality (VR) interventions aimed at inducing empathy and to evaluate if VR could be used in this manner for disability support worker (DSW) training, as well as highlight areas for future research. This included assessing the types of studies done, the location and context, the extent, and what facilitators and/or barriers have been attached to the success and/or failures of the use of this technology in this context. In addition, the review aims to identify and report literature on this subject matter relating to the disability support services sector. The four research questions (RQs) for this scoping review are described below.

(RQ1):

What studies have been done involving the use of VR technology as an empathy enhancement medium, and to what extent, and in what context (e.g. nursing, medicine, gaming, aged care, disability support workers) are they?

(RQ2):

What are the working definitions, and are there different terminologies being used for the same practices surrounding the use of VR technology as an empathy enhancement medium (e.g. virtual reality, augmented reality)?

(RQ3):

What facilitators and/or barriers have been attached to the success and/or failures of the use of VR technology in this context?

(RQ4):

What is known from the existing literature about the effectiveness of VR technology as an empathy enhancement tool in the disability support worker sector?

3 Methods

3.1 Study design

Since we were interested in identifying and mapping existing knowledge and concepts pertinent to VR technology as an empathy inducing intervention, a scoping review was chosen. This methodology is especially beneficial in response to the RQs in this study.

3.2 Protocol

This study was guided based on Arksey and O’Malley’s (2005) scoping review methodology, and the revised adopted framework by The Joanna Briggs Institute Scoping review manual (Peters et al. 2020). Once the research team collected relevant papers, blind screening and data assessing was performed separately by the research team using the Rayyan collaborative platform. The results were then discussed amongst the research team to fine tune any discrepancies. The research team then performed a full-text assessment for eligibility and exclusion using the Mixed Methods Appraisal Tool (MMAT) version 2018 (Hong et al. 2018).

To report our findings, we used components of the PRISMA ScR Extension Fillable Checklist provided by The Joanna Briggs Institute (Peters et al. 2020). This checklist was placed at the front of the working document to facilitate a standardised review process. The review process was carried out by all three members of the research team.

3.3 Eligibility criteria

The following inclusion criteria were used for this review: (1) articles must be written in English; (2) papers must be qualitative or quantitative design; (3) the virtual reality (digital) intervention was aimed to induce empathy; (4) the scenarios must be designed to simulate real-world situations that allow the participant to see what it is like in someone else’s shoes; (5) the experience is immersive and interactive; and (6) the approach is scientific (based on research, or evaluation). A publication date limit of 1960–2021 was applied in the search phase. Articles were excluded if they were non-English written articles, used technology that lacks the ability to interactively engage, used non-computer-generated technology (e.g. role playing, use of mannequin), as well as studies that describe technology development only.

3.4 Information sources and search strategy

The method of source selection for all stages was an iterative process that involved fortnightly zoom meetings between the research team to refine direction and developments and solve any incongruities.

The research team first settled on the inclusion and exclusion criteria, followed by consultation with a librarian with expertise in health and design to ascertain best practice relating to the navigation of the university’s online library to locate useful resources for our subject area.

Databases searched include Web of science, Scopus, and Computers and applied sciences complete (EBSCOhost). Boolean operators were also discussed with the librarian as well as the inclusion of grey articles to attain the most relevant and comprehensive search results (Fig. 1). For this reason, literature reference lists, general google searches, as well as relevant organisations, conferences, and networks were considered as sources. Using Boolean, we searched the title, abstract, and keywords in articles. All duplications were then removed using the Rayyan web tool. Any articles lacking abstracts were appropriately located and assessed to determine their inclusion. Both title/abstract screening, and full-text screening, was initially performed by the research team. The result was then divided between the research team for blind assessment. The research team then met to resolve any conflicts. The most recent search executed prior to the screening process was in January 2021.

Fig. 1

Boolean used during SCOPUS search

3.5 Study selection process

With respect to the eligibility criteria, articles were excluded if they were non-English written articles, used technology that lacks the ability to interactively engage, used non-computer-generated technology (e.g. role playing, use of mannequin), as well as studies that describe technology development only.

Owing to the nature of emerging technology, it was necessary to screen across a broad and multidisciplinary scope. To elaborate, we wanted to screen for works relating to VR technology as an empathy inducing intervention regardless of the location, context or discipline. As such, using the Rayyan web tool, we were able to highlight and screened for a combination of words and phrases where there was reference to VR technology, empathy, and user(s)/participant(s), as well as the technology’s enablement (e.g. perspective-taking, interactivity, immersive) within the titles and abstracts of articles (Fig. 2).

Fig. 2

Rayyan keyword screening

3.6 Methodological quality appraisal

In accordance with the MMAT critical appraisal tool, no overall score was used to assess the quality of the articles in this review (Hong et al. 2018).

3.7 Synthesis

A google form was used to collect the data from the MMAT analysis screening phase. The linked.csv file that captured the data was downloaded to a local drive and rendered as a single Microsoft Excel file. Multiple tabs were also constructed to normalise, breakdown, categorise, and map the data into workable and relevant tables for analysis, charting, validation, and coding (see appendices). The web-tool Rayyan was also frequently used as a point of reference and verification.

4 Results

The literature search returned 707 results (Fig. 3). Duplications were then removed using the Rayyan web tool, which resulted in 500 papers remaining. After both title/abstract screening, and full-text screening, 67 papers (n = 67) were divided between all three members of the research team for blind assessment. It was identified that 23 of the 67 papers failed to meet the eligibility criteria. The final result for inclusion was 44 papers (n = 44) (see Appendix 2). The following flow diagram from the PRISMA-ScR guidelines illustrates each stage of the review process (Fig. 3).

Fig. 3

PRISMA 2009 flow diagram

The 44 articles addressed a wide range of factors related to VR as a tool to induce empathy in participants within a variety of different contexts (see Appendix 2). Factors included discussions about the type of equipment used, the population, individuals’ experiences in different situations, and challenges and barriers that are experienced in these settings, as well as the findings and limitations of the studies.

4.1 General study characteristics

Out of the 44 articles included, 15 were done in the USA, five in the Netherlands, three in the UK, three in Cyprus, and three in Spain. Two studies were done in Australia, and two in South Korea. The remaining countries, Canada, France, Germany, Israel, Malaysia, Malta, Mexico, Italy, the Philippines, Switzerland, and Taiwan all had one study each (Table 1), (see Fig. 4). All papers included in this review were published between 2007 and 2021, with the majority (65.9%) being published after 2017 (see Appendix 2). All studies used VR technology to allow the participants, to some degree, take a first-person perspective (1PP) of what it might be like in the shoes of someone else (see Appendix 2). Finally, all studies considered how, or if, VR can be used to promote empathetic behaviours.

Table 1 Breakdown of Countries where studies was conducted and count

4.2 Studies done surrounding the use of VR technology as an empathy enhancement medium

In response to RQ1: out of the 44 articles included, 34.10% (15/44) were in the context of healthcare and medicine, making it the leading sector researching virtual reality technology as an empathy enhancement medium. In second place was the education sector with 34.10% (15/44), followed by 22.73% (10/44) of studies that fell into a broader prosocial context (see Appendix 3). Significant to the current review, no studies used ‘disability support workers’ (DSWs), and only three studies used informal caregivers (see Appendix 6).

4.3 Terminology and working definitions

In response to RQ2: out of the 44 articles included, “Virtual Reality” was the most commonly used term appearing in 97.8% (43/44) papers. Within these, 3 common working definitions were identified. This was followed by the term “Virtual environment” which appeared in 70.45% (31/44) of papers. “Empathy” was the most frequent cognitive related terminology used, appearing in 100% (44/44) studies. It was also the most frequently challenged term as it came with various definitions (see Appendix 8). The second most common cognitive related word was “Presence”, and appeared in 84.09% (37/44) studies. The most frequent word surrounding VR-related materials and hardware was “Head-mount display” appearing in 50% (22/44) studies. However, there were often alternative terms used in its place such as VR headset, which appeared in 22.73% (10/44) studies (see Appendix 8).

4.4 Facilitators attached to outcomes

In response to RQ3: out of the 44 articles included, 100% (44/44) of studies recognised perspective-taking as an important characteristic of empathy. 65.91% (29/44) papers, to some degree, ascribed VR’s capacity to enable perspective-taking as a facilitator. 45.46% (20/44) papers, noted presence, or the level of presence, as a key facilitator. It should also be noted that presence, along with immersion was frequently discussed as an interrelated factor of perspective-taking (see Appendix 10).

4.5 Barriers attached to outcomes

In response to RQ3: out of the 44 articles included, the most common reported barriers were related to a lack of “measures”, that is 56.81% (25/44). This was followed by both “sample size” and factors relating to “control and reliability”, a total of 43.19% (19/44) (see Appendix 11).

4.6 What is known from the existing literature?

In response to RQ4: out of the 44 articles included, 81.82% (36/44) of studies reported on existing literature that reinforced VR’s potential to facilitate the activation of prosocial characteristics. The remaining studies, 18.19% (8/44), reported on existing literature that used a more disputed, and/or indecisive, narrative towards VR’s capacity to facilitate the activation of prosocial characteristics (see Appendix 8). Problematic to the current review, no studies explicitly used disability support workers, with the closest cohort being informal caregivers (see Appendix 7).

5 Discussion

We performed a systematic and comprehensive scoping review that included 44 papers relating to the use of VR technology as an empathy enhancement tool. Our findings illustrate that since 2017 there has been substantial growth of interest in this area. Although not definitive, there was significant evidence to support VR as an effective intervention to induce empathy in participants, owing to its unique ability to facilitate perspective-taking, engagement, immersion, and presence (see Appendix 9). This calls into question the findings of Bang and Yildirim (2018), Deladisma et al. (2007), Herrera et al. (2018), Jütten et al. (2017), Kim et al. (2020), MacDorman (2019), McEvoy et al. (2016), and Steinfeld (2020), who found VR was not an effective intervention for enhancing empathy, or reported a more disputed, and/or indecisive outcome. In addition, some studies found interesting results when investigating the effects of viewing interventions through different display devices that are purported to facilitate a greater sense of immersion and presence, compared to less immersed systems. For example, Weinel et al. (2018) found no clear benefit in using a VR-cardboard version compared to a 360 YouTube video version, but acknowledge the inferior quality of VR-cardboard devices compared to the more expensive VR HMD solutions that offer higher resolutions and levels of immersion, which may impact the ability to induce empathy. On the other hand, Bang and Yildirim (2018) did compare a VR headset (Oculus Rift) to a YouTube 360° video, via a desktop computer, and found that even with the more expensive HMD, the empathy levels did not vary between display devices. Nevertheless, there was significant variation in the reporting and context of the studies reviewed, which could affect decision-making. Moreover, the research in this area is in its infancy, with some papers identifying important factors that weren’t considered in their study design, such as probable influences like “control”, “reliability”, and “psychometric and physiological measures”. As such, these kinds of probable influences should be considered for any future studies. Furthermore, our results suggest that the methodology used to enhance empathy via VR, can be improved. When we compared the length of the VR experience employed by the 44 studies, we identified a lack of consistency, which suggests a dearth of understanding relating to how the length of VR exposure affects participants (see Appendix 2). Similarly, we compared the types of VR head-mount display gear used and identified a significant variation between studies (see Appendix 4, Appendix 9). This suggests a lack of understanding relating to how the quality, type, and design of the equipment influences the experience. Additionally, our results suggest that the terminology and working definitions also lack consistency. When we investigated this area, we identified numerous studies that reported on the complex and/or wide-ranging definition of empathy. One explanation for this was attributed to its use by different disciplines (Stavroulia and Lanitis 2019). In any event, this lack of consensus on the meaning of empathy further highlights the need for greater definition and understanding of conditions and findings, particularly since our results illustrate the different sectors and context in which this field of research is occurring.

In regard to barriers attached to outcomes, our results suggest that a lack of measures was the most common, including the need for greater “psychometric and physiological” considerations. This was followed by sample size and diversity, and factors relating to control and reliability, which were reported by several studies to be the factor that influenced their abilities to make generalisations. In addition, we also identified other less common factors such as scenario content, time restrictions, technology, and study design limitations (see Appendix 11).

In regard to facilitators attached to outcomes, our results suggest that perspective-taking is the most commonly agreed factor that facilitates empathy. Despite the fact that VR has been labelled the “ultimate empathy machine” (Milk 2015); it is VR’s ability to allow perspective-taking, as well as other interrelated factors, such as presence, immersion, embodiment, and interactivity that has made it popular amongst researchers in this field (Barbot and Kaufman 2020; Ventura et al. 2021). The level of these factors was also reported as playing a key role in influencing prosocial change in participants, as well as other factors such as, the level of user VR experience, avatar relatability, and individual personality qualities. However, this varied across studies, suggesting a lack of consensus and understanding concerning individual facilitators and how they influence the VR experience. Therefore, it could be argued that the addition of a more holistic and longitudinal standpoint is needed to appreciate how these interrelated factors best work together in VR environments to activate prosocial qualities.

In regard to the existing literature, our results point to VR as a promising medium to facilitate the activation of prosocial characteristics, including empathy. Though some studies did provide indecisive or disputative findings, an explanation for this could be the infancy of their research as well as measuring and sample limitations.

It should be noted that there are some limitations in our scoping review. First, the nature of scoping reviews is that the focus is on breadth rather than depth of information, which is the case here. Secondly, though it is generally accepted that meta-analyses are not typical characteristics of scoping reviews, it was appropriate for our objectives to use this method to map and analyse key information. Finally, our findings are generalisable to the limitations discussed in the eligibility criteria section.

We believe our results will be useful and of interest to those researching in the field of VR as an empathy enhancement medium. The knowledge we have gained from conducting this scoping review will be used to advance our own research in this exciting and promising new area. It is clear from this scoping review, that there is a dearth of understanding and consensus in this research, and in particular, in the area of disability support workers. As such, we intend to conduct empirical research in this field, with a particular interest in contributing to the disability support sector.

6 Limitations

Because studies exploring the effectiveness of VR as an empathy enhancing intervention are in their early stages, the inclusion of quasi-experimental studies in this review may be problematic since they lack features of random assignment to VR treatment and control. Furthermore, the generalisability of findings is questionable given that interpretations are largely based on limited studies where not all variables were considered, such as “psychological proximity”, “pre-existing biases”, “cultural factors”, “gender effects”, and “practice effects”. Moreover, the results of some studies we reviewed were based on a modest sample size (Barbot and Kaufman 2020; Cheng et al. 2010; Hamilton-Giachritsis et al. 2018; Johnsen and Lok 2008; Muller et al. 2017; Trinidad and Linsangan 2018), which may not offer a true representation of the targeted population. Likewise, findings are questionable due to the lack of real-world application, conditions and environments in which evaluations occurred. In addition, there was a significant lack of studies done that used caregivers or disability support workers (DSWs) as participants, which was problematic for our research aims.

7 Conclusion

From the forty-four articles reviewed, thirty-five studies reported in the literature reinforced VR’s potential to facilitate the activation of prosocial characteristics to some degree. This is encouraging, suggesting that VR may be an acceptable intervention for DSW training. This is important since studies on disability have reported the need for advancements in support training that facilitates personalised disability support. Moreover, governments and organisations around the world continue to report that there is a lack of knowledge and understanding of people with disability in the support sector (Commonwealth of Australia 2020; Van Mierlo et al. 2012; World Health Organization and World Bank 2011). Nevertheless, studies in this field are limited and in their early stages, even more so involving DSWs as participants, which is problematic for our research focus for the current review. It is hoped that findings from this review will motivate new research in this area.

We offer some suggestions for future research. For instance, some industry sectors may traditionally have limited experience with technology. As such, it may be beneficial to pay greater attention to influencing variables, such as “practice effects” and sample size. Moreover, in industries where tight budgets tend to be the norm, such as the disability support work sector (NDS 2021; PWD 2022; Ryan and Stanford 2018); greater attention to cost-effectiveness and practicality may be beneficial towards understanding the feasibility of introducing a VR intervention into real-world settings.

Appendices

Appendix 1: Breakdown of countries where studies were conducted and count

Fig. 4

Country studies done

Appendix 2: studies reviewed with first author, title, country, objectives, sample size, display device, software, scales analysis, study design, findings – sorted by year of publication

First author, year of publication	Title	Country	Objectives	Sample size	Display Device	Software	ScalesAnalysis	Study Design	Findings
Deladisma et al. (2007)	Do medical students respond empathetically to a virtual patient?	USA	This study investigated whether more complex communication skills, such as nonverbal behaviours and empathy, were similar when students interacted with a VP or standardised patient (SP)	84 2nd year medical students at the University of Florida and the Medical College of Georgia	HMD	virtual patients (VP) (DIgital ANimated Avatar, DIANA)	Cronbach’s alpha (measured consistently), t-test (Comparison), Pearson’s correlation coefficient (correlation between nonverbal communicative behaviours and the observed measure of empathy)	Between-subjects (Randomised)	Medical students demonstrate nonverbal communication behaviours and respond empathetically to a VP, although the quantity and quality of these behaviours were less than those exhibited in a similar SP scenario. Student empathy in response to the VP was less genuine and not as sincere as compared to the SP scenario
Johnsen and Lok (2008)	An Evaluation of Immersive Displays for Virtual Human Experiences	USA	This study compares a large-screen display to a non-stereo head-mounted display (HMD) for a virtual human (VH) experience	27 medical students. 3rd year Med (13 male, 10 female). 1st year physician’s assistant school (2 male, 2 female)	HMD (non-stereo), and a fish-tank projection display (FTPD)	Interpersonal Simulator (IPS)	Self-Ratings, ANOVAs	Within-subjects (Comparison)	Results showed that student self-ratings of empathy were significantly higher in the HMD; however, when compared to observations of student behaviour, students using the large-screen display were able to more accurately reflect on their use of empathy.—Self-Ratings: students in the HMD group (M = 5.15, SD = 1.82) rated their use of empathy higher than students in the FTPD group (M = 3.64, SD = 1.34)
Cheng et al. (2010)	Enhancing empathy instruction using a collaborative virtual learning environment for children with autistic spectrum conditions	Taiwan	The study investigated evidence of improved understanding of empathy using a collaborative virtual learning environment (CVLE)—3D empathy systems	3 children with Autistic Spectrum Condition (ASC) who attended mainstream schools. Boys aged 8–10	Desktop computer	collaborative virtual learning environment (CVLE)—3D empathy system. Avatars	Empathy Rating Scale (ERS)	Within-subjects	The CVLE 3D empathy system had significant and positive effects on participant use of empathy, both within the CVLE 3D empathy system and in terms of maintaining learning in understanding empathy
Kalyanaraman et al. (2010)	The Virtual Doppelganger	USA	The study investigated the effectiveness of virtual simulations of mental illnesses in inducing empathy to combat stereotypical response	112 participants (68 women, 44 men, mean age = 22.25 years) from a psychology research participant pool as well as from the university community	HMD, Desktop computer	VR simulation (immersive experience simulating the symptoms of schizophrenia)	Index of 12 items asking participants to rate how well a series of adjectives. Adapted from Batson et al. (1997)	Between-subjects (Randomised)	The virtual simulation + empathy condition induced greater empathy and more positive perceptions towards people suffering from schizophrenia than the control or written empathy-set condition. Interestingly, the simulation-only condition resulted in the greatest desire for social distance whereas not significantly differing on empathy and attitude measures from either the written empathy or simulation + empathy conditions
Sulpizio et al. (2015)	Visuospatial transformations and personality: evidence of a relationship between visuospatial perspective taking and self-reported emotional empathy	Italy	The study investigated the relationship between visuospatial perspective taking and self-report measures of the cognitive and emotional components of empathy in young adults	148 volunteers (85 females; mean age = 25 years, SD = 4.4). All subjects were right-handed	Monitor	Virtual environment used by [72, 73]. Avatar	Interpersonal Reactivity Index (IRI) and Emotional Empathy Scale (BEES). ANOVA, Pearson’s correlation	Within-subjects	Significant gender effect on the empathy scores, with the females scoring higher than the males. 2) The main finding is that individuals who were able to more rapidly recall the target position from the perspective primed by another observer, obtained higher scores at the BEES, which assesses the tendency to share the emotional experiences of others and represents a genuine measure of emotional/affective empathy
Adefila et al. (2016)	myShoes—the future of experiential dementia training?	UK	This study investigates the use of virtual reality (VR) to enhance experiential dementia training that would expose the user to an experience that gives them a sense of what living with dementia might be like	55 self-selecting students studying health and social care degrees, including adult and mental health nurses, clinical psychologists, occupational therapists, paramedics, physiotherapists and social workers	HMD	Dementia simulation. Avatar	Self-assess empathy, confidence and competence (in relation to dementia patients) in pre- and post-tests. (two-tailed ANOVA test)	Within-subjects. Pilot (Exploratory study)	Despite a limited sample on which the simulation was tested, it appears to have enabled students to think beyond ‘treatment, to consider how the person might feel, and shift their approach accordingly
Kors et al. (2016)	A Breathtaking Journey. On the Design of an Empathy-Arousing Mixed-Reality Game	Netherlands	This study investigates the use of an embodied and multisensory mixed-reality game aimed to induce empathy for refugees by providing a first-person perspective	70 from the Netherlands, Belgium, Germany and England. Group 1: 32 participants (13 females, 19 males,). Group 2: 38 participants (13 females, 25 males)	HMD (Oculus Rift Development Kit 2)	A Breathtaking Journey (ABTJ) is an embodied mixed-reality game	Four coding schemes were supported by theoretical grounding for each code (Socially-Shared Narrative Schemas, Post-hoc Narrative Interpolations, Emotional Markers, and Embodied Feelings). To examine them more in detail, the researchers made a first broad pass coding emotional statements utilising ‘factor model for correlated basic emotions'	Between-subjects (Randomised) (Qualitative study w/grounded theory/open coding methodology)	Participants mostly expand through emotions rather than logic. This is somewhat owing to the setup of the design, but also an indication that immersive technology is able to convey complex emotional experiences
McEvoy et al. (2016)	Through the eyes of a bystander: The promise and challenges of VR as a bullying prevention tool	USA	This study investigates the potential of virtual reality (VR) in bystander-focused bullying prevention campaigns. It compares the effects of virtual reality simulations to that of video intervention	78 Participants in a one-factor, three-condition laboratory experiment. w/follow-up qualitative focus group study (N = 10)	HMD (Oculus Rift Development Kit), LCD monitor	Unity Software package. Avatars	item index measures w/ Cronbach's Alpha	Between-subjects (Randomised). Three conditions	The only significant effects observed were on feelings of empathy, with scores in the video condition higher than in the other two conditions, and on perceptions of bullying as a problem in participants’ schools, again with scores highest in the video condition
Oh et al. (2016)	Virtually old: Embodied perspective taking and the reduction of ageism under threat	USA	This study investigates how the level of immersion, afforded by different media platforms, can facilitate perspective taking in demanding (presence of intergroup threat) or less demanding (absence of intergroup threat) in the context of ageism	148 participants (53 men, 95 women) from a medium-sized western university. 64 (43.2%) were White, 47 (31.8%) were Asian, 16 (10.8%) were Latino, 11 (7.4%) were Black, and 10 (6.8%) reported another ethnicity. The mean age of the participants was 21.03 (SD ¼ 2.00)	HMD ((Oculus Rift Development Kit 2)	immersive virtual environment (IVE). Avatars	7-point Likert-type scale w/Cronbach's a. 2 × 2 analyses of covariance (ANCOVA) tests were performed with gender and race as covariates	Between-subjects (Randomised)	Study2 (direct and concrete)—In contrast to the promising results in Study 1 (indirect), when the threat manipulation was more experiential and intentional, increasing immersion was not enough to overcome empathic avoidance. This impact of inferred intentionality also closely echoes (Segovia and Bailenson 2012) study. However, it is worth noting that intergenerational tension is typically caused by the notion that the elderly are inconveniencing the youth [75] rather than by hostile intergenerational contact
Camilleri et al. (2017)	Walking in small shoes: investigating the power of VR on empathising with children's difficulties	Malta	This study investigates what effect a VR environment would have on the individuals’ perceptions and whether it could lead to a change towards a more empathic behaviour in a school setting	63 participants (convenience sampling) recruited from teachers’ continuous professional development sessions, parental meetings and two educator conferences. 26.2% (male), 73.8% (female), 42.2% (25–34 age range), and 29.7% (35–44 age range)	HMD (Samsung Gear VR Headset)	The VR experience (1PP) was designed for the Headset. Head tracking technology (Unity 3D platform). The experience used the primarily visual and auditory sensory cues. 360 film (immersion)	5-point Likert Scale for both pre- and post-VR surveys. w/ paired-samples t-test	Within-subjects	Participants did register a statistically significant change in attitude towards being able to associate to another person’s suffering
Muller et al. (2017)	Through Pink and Blue Glasses	Netherlands	This study investigates the prospects of combining the concepts of Virtual Reality empathy games and sexism to enhance empathy	19 participants from the faculty of Industrial Design at Eindhoven University of Technologys	HMD (HTC Vive)	Through Pink and Blue Glasses (TPBG). The experience is designed using Unity for the HTC Vive headset. Mixamo (software used to give characters a skeleton and standard animations)	7-point Likert-scale. Empathy questions are built upon the interpersonal reactivity index (IRI)	Within-subjects	It was concluded that a relation exists between how relatable the experience is to the personal life of the player, and the stimulation of dispositional empathy. 2) being able to switch perspectives during the game turned out to help the players empathise with the other gender in real life. 3) Choosing a character can highly impact the player. 4) using thoughts and comments through sound design works for increasing the feeling of identification and creating a touching experience. 5) found a link between the feeling of credibility and the amount of people (models) in the room
Schutte and Stilinović (2017)	Facilitating empathy through virtual reality	Australia	This study investigates whether Virtual Reality (VR) experience can prompt greater empathy. The context focuses on a young girl living in a refugee camp. It also explores whether greater engagement with VR connects VR experience to empathy	24 university students from Australia (14 women and 10 men). Mean age of 19.92 (SD = 3.46)	VR Head-mount Used, 360 film	‘Clouds over Sidra’ (a young girl living in a refugee camp). 360 film (immersion)	5-point scale w/Chronbach’s alpha	Between-subjects (Randomised)	Both empathic perspective-taking and empathic concern were greater among participants in the virtual reality condition, with t(22) = 2.36, p = .03, partial eta squared = 0.20. and t(22) = 2.34, p = .03, partial eta squared = 0.20, respectively. The effect sizes for all of these comparisons between participants in the virtual reality condition and the control condition are large [76]
Bang and Yildirim (2018)	Virtually empathetic?: Examining the effects of virtual reality storytelling on empathy	USA	The study investigates whether VR storytelling was a viable intervention for inducing a state of empathy	44 students (15 women, 29 men). Average age of 22.35 (SD = 3.49)	HMD (Oculus Rift). Desktop computer via a YouTube 360° video	After Solitary (short documentary about a prison inmate’s solitary confinement experiences)	State Empathy Questionnaire (SEQ) 7-point Likert scale	Between-subjects	This finding suggests that watching the documentary in VR was not substantially different from watching it on YouTube with respect to the extent to which an individual empathises with the emotional experience of another person
Hamilton-Giachritsis et al. (2018)	Reducing risk and improving maternal perspective-taking and empathy using virtual embodiment	Spain	This study investigates the use of immersive virtual reality to place parents in the position of a child to assess the effect on perspective-taking and empathy	20 Spanish mothers aged 31 to 47 years (mean age 39.3, SD = 4.05, SE = 0.9). All participants were the biological mother of at least one child (total of 30 children, M = 1.51 children, range 1–3); children’s ages were 6 months to 15 years (M = 6.23 years, SD = 3.36, SE = 0.61)	HMD	IVR environment. Avatars	Empathy was measured in two ways: Mind in the Eyes test (general empathy) and AAPI subscale (parenting empathy). w/ANOVA	Within-subjects. Pilot (Randomised). Exploratory study	Participants reported a strong body ownership illusion for the child body that led to cognitive, emotional and physical reactions. Experiencing negative maternal behaviour increased levels of empathy. In addition, the Negative mother led to increased feelings of fear of violence. Physiological data indicated greater stress in the Negative than Positive condition
Herrera et al. (2018)	Building long-term empathy: A large-scale comparison of traditional and virtual reality perspective-taking	USA	This study investigates two experiments that were conducted in order to compare the short and long-term effects of a traditional perspective-taking task and a VR perspective-taking	117 participants (40 men and 75 women), and 2 participants who identified as other. The ages ranged between 15 and 57 (M = 22.94, SD = .95). 33 (28%) White, 7 (6%) Hispanic, 8 (6.8%) Indian, 49 (41.8%) Asian, 7 (6.8%) African American, and 13 (11.1%) multiracial	HMD (Oculus Rift DK2) w/infrared camera. Desktop computer	IVE (1PP). Avatars	All participants completed a pre-intervention questionnaire which included demographic questions, the Interpersonal Reactivity Index (IRI), and the Beliefs about Empathy scale. w/ANOVA	Mixed design (Randomised)	Results show that participants who performed any type of perspective-taking task reported feeling more empathetic and connected to the homeless than the participants who only received information
Ingram et al. (2019)	Evaluation of a virtual reality enhanced bullying prevention curriculum pilot trial	USA	This study is a pseudo-randomised pilot trial of a virtual reality enhanced bullying prevention programme among middle school students in the Midwest United States	118 (7th and 8th grade students) from two Midwest United States middle schools. (72 control condition school, 46 experimental condition school). 55% girls, 43% boys, and 2% as non-binary or another gender. Ages ranged from 11 to 14 years (x¯ = 12.50, SD = 0.61). 25% African-American/Black, 3% Asian or Pacific Islander, 9% Hispanic/Latinx, 24% mixed race, 37% white, and 2% other. The schools were demographically similar (Intervention School: 785 students, 34% African/American/Black, 20% White, 54% female; Control School: 680 students, 33% African/American/Black, 29% White, 54% female)	HMD (Daydream goggles)	The virtual reality scenarios (realistic bully relevant scenarios using Daydream goggles), a commercially available virtual reality delivery system that has been used in previous virtual reality research	5-item Empathy subscale of the Teen Conflict Scale. w/Cronbach's alpha	Between-subjects (Pseudo-randomised pilot trial)	The virtual reality condition yielded increased empathy from pre-to post-intervention compared to the control condition. Through the mediating role of empathy, changes in the desirable directions were also observed for traditional bullying, sense of school belonging, and willingness to intervene as an active bystander, but not for cyberbullying or relational aggression
Jütten et al. (2018)	Can the Mixed Virtual Reality Simulator into D'mentia Enhance Empathy and Understanding and Decrease Burden in Informal Dementia Caregivers?	Netherlands	This study investigates whether the mixed virtual reality dementia simulator training Into D'mentia increased informal caregivers' understanding for people with dementia, their empathy, sense of competence, relationship quality with the care receiver, and/or decreased burden, depression, and anxiety	145 (intervention group), 56 (control group). Group-matched on sex and level of education. All participants were adult informal caregivers (who spent at least 8 h per week on caregiving) of a relative, spouse, or friend with dementia who lived at home	Not Specified	Mixed virtual reality dementia simulator	Two subscales of the Interpersonal Reactivity Index (IRI) (Davis, 1980, as cited in [21], were used to measure empathy: Perspective Taking and Empathic Concern. w/Cronbach's α. Five-point Likert scale	Between-subjects (Quasi-experimental longitudinal)	Eighty-five per cent of the participants in the intervention group found the intervention useful; 76% said they had changed their approach to caregiving, and 61% stressed that the intervention had increased their understanding of dementia. No significant differences were found between the two groups over time regarding empathy, sense of competence, relationship quality with the care receiver, burden, depression, and anxiety, at either group or individual level
Kang (2018)	Effect of Interaction Based on Augmented Context in Immersive Virtual Reality Environment	South Korea	To verify the effect of the interaction based on augmented context, a test that compared a VR environment that replicates the real world with a VR environment to which augmented information is added was conducted	30 men and women (ages 23–38, average age 29 years) participated in the evaluation conducted of the two different VR interfaces	HMD, Desktop computer Used, Avatars	A 3D digital girl was created for the test using the software ‘Maya’. Kinect SDK	Qualitative assessment used to determine the level of users’ emotional immersion (Scale 1 to 10)	Between-subjects	The results of the questionnaire survey indicate that the users who experienced the interaction based on augmented context were more satisfied with the contents and also felt more empathetic with the contents. This indicates that augmented information related to a story and situation in a VR space, which does not exist in the real world, positively affects the level of user immersion in terms of gesture interaction, efficiency of the interaction, and level of emotional satisfaction
Formosa et al. (2018)	Testing the efficacy of a virtual reality‐based simulation in enhancing users’ knowledge, attitudes, and empathy relating to psychosis	Australia	This study examined the efficacy of a virtual reality (VR) education system that simulates the experience of the positive symptomology associated with schizophrenic spectrum and other psychotic disorders	50 participants. 22 male (age range: 21–63 years) and 28 females (age range: 21–61 years), 3 students (graduated from an Australian undergraduate psychology degree. 47 individuals from the general public	VR Head-mount Used, Avatars	VR simulation in psychological education	A similar model of [77] quantitative assessment was used. Only, the items on the questionnaire were changed to measure knowledge of diagnostic criteria (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013, as cited in [51]. w/Cronbach's α and point system	Within-subjects (Experimental group)	After VR exposure, participants demonstrated significantly more favourable attitudes and empathetic understanding at post-intervention compared to pre-intervention. Participant’s knowledge also measured significantly higher post intervention. In addition, gains in empathy shared a positive relationship with both fidelity and user buy-in, suggesting that the gain in empathy towards individuals diagnosed with a schizophrenic or other psychotic disorder was linked to both the emotional experience of the ‘stigmatised other’ (fidelity) and the perceived utility of VR simulation in psychological education (user buy-in)
Stavroulia et al. (2018)	Designing a virtual environment for teacher training	Switzerland	This study aims to assess the influence of the graphical realism of a virtual classroom to the levels of presence and development of empathy skills for trainee teachers. It also investigates whether there are significant differences between training in a VR classroom and a real physical classroom and how this affects the trainee teacher	33 participants took part in the experiment all from higher education (66.6% male and 33.3% female). 63.6% (25 to 29 age range). 27.3% (30 to 39 age range), two (50 to 59 age range), and one (18 to 24 age range). There are differences between the three groups relative to teaching experience. First group (54.6% had 1 to 2 years teaching experience), (36.4% no teaching experience at all). Second group (72.8% had 1 to 5 years teaching experience). The third group (45.5% had 1 to 5 years teaching experience), (36.4% had 6 to 10 years’ experience). Most participants were not accustomed to virtual reality technology (57.6% reported to have little user experience)	HMD (VIVE)	VR application (Developed with the Unity© game engine). The 3D avatars (teachers and students) were created using the online software Autodesk® Character Generator	Empathy Scale w/Cronbach’s Alpha and Kruskal–Wallis H test	Between-subjects, (Three conditions)	Concerning empathy, the results indicate cultivation of empathy skills. What is important is that the participants of all groups claim the importance of entering the students’ position to understand his/her perspective. There are no significant differences between the three groups except for one variable that relates with teachers’ ability to put himself/herself in the position of a student who is racially and/or ethnically different. The results revealed a significant difference between the participants that used the VR system and those who were trained in the physical environment as those who experienced the virtual world claimed that teachers can put himself/herself in the position of someone who is racially and/or ethnically different, while the physical group tend to disagree
Trinidad and Linsangan (2018)	Understanding the mentally disturbed's reality through heart rate controlled virtual reality inducing artificial auditory hallucination and persecutory paranoia	Philippines	The study aims to develop a virtual reality (VR) system as a supplemental tool in training would be mental health clinicians	5 young adults	HDM (OCULUS RIFT)	VR with Auditory Hallucination and Persecutory Paranoia Stimuli	Empathy scale (based on Kiersma-Chen). T-statistic measurements for heart rate sensing node. w/Shapiro–Wilk test	Within-subjects	The examination of log file entries showed the game is able to detect negative effect and adjusted the simulations’ attributes accordingly.—(T-statistic, Critical T-statistic, p-value). Based on a right-tailed test for dependent samples, the t-statistic was computed to be 0.3178 which is less than the critical t-value, 2.1318. The p-value was found to be 0.3833 which is greater than α = 0.05. Hence, there is sufficient evidence to support the claim that the virtual reality system cannot develop or enhance an individual's empathy towards a person with mental health problems. The results of the quantitative measurement suggested that the system did not enhance a player's empathy towards persons
van Loon et al. (2018)	Virtual reality perspective-taking increases cognitive empathy for specific others	USA	The study aims to further the research on an "exercise" for the "muscle" that is empathy, which, in doing so, increases an individual's capacity to be prosocial	180 participants from a medium-sized private university on the west coast (72 males, 106 females, and 2 individuals who identified as some other gender). Ages ranged from 18 to 29 (M = 20.28) and was racially diverse	HMD (HTC Vive)	Software not specified. Three IVEs were created independent of any participant’s responses. Steve or James Avatar	Interpersonal Reactivity Index (IRI). The IRI measures tendency towards empathic concern. w/Cronbach’s α	Between-subjects (Randomised), three conditions	The VRPT experience increased participants’ ensuing propensity to take the perspective of their partner, only if it was the matching individual whose perspective participants assumed in the VR. This effect of VRPT on perspective-taking was qualified by participants self-reporting of immersion in the virtual environment. The researchers found no effects of VRPT experience on behaviour in the economic games
Weinel et al. (2018)	Deep Subjectivity and Empathy in Virtual Reality: A Case Study on the Autism TMI Virtual Reality Experience	UK	This study provides a case study of the Autism TMI Virtual Reality Experience, as a way to investigate design issues for these simulations. The study suggests that VR may offer limited benefits over 360-video for generating a sense of empathy	20 participants were recruited from a University campus and consisted of undergraduate and postgraduate students, faculty staff and administrative staff (1 female and 19 male)	VR-cardboard and the 360 YouTube video (Viewed on Apple iMac with a built-in 21-inch display full screen mode)	The Autism Too Much Information (TMI) Virtual Reality Experience is a virtual reality (VR) application produced by The National Autistic Society (NAS) as part of an awareness campaign	Likert scale. w/two open-ended questions. A one-way MANOVA test. w/Wilk’s test	Between-subjects (Randomised)	No difference overall between the VR-cardboard and 360 YouTube formats. The results of the user experience study suggest that the participants found the Autism TMI VR Experience provides an effective means through which to communicate the subjective experience of an autistic person, leading to a sense of empathy: both groups in the study indicated high levels of agreement with the empathy overall impression. This is achieved through the use of a first-person POV representation
Wijma et al. (2018)	A virtual reality intervention to improve the understanding and empathy for people with dementia in informal caregivers: results of a pilot study	Netherlands	To enhance understanding and empathy in caregivers, the virtual reality intervention programme “Through the D’mentia Lens” (TDL) was developed to experience dementia. It consisted of a VR simulation movie and an e-course. A pilot study of TDL was conducted to assess the programme’s effectiveness on enhancing empathy	35 informal Dutch speaking caregivers	HMD, 360 film	VR intervention Through the D’mentia Lens (TDL). (simulation movie and e-course were based on Into D’mentia) VR (13-min.), e-course (three 20-min lessons)	Empathy was measured using the person-centeredness ‘PC’ subscale of the Approach to Dementia, ‘perspective-taking’ (PT) subscale of the Interpersonal Reactivity Index (IRI). 5-point Likert w/ Cronbach’s α. To analyse the impact of TDL, either a parametric paired-samples t test or a non-parametric Wilcoxon signed-rank test was performed to test for important changes	Within subjects (Pre-test–post-test designpilot study)	Impact—Primary outcome measures—Considering the primary outcome measures, the PT subscale of the IRI showed a significant increase between pre-test and post-test scores (t(34) = 2.91, p = 0.006), indicating that participants were better able to empathise with the person with dementia compared to before TDL. The effect size was moderate (d = 0.42). The participants’ PC did not increase
Buchman and Henderson (2019)	Interprofessional empathy and communication competency development in healthcare professions’ curriculum through immersive virtual reality experiences	USA	The purpose for this experience was to assess whether students would be able to develop empathy and communication competency as a result of increased presence and immersion during a VR 360 simulation. It also aimed to assess if students would be able to report increased communication competency in a health team as a result of participation in interprofessional training focused on communication	Number not specified. Undergraduate and graduate students from eight health sciences professions were represented	HMD (Ocular Go)	Alfred © by Embodied Labs. The VR 360 immersion lasted for 7 min and had six mini scenarios that merged into the one simulation VR 360 experience	Following the VR viewing, participants provided feedback. Learning was assessed via focus groups and included Seven-point Likert scales. Questionnaires by Witmer and Singer, as cited by [54]	Within subjects	The fact that participants reported an increase in their overall empathy towards the patient alone is a rewarding impact. When empathy is coupled with the presence and immersion of the VR experience, participants reported that they could not have obtained this level of experience through more traditional learning methods
MacDorman, (2019)	In the uncanny valley, transportation predicts narrative enjoyment more than empathy, but only for the tragic hero	USA	To examine how the uncanny valley influences narrative empathy and enjoyment	738 participants randomly assigned to eight groups, with 88–105 in each group, completed the experiment (73% female, n = 538)	Not Specified	The doctor’s Character changed (hero or villain, i.e. good or poor bedside manner), Outcome/Ending (received a fellowship or sued for malpractice), and Depiction (a recorded video of a real human actor or of his 3D computer-animated double)	A 7-item assessment of emotional empathy was designed to measure the intensity of the experience of Dr. Richards' emotional state as distinct from the participant's own emotional state. Test statistics were two-tailed w/ Cronbach's α. Hypotheses testing used a three-way MANOVA	2 × 2 × 2 Between-groups. Posttest-only experimental design (Independent Variables). (Randomised)	The participants' post-test results showed greater emotional empathy and enjoyment in the hero condition and no significant difference in emotional empathy for the computer animation but greater narrative enjoyment and persuasion. Just endings (hero rewarded, villain punished) elicited much greater pleasure than unjust endings. In comparing computer animation with recorded video, emotional empathy was a significantly stronger predictor of narrative enjoyment than transportation only for the real hero with a tragic ending. The enjoyment and persuasiveness of the computer-animated doctor–patient consultation bodes well for the use of animation in interactive visual narratives
Slater et al. (2019)	Virtual simulation training: Imaged experience of dementia	UK	This study explores the impact of an interactive training experience on moral, emotive, behavioural and cognitive elements of empathy	52 people (both healthcare staff and family carers) recruited from a Health Service Executive region in Ireland. 18 provided reflective data	HMD	Virtual Dementia Tour (VDT)	Mayring's (2000) approach, which is a four‐stage thematic framework, w/Consolidated Criteria for Reporting Qualitative Research (COREQ)	Within subjects (qualitative exploratory design)	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
Stavroulia and Lanitis (2019)	Enhancing Reflection and Empathy Skills via Using a Virtual Reality Based Learning Framework	Cyprus	The study aimed to investigate the possibility of using a VR-based approach to enhance teacher’s reflection and empathy skills. It also aimed to identify potential differences between the groups that used the VR system and those who were trained in a real classroom without using the VR system	33 participants (22 male and 11 female)—from the higher education sector. 63.6% (25 to 29 years old) 27.3% (30–39 years old), 18.2% (50–59 years old) and 9.1% (18–24 years old)	(HMD) HTC VIVE Avatars	VR system (Unity© game engine). The 3D avatars (online software Autodesk® Character Generator) and the 3D models (Maya Autodesk student version)	For the measurement of reflection and empathy, a questionnaire was developed. w/ Cronbach’s Alpha. Mann–Whitney U test (was used for measuring statistically significant differences between the two groups in most of the items of the empathy scale). Normality testing was primarily done using the Kolmogorov–Smirnov Test and the Shapiro–Wilk Test	Between-subjects. Three conditions	The results indicate that the use of the VR system and the opportunity to view a scenario from the eyes of a different person affected more the cultivation of empathy skills towards foreign students to the group that used the virtual classroom as they scored higher to the scale, while the control group tended to be undecided
Stavroulia (2019)	Designing immersive virtual training environments for experiential learning	Cyprus	The study aims to present an innovative VR-based approach for teacher education with the main objective of the VR application to enhance empathy skills	education experts (Number not specified)	HMD (VIVE and Oculus Rift CV)	The application was developed using Unity 3D real-time development platform. Avatars	Questionnaires were used to measure the sense of presence, embodiment, emotions and empathy, while interviews were also conducted for in depth investigation of the VR intervention. (Electroencephalogram (EEG) and questionnaire scales confirmed each other)	Mixed design (Experimental Design)	The results showed that empathy skills were enhanced after the use of VR, whereas the results from the final experiment indicate that the cultivation of empathy was related to the users’ perspective taking and body changing within the virtual world. According to the results, users who experienced only teachers’ perspective did not present statistically significant changes related to their empathy skills, compared to the other two groups that presented significant changes after the VR intervention
Washington and Shaw (2019)	The Effects of a VR Intervention	USA	The pilot study aimed to assess whether embodying a patient in The Alfred Lab would lead to greater empathy, a better understanding of the pathologies that affect ageing adults, and more interest in pursuing a geriatrics specialty among second-year medical students	200 (Approx.) from the University of Illinois, Chicago—All students except for one were 2nd year medical students	HMD (Oculus Rift headset with Leap Motion VR)	The core VR simulation (the Alfred Lab) was based on the curriculum for the geriatrics workshop part of the Essentials of Clinical Medicine course taken by second-year medical students at the University of Illinois Chicago. (7-min 360 film)	Scale used. key: 0 = strongly disagree, 1 = somewhat disagree, 2 = somewhat agree, 3 = strongly agree. w/paired t test	Between-subjects. (Pilot study)	The results suggest that the VR pilot had a significant effect on the ability of learners to take the perspective and empathise with older adults. An average of 30% more students = “strongly agree” or “somewhat agree” in both of the VR intervention groups when asked if they understand the perspective of an ageing patient
Barbot and Kaufman (2020)	What makes immersive virtual reality the ultimate empathy machine? Discerning the underlying mechanisms of change	USA	The study aimed to investigate the unique and combined UX variable contributions to empathy change of the sense of Immersion/Presence, illusion of virtual body ownership (IVBO), Engagement, and Agency while also accounting for Discomfort (i.e. cybersickness)	65 participants (46.2% female, 52.3% male, and 1.5% other) were recruited from a large urban University in the North-eastern region of the United States	HMD (Oculus Rift and HTC Vive, and handheld controllers in a 3 m × 3 m room scale tracking settings)	Developed Immersive virtual reality experience (IVRE) program. (5 to 10 min depending on the experience)	Online pre-test (which included the baseline assessment of empathy). Subscale of the Interpersonal Reactivity Scale (IRI-PT). Descriptive statistics and inter-correlations of the main study variables. (before and after the IVR)	Within-subjects (Randomised). Five conditions	key findings were that both IVBO and Agency were the largest determinants of empathy change, with both predictors having large effect sizes even after accounting for other UX variables. The authors also found that the nature of the media content delivered in IVR may be less important than previously thought as these effects were consistent across a range of IVR modalities not explicitly evoking empathy-related contents
Barreda-Ángeles et al. (2020)	An “Empathy Machine” or a “Just-for-the-Fun-of-It” Machine? Effects of Immersion in Nonfiction 360-Video Stories on Empathy and Enjoyment	Barcelona (Spain)	This study examines how the immersive presentation of 360-video nonfiction contents impacts both empathy towards the characters and enjoyment of the experience and the interplay between these two psychological outcomes	37 volunteers (17 males and 20 females) aged between 19 and 43 years old (M = 24.51; SD = 6.12) were recruited through an ad in a university campus in Barcelona (Spain)	Samsung Gear VR headset (VR condition). Samsung Galaxy S6 smartphone or in a 17† laptop screen (screen condition)	The materials were eight stories originally produced by major media companies, all of them originally produced in 360-video and freely available on the Internet. The clips were edited to reduce their duration	Subscales from the interpersonal reactivity index (IRI). w/Cronbach’s a	Within-subject. (Experiment Design)	Mediation analyses and structural equation models showed a direct positive effect of spatial presence on perspective taking and empathic concern, and an indirect negative effect of immersive presentation on empathic concern through enjoyment. These findings indicate that enjoyment of pleasurable aspects of the experience may hinder the affective dimension of empathy towards the characters, and point out to the need to carefully consider the targeted reactions from the audience, since different intended psychological outcomes may not be fully compatible
Christofi et al. (2020)	A Virtual Reality Simulation of Drug Users' Everyday Life: The Effect of Supported Sensorimotor Contingencies on Empathy	Cyprus	This study compared a perspective taking immersive Virtual Reality system which supports a number of sensorimotor contingencies (SC group) with a perspective-taking desktop system of the same application but without support of any sensorimotor contingencies (NSC group), to investigate the effect of the supported sensorimotor contingencies in promoting empathy and positive attitudes towards drug users	40 participants (n = 40). 21(male) and 19 (female). Convenience sampling size used. Ages varied from 18 to 59 with the majority (42.5%) in the range of 18–24 years old. Experience in using VR environments (42.5%) had little experience with VR	HMD (Oculus Rift CVstereo viewing in 360 degrees). NSC condition the application was displayed to participants through 19201080 pixels 24-inch computer screen	An application was designed and developed in which participants were able to virtually experience some scenes of the life of a person who became a drug user, through his point of view, in order to debunk stereotypes surrounding drug users. Avatar	Interpersonal reactivity index (IRI). A self-report tool that consists of four 7-item subscales answered on a 5-point Likert scale	Between-groups (Experimental Design)	The findings of this study indicated that VRPT, can be used to induce empathy and prosocial behaviour of the participants towards members of stigmatised groups
Kim et al. (2020)	Feasibility of a virtual reality-based interactive feedback program for modifying dysfunctional communication: a preliminary study	South Korea	The paper investigates feasibility of a virtual reality (VR)-based interactive feedback programme for the modification of dysfunctional communication	37 healthy unmarried, young males and adult males. Majority university students (N = 35). Mean age 22.20 (SD, 13.20). Average education level 14 years (SD, 1.31)	HMD (Oculus Rift head-mounted display with a tracker (Oculus VR, LLC, USA)	VR-based interactive feedback program, “Enhancing Functional Communication,” (45 min)	To measure the level of empathy, we used the Interpersonal Reaction Index (IRI), with a 28-item 5-point Likert scale, that contains four subscales (fantasy, perspective-taking, empathetic concern, and personal distress) with seven items for each subscale Descriptive statistics of psychological assessments	Within-subject (Experimental design)	Significant correlations of the parameters from the task of expressing empathy were identified only in the two pairs: between the empathetic feeling score and IRI-perspective-taking score (r =  − 0.372, p = 0.023) and between the emotional intensity score and the DSI-R score (rr = 0.351, p = 0.033)
Kors et al. (2020)	The Curious Case of the Transdiegetic Cow, or a Mission to Foster Other-Oriented Empathy Through Virtual Reality	Netherlands and Japan	This study aimed to capture responses in relation to empathy and assess their orientation, gain insight into participants’ experiences, and finally, reflect on Permanent’s (i.e. VR game) design and participants’ experiences to inform the future design of empathy-arousing appeals in persuasive game design using immersive technologies	78 users (of the 104), 51 in the Netherlands and 27 in Japan, interacted with (and finished) Permanent and consented to participation in the study (public showroom context)	HMD (HTC Vive virtual reality headset)	Permanent is a virtual reality game designed to foster empathy towards evacuees from the 2011 Fukushima Daiichi nuclear disaster. Avatars	The delineation described by [78], which involved two other-oriented empathic states: Imagine-other Perspective and Empathic Concern; and two self-oriented empathic states: Imagine-self Perspective and Emotion Matching was used. Cohen’s κ was calculated for each empathic state. (Thematic Analysis)	Within-subject (Experimental design)	A close coding on empathic states revealed that participants reported other-oriented empathic states more than twice as often as self-oriented empathic states. Furthermore, through the open coding, four themes characterising participants’ experience with Permanent was identified. Notably, the capacity of virtual reality games to foster other-oriented empathic states in addition to self-oriented empathic states
Misztal et al. (2020)	Simulating Illness: Experiencing Visual Migraine Impairments in Virtual Reality	Germany	To investigate the empathic response of human users in a Virtual environment towards migraine patients	32 subjects participated in our study, 13 women and 19 men with an average age of 32.19 (min. 20, max. 61). (university employees and students)	HMD (VIVE Pro)	A visual migraine simulation in a virtual environment (VE) was developed, consisting of a migraine aura and an overexposure effect	Three subscales: fantasy, perspective-taking and empathic concern of the IRI which sum up to a general empathic tendency. Besides the Basic Empathy Scale (BES) and the Toronto Empathy Questionnaire (TEQ), the Interpersonal Reactivity Index (IRI) offers comprehensive questions to assess empathy, but required six additional questions individually adapted to the studies design. w/Cronbach’s alpha. MIDAS (Migraine Disability Assessment)	Within-subject design (Two conditions)	Compared empathic reaction scores between CPT (Condition Perspective Taking) and CEE (Condition Embodied Experience) revealing a significantly higher empathic reaction after CEE compared to CPT—both conditions of empathic reaction correlates with experienced realism
Mustapha and Razali (2020)	Rediscovery of Empathy in Youth through an Interactive Virtual Reality Experience	Malaysia	To understand the efficiency of immenseness and interactivity in virtual reality as a tool to provoke empathy	60 people—students. age range 58% (18–21), 36% (22–24), 6% (15–17). 54% (female), 46% (male)	Not Specified	“Mercy” (a short 3D virtual reality interactive story application)	Analysis based on 'Toward Measuring Empathy in Virtual Reality'. Carey et al. 2017, as cited in [65]	Within-subject. (Experiment Design)	95% agreed afterwards that the Mercy application increased their empathy. Participants expressed their empathy experience during the story in Mercy (an interactive virtual reality environment)
Patané et al. (2020)	Exploring the Effect of Cooperation in Reducing Implicit Racial Bias and Its Relationship with Dispositional Empathy and Political Attitudes	France/Italy	The aim of the study was to assess the beneficial effects of cooperation within a VR scenario and provide preliminary testing of the hypothesis that empathy and political attitudes could contribute to implicit bias about race. In addition (to this), it aimed to explore the relationship between political attitudes and empathy	40 participants (13 men, 27 women, mean age = 25.8 years, SD = 5.46) with normal or corrected-to-normal vision and no history of neurological or psychiatric disorders took part in the study	HMD (Oculus Rift CV1)	The virtual environment was created with 3D Studio Max 2018 and implemented on the Unity 3D platform (Unity 5.5.1). A Repeated ANCOVA was conducted	To measure dispositional empathy, the Interpersonal Reactivity Index scale (IRI) was used. IRI measures on a 5-step Likert-type scale various facets of empathy through four scales of 7 items each	Between-subjects (Randomised)	When the interaction is not cooperative the effects following the embodiment of a Black avatar depend on the perceived distance with the other person: only when people perceive the other person as closer to themselves does their initial racial bias diminish.—empathy–the higher the empathic concern and perspective taking skill, the lower the initial bias
Roswell et al. (2020)	Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism, Inequity, and Climate in Medicine	USA	To evaluate the utility of integrating a racism-focused VR experience into existing diversity and equity initiatives at the school and health system level—Central to this was cultivating empathy and racial awareness through VR technology	112 faculty and staff—out of 112 participants (from the Zucker School of Medicine [ZSOM]) who completed the sessions, 76 submitted an evaluation	HMD (HTC Vive—Dongguan, China)	1000 Cut Journey developed at research labs at Columbia and Stanford Universities	A short survey using Qualtrics software w/ 10-question	Within-subject. (Experimental Design)	The researchers found the 15-min table discussion to be critically important, for it allowed participants to develop comfort in sharing their experiences openly.—A great majority of respondents (N = 72, 94.7%) also agreed or strongly agreed that VR was an effective tool for enhancing empathy, and 65 (85.5%) agreed that the VR experience enhanced their own empathy towards racial minorities
Steinfeld (2020)	To Be there when it Happened: Immersive Journalism, Empathy, and Opinion on Sexual Harassment	Israel	To examine the use of journalistic storytelling using Virtual Reality, as a tool to promote knowledge, empathy, and change in views and opinions on the phenomenon of sexual harassment among men and women	73 university students in Israel, aged between 18 and 28 (M = 24, SD = 2), 64% women and 36% men	HMD (Homido virtual reality headset v2)	360-degree immersive VR video (5 min, each scene × 3)	Two questions measured identification and empathetic reaction to the victim. 10 items measured participants’ general tendency to feel empathy towards others. A confirmatory factor analysis using AMOS was also used to perform further empathy analysis	Between-groups (randomised). (Experimental Design)	Interestingly and contrary to the study’s hypothesis, there was no correlation between the method of content consumption and participants’ empathetic reaction, or identification with the victim. The immersive experience did not produce more empathy or identification with the character than other forms of content consumption
Tong et al. (2020)	Designing a Virtual Reality Game for Promoting Empathy Toward Patients with Chronic Pain: Feasibility and Usability Study	Canada	To determine if a serious VR game such as IF may influence participants’ empathy for patients with chronic pain (raising awareness and fostering positive attitudes towards patients) and to explore what factors may be important to elicit empathy	18 participants (4 females), aged 19–39 years (mean 24.8, SD 3.8 years) recruited through the university for convenience	HMD (HTC VIVE)	VR game entitled AS IF. In this VR game, participants inhabit an avatar—a 3D character who has chronic pain—from a first-person perspective (Developed w/Microsoft Kinect and advanced w/Unity3D)	Empathy Scale (Adapted Compassion Scale) w/paired t test to analyse the differences between the before and after empathy ratings	Mixed methods approach	Overall, after playing the VR game AS IF, participants scored significantly higher on the Willingness to Help Scale and the kindness subscale—an adaptation of the Empathy questionnaire.—These two scores revealed that not only could one VR experience of AS IF raise people’s awareness of chronic pain but it could also increase their implicit and explicit empathy. Data from the kindness subscale showed implicit cognitive changes, whereas data from the Willingness to Help Scale revealed changes in explicit empathic attitudes towards patients with chronic pain
Denise Campbell et al. (2021)	Increasing awareness, sensitivity, and empathy for Alzheimer's dementia patients using simulation	USA	To evaluate perceptions of awareness, knowledge and sensitivity of future nurses concerning Alzheimer’s Disease (AD) patients before and after participation in a simulated virtual reality dementia experience	163 undergraduate baccalaureate nursing students from three different courses at a large public university in the Midwest. Students were enrolled in a fundamentals course (n = 48), traditional medical/surgical I course (n = 41), accelerated medical/surgical I course (n = 40) or a mental health course (n = 34)	Not Specified	Virtual Dementia Tour (VDT). (45-min)	The Dementia Attitudes Scale (DAS) (a 20-item scale that reflects affective behaviour, and cognitive components of people’s feelings and behaviours towards those living with dementia). w/ seven-point Likert. The Knowledge about Memory Loss and Care (KAML-C) test (a 15-item test that assesses the knowledge of caregivers regarding memory loss for patients who are in the early stages of AD). w/Cronbach’s coefficient alpha	Quasi-experimental repeated measure pre-post design	Findings support the use of a virtual reality AD experience to enhance perceptions of awareness, knowledge and sensitivity of the complexities of AD (Kimzey et al. 2018; Scerri and Scerri, 2013; Maharaj, 2017; Werner et al. 2014, as cited in [79]
Navarrete et al. (2021)	Compassionate Embodied Virtual Experience Increases the Adherence to Meditation Practice	Spain	To evaluate the effectiveness of an embodied-VR system in generating a compassionate response and increasing the quality and adherence to meditation practice	41 health professionals or healthcare students	VR Head-mount Used (VR Oculus Rift)	Embodied-VR system, “The machine to be another”	Descriptive statistics and independent-samples t-test results of baseline data. Paired-samples t-tests and analyses of covariance (ANCOVAs). Plus 7-point Likert scales w/(Cronbach’s α)	Between-groups (randomised)	Results revealed that participants from the embodied-VR condition meditated for double the amount of time at home than participants who only listened to the usual guided meditation. However, there were no significant differences in the overall quality of at-home meditation. In conclusion, this study confirms that embodied-VR systems are useful for increasing adherence to meditation practice
Ventura et al. (2021)	How Does It Feel to Be a Woman Victim of Sexual Harassment? The Effect of 360 degrees-Video-Based Virtual Reality on Empathy and Related Variables	Mexico	To study the effect of a 360-video-based VR experience (vs. traditional perspective-taking task) on empathy and related concepts (i.e. violent attitude, perspective taking, sense of oneness) towards a female victim of SH in a male sample	44 Mexican men participated in this study. The exclusion criteria; younger than 18 years old, having physical problems that could inhibit free movements; a history of SH with legal consequences; use or abuse of drugs; and receiving psychological treatment	360 film	Sexual harassment scenarios in the 360°-video VR experience (10 min)	Empathetic abilities: interpersonal reactivity index.w/Cronbach's alphas. Descriptive Statistics of Sociodemographic and Trait Measures. 3 × 2 mixed-design (ANOVA)	Within-subject design	Results of this study showed that both types of tasks (360 video and narrative) led to changes in empathy and violent attitudes, compared with baseline, in a sample of men. In addition, the authors found a tendency (marginally significant) to experience higher empathy after the 360 video than after the narrative

Appendix 3: Numerical breakdown of the VR experience length and perspective

Table 3 provides a breakdown of the length of the VR experience and perspective. It highlights no best practice intervention characteristics identified in the studies reviewed in this paper (Sorted by count from highest to lowest).

Length of VR experience	Count %	Perspective
Not Specified	11 (25.00%)	1PP
10 min	7 (15.91%)	1PP
15 min	2 (4.55%)	1PP
5 min	2 (4.55%)	1PP
10–15 min	2 (4.55%)	1PP
20 min	2 (4.55%)	1PP
7 min	2 (4.55%)	1PP
40 min	1 (2.27%)	1PP
4.5 min	1 (2.27%)	1PP
4 s (first view—study phase)	1 (2.27%)	1PP
30 s	1 (2.27%)	1PP
8 min	1 (2.27%)	1PP
6 min	1 (2.27%)	1PP
13 min	1 (2.27%)	1PP
10–12 min	1 (2.27%)	1PP
3–4 min	1 (2.27%)	1PP
5 min (each)	1 (2.27%)	1PP
9 min	1 (2.27%)	1PP
2 min	1 (2.27%)	1PP
45 min	1 (2.27%)	1PP
30 min (playtime w/ quite anytime)	1 (2.27%)	1PP
5–10 min (depending on the experience)	1 (2.27%)	1PP
5 min (Phase A), 4 min and 30 s (Phase B), 3 min (Phase C)	1 (2.27%)	1PP

Appendix 4: Numerical breakdown of the sector in which studies were done

The following table summarises the various sectors in which the studies occurred. The categories are determined by the study’s participant cohort and/or context. Sorted by highest to lowest count (Fig. 5).

Studies done (N = 44)	Count (%)
Healthcare and Medicine Sector	15 (34.10%)
Caregivers (Dementia, Alzheimer’s, chronic pain, migraine)	8 (18.19%)
Ageism and geriatrics	2 (4.55%)
Autism	2 (4.55%)
Schizophrenic spectrum and other psychotic disorders)	1 (2.23%)
Training new mental health clinicians	1 (2.23%)
Racism in medicine	1 (2.23%)
Education sector	15 (34.10%)
Bullying	2 (4.55%)
Sexism and sexual harassment	2 (4.55%)
Enhance teacher’s reflection and empathy skills	2 (4.55%)
Refugees	1 (2.23%)
School culture	1 (2.23%)
Storytelling	1 (2.23%)
VR classroom vs a real classroom	1 (2.23%)
Empathy exercise	1 (2.23%)
Develop empathy and communication via VR	1 (2.23%)
Impacts of immersive presentation of 360-video nonfiction content	1 (2.23%)
Modification of dysfunctional communication	1 (2.23%)
Immersion/embodiment	1 (2.23%)
General sector	10 (22.73%)
Refugees	1 (2.23%)
Young adults	1 (2.23%)
Sexism and sexual harassment	1 (2.23%)
Parenting	1 (2.23%)
Attitudes toward drug users	1 (2.23%)
Short and long-term effects of a traditional perspective-taking task and a VR perspective-taking	1 (2.23%)
Comparison. VR (real world) vs VR (augmented info added)	1 (2.23%)
How the uncanny valley influences narrative empathy and enjoyment	1 (2.23%)
Empathy-arousing (Game design)	1 (2.23%)
Racism	1 (2.23%)

Fig. 5

Numerical breakdown of the sector in which studies were done

Appendix 5: Numerical breakdown of the Display Devices used in studies

Table 5 provides a numerical breakdown of the Display Device used in studies and count. It highlights no best practice intervention characteristics identified in the studies reviewed in this paper

Display Device	Description	Count %
HMD	Not Specified	5 (11.37%)
Not Specified	Not Specified	5 (11.37%)
HMD	HTC VIVE	3 (6.82%)
HMD	Oculus Rift Development Kit 2	3 (6.82%)
HMD	OCULUS RIFT	2 (4.55%)
HMD and Desktop computer	Not Specified	2 (4.55%)
Desktop computer	No Specified	1 (2.27%)
HMD	Samsung Gear VR Headset	1 (2.27%)
HMD	Oculus Rift. Desktop computer via a YouTube 360° video	1 (2.27%)
HMD	VIVE	1 (2.27%)
HMD	Experienced in 360 film	1 (2.27%)
HMD	Ocular Go	1 (2.27%)
HMD	HTC VIVE Avatars	1 (2.27%)
HMD	VIVE and Oculus Rift CV	1 (2.27%)
HMD	Oculus Rift CVstereo viewing in 360 degrees. NSC condition the application was displayed to participants through 1920 × 1080 pixels 24-inch computer screen	1 (2.27%)
HMD	Oculus Rift head-mounted display with a tracker (Oculus VR, LLC, USA)	1 (2.27%)
HMD	HTC Vive virtual reality headset	1 (2.27%)
HMD	VIVE Pro	1 (2.27%)
HMD	Oculus Rift CV1	1 (2.27%)
HMD	HTC Vive—Dongguan China	1 (2.27%)
HMD	Homido virtual reality headset v2	1 (2.27%)
HMD	Not Specified. Experienced with 360 film	1 (2.27%)
HMD	Oculus Rift DK2. With infrared camera and desktop computer	1 (2.27%)
HMD	Daydream goggles	1 (2.27%)
HMD	Non-stereo and a fish-tank projection display (FTPD)	1 (2.27%)
HMD	Oculus Rift headset with Leap Motion VR	1 (2.27%)
HMD	Oculus Rift and HTC Vive, and handheld controllers in a 3 m x 3 m room scale tracking settings	1 (2.27%)
HMD and Desktop computer	Samsung Gear VR headset (VR condition). Samsung Galaxy S6 smartphone or in a 17 inch laptop screen (screen condition)	1 (2.27%)
Monitor	Not Specified	1 (2.27%)
VR-cardboard and the 360 YouTube video	Viewed on Apple iMac with a built-in 21-inch display full screen mode	1 (2.27%)

Appendix 6: Numerical breakdown of the sample size used in studies

Sample size	No. of studies %
Not specified	2 (4.55%)
112	2 (4.55%)
148	2 (4.55%)
78	2 (4.55%)
20	2 (4.55%)
33	2 (4.55%)
44	2 (4.55%)
40	2 (4.55%)
37	2 (4.55%)
84	1 (2.27%)
27	1 (2.27%)
3	1 (2.27%)
55	1 (2.27%)
70	1 (2.27%)
24	1 (2.27%)
53	1 (2.27%)
19	1 (2.27%)
50	1 (2.27%)
145	1 (2.27%)
35	1 (2.27%)
5	1 (2.27%)
30	1 (2.27%)
118	1 (2.27%)
180	1 (2.27%)
117	1 (2.27%)
52	1 (2.27%)
738	1 (2.27%)
200	1 (2.27%)
18	1 (2.27%)
32	1 (2.27%)
73	1 (2.27%)
60	1 (2.27%)
65	1 (2.27%)
41	1 (2.27%)
163	1 (2.27%)

Appendix 7: Numerical breakdown of the studies that sampled disability support workers

No studies used DSWs in their study. The closest cohort used to DSWs was informal caregivers.

First Author	Sample Description Used
Jütten et al. (2017)	Informal caregivers
Wijma et al. (2018)	Caregivers
Slater et al. (2019)	Caregivers

Appendix 8: Numerical breakdown of key themes in the existing literature

Author/Date	Key themes in the existing literature?	Count %
(Johnsen and Lok 2008), (Cheng et al. 2010), (Kalyanaraman et al. 2010), (Sulpizio et al. 2015), (Adefila et al. 2016), (Kors et al. 2016), (Camilleri et al. 2017), (Muller et al. 2017), (Schutte and Stilinović 2017), (Hamilton-Giachritsis et al. 2018), (Ingram et al. 2019), (Jütten et al. 2018), (Kang 2018), (Formosa et al. 2018), (Stavroulia et al. 2018), (van Loon et al. 2018), (Weinel et al. 2018), (Wijma et al. 2018), (Buchman and Henderson 2019), (Slater et al. 2019), (Stavroulia and Lanitis 2019), (Stavroulia 2019), (Barbot and Kaufman 2020), (Barreda-Ángeles et al. 2020), (Christofi et al. 2020), (Kim et al. 2020), (Kors et al. 2020), (Misztal et al. 2020), (Mustapha and Razali 2020), (Patané et al. 2020), (Roswell et al. 2020), (Tonget al. 2020), (Campbell et al. 2021), (Navarrete et al. 2021), (Ventura et al. 2021)	Papers that discussed the existing literature in a more supportive manner (i.e. VR’s potential as an empathy enhancement tool)	36 (81.82%)
(Deladisma et al. 2007), (McEvoy et al. 2016), (Oh et al. 2016), (Bang and Yildirim, 2018), (Herrera et al. 2018), (Trinidad and Linsangan 2018), (MacDorman 2019), (Steinfeld 2020)	Papers that discussed the existing literature in a more disputed and Indecisive manner	8 (18.19%)
	Papers that reported the complex and/or varied definition of empathy	11 (25.00%)
	Relatability	7 (15.91%)
	Empathy definition inconsistency	11 (25.00%)
	Females reported as typically more empathetic	3 (6.82%)

Appendix 9: Numerical breakdown of key words used, the working definitions, and terminologies being used (sorted by count from highest to lowest)

Table 9 gives the working definitions, and terminologies being used in the studies reviewed surrounding the use of VR technology as an empathy enhancement medium. To obtain a comprehensive insight into the usage of words and related terminologies, the cited references in studies were also included in the analysis (Fig. 6).

Words	Working definitions	Related terminology	Count (%)
Empathy	“Empathy allows us to understand the feelings of others, predict their behaviours, and experience emotions triggered by their emotions” (Cheng et al. 2010), “Cognitive empathy refers to a controlled process in which individuals understand the mental states of others while adopting their psychological point of view. Emotional empathy commonly refers to the more automatic affective response to the experience of others, which can motivate concern and subsequent helping behaviour” (Sulpizio et al. 2015).  “Empathy is defined in many different ways (Davis, 1996; Decety and Jackson, 2004; Ickes, 2003, as cited in Adefila et al.2016), however, one significant and common conceptual characterization relates to subjectively experience and share in another’s psychological state or feelings; what is termed an “affective response” to another” (Jeffrey 2016). “Empathy, the ability to share and understand someone else's emotions” (Herrera et al. 2018) , “Empathy entails the ability to understand the thoughts and feelings of someone else” (Singer et al. 2004, as cited in Wijma et al. 2018) “Whilst empathy has been defined and conceptualised in different ways (Jeffrey 2016), the central tenet of most definitions refers to the ability to understand another person's experiences and feelings (Cunico et al. 2012; Lemogne, 2015, as cited in Slater et al. 2019). However, research suggests that empathy is not a singular entity rather it is composed of different dimensions” (Bylund and Makoul, 2002, as cited in Slater et al. 2019). “Empathy is the ability to place oneself in another's position, participate in what one suffers until complete empathetic identification without the loss of the personal identity (Kirman et al. 2010, as cited by Stavroulia and Lanitis 2019). There is no consensus on the meaning of empathy, as it is used by several disciplines and thus the different definitions reflect the differences of the fields (Gerdes 2011, as cited by Stavroulia and Lanitis 2019). Empathy refers to the ability to enter the position of another person and see the world with his/her own eyes” (Stavroulia and Lanitis 2019). “In its original sense, empathy can be considered as the tendency to project oneself into an observed entity with the mechanism of an inner imitation” (Davis, 1996, as cited by Misztal et al. 2020)	Perspective-taking (Muller et al. 2017), perspective, 1PP, understanding, compassion, kindness, empathic concern, other-oriented empathic states, self-oriented empathic states	44 (100%)
Virtual Reality (VR)	“VR can be described as a concerted representation of sensory illusions that help create a sense of presence into an alternate world” (Camilleri et al. 2017). “Virtual reality (VR) refers to computer technologies that use software to generate realistic images, sounds, and other sensations that replicate a real environment or create an imaginary setting, and simulate a user’s physical presence in this environment” (Kang 2018). “Virtual Reality (hereafter VR) technologies are advanced interfaces creating a virtual, immersive, simulated environment which replaces the actual surroundings of a user so that the user may experience the virtual as real” (Guttentag 2010; Zheng, Chan, and Gibson 1998, as cited in Steinfeld, 2020).	Intervention, multiple sensory, virtual environments, virtual patients (VP), virtual human, virtual consultation	43 (97.73%)
Presence	The user feels being there inside the virtual world	Sense of presence, spatial presence, transportation	37 (84.10%)
Perspective taking (PT)	The ability to experience a situation from a different perspective (i.e. walking in the shoes of someone else)	1PP, Empathy, walking in another person’s shoes, experiencing what someone else might, First-person POV, Deep subjectivity. Virtual reality perspective-taking experiences (VRPT), perspective, viewing others’ perspectives, partaker-perspective, first-person perspective, Perspectives	32 (72.73%)
Virtual environment (VE)	Computer-generated environment	VE, Immersive virtual environments (IVE), 3D environments, Virtual simulation training, simulated environment, virtual reality simulation, Virtual Worlds, Virtual Environments, virtual reality environment	31 (70.46%)
Various software and terminology	“The set of instructions or programs that tell a computer what to do” (IBM, 2023).	Unity software, Audition CS6 software, Software, Premiere Pro, game engine, Worldviz PPT E, Xsens, Adobe “Mercy”, 1000 Cut Journey, Adobe AS IF, Autodesk, HTC Vive technology, Into D’mentia simulator, Kinect, online software, Permanent, The Autism Too Much Information (TMI), the machine to be another (TMTBA), Through Pink and Blue Glasses, Through the D’mentia Lens (TDL), Unity, Unity 3D platform, Unity Technologies, Unity, UnityPro4, Virtual Dementia Tour (VDT), Virtual Dementia Tour, Alfred by Embodied Labs,	30 (68.19%)
Immersive	Experiencing the same sensations of ownership over a virtual body inside an immersive virtual environment. A technical property of the medium, related to its capacity to provide natural sensorimotor contingencies to the user (e.g. a wide field of view, or a quick update of the visual field when the user turns his or her head)	Immersion, Reality environment, Immersive virtual environment (IVE), immersive virtual reality, 3D environments, immersive journalism, immersive VR, immenseness (Mustapha and Razali 2020), immersive technology, immersive VR environment, immersive environments, immersive virtual environments, Immersion virtual reality	26 (59.10%)
Embodied	Feeling of being “embodied” in a virtual body	Embodiment, Sense of Embodiment, metaphorical embodiment, immersive Embodied, embodied virtual reality (EVR), embodied agents, Virtual Embodiment	25 (56.82%)
Head-mount display	A device worn on the head to display or project the visual content for the user	HMD, display device, head-mounted VR camera, VR headset, headset, daydream goggles, HTC Vive, Oculus CV, Oculus CV1, Oculus Rift DK2, head-mounted, VR simulator, head mounted device, Oculus Rift, virtual reality headset, Samsung Gear VR Headset, head mounted display, HTC Vive headset, Oculus Rift VR headset, VIVE, HTC Vive HMD, VR-cardboard headset, head-mounted camera, Ocular Go Headsets, virtual reality headset, VIVE Pro, Homido virtual reality headset, head mounted VR	22 (50%)
Avatar	Digital representation of the user	3D avatar, avatars (Johnsen and Lok 2008), (Cheng et al. 2010), (Kors et al. 2016), (Herrera et al. 2018),  (Stavroulia et al. 2018), (Stavroulia and Lanitis 2019), (Christofi et al. 2020), (Kim et al. 2020), (Ventura et al. 2021) virtual persona, on-screen persona, self-avatar (van Loon et al. 2018), agents (Herrera et al. 2018).	20 (45.46%)
Story	Experiencing the narrative from a first-person point of view	Virtual reality journalism, 360-degree video, story, immersive journalism, storyline, interactive storybook, immersive story-driven Replication, storytelling, immersive storytelling, VR Storytelling	15 (34.10%)
Experiential learning	Learning in which the learner is directly in touch with the realities being studied, instead of only reading, hearing, or writing about it	Constructionist education, experiential learning theory (ELT), game Based Learning (Tong et al. 2020), active learning (Washington and Shaw 2019), “problem-based learning” (PBL) (Washington and Shaw 2019), “case study-based learning (Washington and Shaw 2019),” competency-based learning (Washington and Shaw 2019), flipped classroom (Washington and Shaw 2019), Games-based learning (Kors et al. 2016), student-centred learning, practical ‘hands-on’ engagement, embodied learning (Washington and Shaw 2019), Discovery learning, student centred learning, practical ‘hands-on’ engagement, active engagement, experimental Intervention, Constructionist education	10 (22.73%)
Headphones	“A device that converts electrical energy into sound waves and is worn over or inserted into the ear” (Merriam-Webster 2021)	Earphones	10 (22.73%)
Healthcare	Care and support to people with a disability, a medical condition, mental illness or age related	Health care workers, healthcare professionals, healthcare training	8 (18.19%)
Caregivers	Someone who provides care and support to people with a disability, a medical condition, mental illness or aged related ailments	Caregiver, informal caregiving, caregivers, carers, health care workers, healthcare professionals, Care nurses, social care practitioners, dementia care	7 (15.91%)
Augmented	An interactive real-world experience with blended computer-generated objects to enhance the experience	Multiple sensory, Intervention, virtual environment, augmented context-based interactions, augmented, augmented reality systems, augment, Augmented Virtuality, Augmented reality (AR)	7 (15.91%)
Mixed reality	A hybrid of reality and virtual reality	MR, Mixed Virtual Reality, Augmented, reality, AR, virtual environment	6 (13.64%)
Psychometric	Theory and technique of psychological measurement	Psychometric test	6 (13.64%)
360-degree	Video recordings that capture multiple directions at once. Typical using omnidirectional camera or an assembly of cameras	Immersive technology, Intervention, VR storytelling, Virtual reality journalism, 360-degree, 360° tour, 360° film, 360 Samsung Gear camera, 360-degree immersion, 360° simulation video, YouTube 360° video, 360-degrees video, Virtual Reality 360, VR 360 immersion simulation, 360° video, 360° videos, 360-Video, 360 degrees, 360°-video-based, 360-degree video	5 (11.37%)
Artificial	The science and engineering of making intelligent machines, especially intelligent computer programs. It is related to the similar task of using computers to understand human intelligence, but AI does not have to confine itself to methods that are biologically observable (McCarthy 2007)	Intelligence demonstrated by machines, the simulation of human intelligence processes by machines. Stimulus, Stimuli, visual and haptic senses to increase the embodied illusion, Artificial Reality, artificial nature, Artificial, Artificial intelligence (AI)	4 (9.10%)
Virtual reality programmes for dementia training	Used to stimulate experiences of what it might be like for a person with dementia	Virtual dementia Experience, Virtual Dementia Tour, myShoes project, simulating dementia, dementia simulation, Into D’mentia, Through the D’mentia Lens (TDL), Virtual Dementia Tour (VDT)	3 (6.82%) Programs
Cybersickness	Exposure to a virtual environment causes similar symptoms to motion sickness. Or psychological impact of feeling oneness with the avatar (Ventura et al. 2021)	Cybersickness, sickness, ataxia, headache, or “feeling off”, simulation sickness, motion sickness, Simulator Sickness), Virtual reality sickness	3 (6.82%)
Transportation	The extent that individuals are absorbed into a story or transported into a narrative word	Presence, intensity of absorption, transport	3 (6.82%)
Deep subjectivity	First-person POV simulations that utilise the audio-visual Medium to reflect not only the perceptual experience of visual and auditory information, but also aspects of perception that are non-aural or non-visual. Sensory experience of that person may be like (e.g. multimodal senses and emotions)	Perspective taking (Adefila et al. 2016), subjective attention, attention filters, immersive experience and deeper understanding perceptual awareness, sensory experience, deeper understanding (Stavroulia and Lanitis 2019), (Tong et al. 2020), deep (Kors et al. 2016), (Roswell et al. 2020), deeper understanding of Oneself (Kalyanaraman et al. 2010), viscerally engaging experiences	1 (2.27%)
Pulse sensor	A device used to check and monitor a pulse	Interbeat intervals (IBIstime between pulses), The heart rate is known as beat per minute (BPM), pulse rate sensing node	1 (2.27%)
Electroencephalogram (EEG)	An electroencephalogram (EEG) is a test that detects electrical activity in your brain using small, metal discs (electrodes) attached to your scalp. Your brain cells communicate via electrical impulses and are active all the time, even when you're asleep. This activity shows up as wavy lines on an EEG recording. Mayo Foundation (MFMER 2023)	EEG brain activity, BIOSEMI (EEG signal acquisition device used), EMOTIV EPOC + (high resolution, multi-channel, wireless neuroheadset), electroencephalographic (EEG), EEG signals, EEG	1 (2.27%)
Information communication technology (ICT)	Extensional terminology for information technology	Information technology (IT), ICT-based, Information Communication Technologies	1 (2.27%)
Image-based gesture interface	Gesture recognition technology	Hand gesture recognition technology, hand gesture controlled (Kim et al. 2020).	1 (2.27%)
Artificial auditory hallucination	Audio recordings used to simulate auditory hallucination	Simulated of artificial hallucination, Stimulus, Stimuli, persecutory paranoia	1 (2.27%)

Fig. 6

Numerical breakdown of key words used

Appendix 10: Numerical breakdown of reported factors that Facilitated empathetic feelings (Sorted by highest to lowest count)

See Fig. 7.

Factors	Count %
Perspective-taking as an important characteristic of empathy	44 (100%)
VR’s capacity to facilitate perspective-taking	29 (65.91%)
Presence	20 (45.46%)
Embodiment	19 (43.19%)
Immersion	16 (36.37%)
Personality traits	16 (36.37%)
Interactivity	14 (31.82%)
Relatability	7 (15.91%)

Fig. 7

Numerical breakdown of reported factors that Facilitated empathetic feelings

Appendix 11: Numerical breakdown of reported barriers that contributed to study limitations (Sorted by highest to lowest count)

See Fig. 8.

Factors	Count %
Additional measures needed	25 (56.81%)
Sample Size	19 (43.19%)
ControlValidityReliability	19 (43.19%)
Design	16 (36.37%)
Ability to Generalise	16 (36.37%)
Personality traits	16 (36.37%)
Content	5 (11.37%)
Not reported	3 (6.82%)
Technology	2 (4.55%)
Questionnaire difficulty	1 (2.27%)

Fig. 8

Numerical breakdown of reported barriers that contributed to study limitations