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Improving the Quality of Communicating with Dementia Patients: A Virtual Reality-Based Simulated Communication Approach

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Title: Improving the Quality of Communicating with Dementia Patients: A Virtual Reality-Based Simulated Communication Approach
Language: English
Authors: Hui-Chen Lin (ORCID 0000-0001-8074-8884), Hsin Huang, Chia-Kuang Tsai (ORCID 0000-0001-7693-1408), Shao-Chen Chang
Source: British Journal of Educational Technology. 2025 56(1):167-189.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 23
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Dementia, Patients, Language Impairments, Communication Problems, Speech Therapy, Computer Simulation, Training, Caregivers, Outcomes of Treatment, Communication Skills
DOI: 10.1111/bjet.13497
ISSN: 0007-1013
1467-8535
Abstract: Dementia patients may have language barriers and decreased comprehension ability. Their family caregivers can feel frustrated when communicating with them. Poor communication hinders family caregivers from obtaining accurate health information about patients, and may also increase their emotional burden, affecting patient care quality. The present study developed a virtual reality-based simulated communication training (VRSCT) system and applied it to a training course for family caregivers of dementia patients. It allowed family caregivers to simulate real-world situations in a VR environment, experience the daily communication barriers and stress with dementia patients, and apply their acquired knowledge and skills to solve related problems. This study used a randomised control experimental design with mixed analysis methods. A total of 63 family caregivers were recruited and randomly divided into the experimental group (N = 32) learning with the VRSCT system to interact with virtual dementia patients and practice communication skills, and the control group (N = 31) using the traditional role-playing method for practice. Quantitative data were analysed to determine participants' knowledge of dementia care, attitudes, communication confidence and skills. In addition, the qualitative method was used to analyse the participants' discussion records. The results showed that by using the VRSCT approach, participants significantly improved their knowledge of dementia care, attitudes, communication confidence and communication skills compared to the control group. In addition, participants reported that through the real-time feedback of the VRSCT system, they could recognise their previous incorrect communication approach. As a result, they adjusted their communication strategies and increased their self-confidence.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1456975
Database: ERIC
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  Value: <anid>AN0183820127;58i01jan.25;2025Mar20.07:14;v2.2.500</anid> <title id="AN0183820127-1">Improving the quality of communicating with dementia patients: A virtual reality‐based simulated communication approach </title> <p>Dementia patients may have language barriers and decreased comprehension ability. Their family caregivers can feel frustrated when communicating with them. Poor communication hinders family caregivers from obtaining accurate health information about patients, and may also increase their emotional burden, affecting patient care quality. The present study developed a virtual reality‐based simulated communication training (VRSCT) system and applied it to a training course for family caregivers of dementia patients. It allowed family caregivers to simulate real‐world situations in a VR environment, experience the daily communication barriers and stress with dementia patients, and apply their acquired knowledge and skills to solve related problems. This study used a randomised control experimental design with mixed analysis methods. A total of 63 family caregivers were recruited and randomly divided into the experimental group (N = 32) learning with the VRSCT system to interact with virtual dementia patients and practice communication skills, and the control group (N = 31) using the traditional role‐playing method for practice. Quantitative data were analysed to determine participants' knowledge of dementia care, attitudes, communication confidence and skills. In addition, the qualitative method was used to analyse the participants' discussion records. The results showed that by using the VRSCT approach, participants significantly improved their knowledge of dementia care, attitudes, communication confidence and communication skills compared to the control group. In addition, participants reported that through the real‐time feedback of the VRSCT system, they could recognise their previous incorrect communication approach. As a result, they adjusted their communication strategies and increased their self‐confidence. Practitioner notesWhat is already known about this topic Situational simulation helps learners improve their communication skills in a safe environment.Virtual reality (VR) creates a realistic, highly interactive learning environment, allowing users to be deeply immersed in the learning experience.What this paper adds This study proposed a VR‐based simulated communication training (VRSCT) approach; moreover, seven dementia cases of different degrees of severity were designed in the VR system to enable family members to experience possible challenges of taking care of dementia patients they might encounter in their daily lives.Each case in the VRSCT system has its unique symptoms and communication barriers. The learner in the story plays a caregiver, experiencing and solving the problems and challenges posed by the system.The experimental results show that the proposed method improves learners' knowledge, attitudes, communication confidence, and communication skills related to dementia care.Implications for practice and/or policy Utilising VR training can amplify awareness and secure enhanced social support for dementia‐related challenges.Using VRSCT, as governments and institutions recognise the effectiveness of VR training, they will provide more resources and promote its widespread application.</p> <p>Keywords: communication skill; experiential learning; simulation; virtual reality</p> <hd id="AN0183820127-2">INTRODUCTION</hd> <p>As the global population ages, the number of people suffering from dementia will increase year by year. In the coming decades, dementia will become one of the major challenges for social and healthcare systems worldwide (Banovic et al., [<reflink idref="bib5" id="ref1">5</reflink>]). During the course of dementia, patients' abilities to express and understand language gradually deteriorate, making them unable to communicate their needs effectively. This makes patients feel frustrated, anxious and depressed. When their needs are ignored or not satisfied, it may develop or aggravate their psychological symptoms and problematic behaviours such as delusions, hallucinations, aggression and screaming (Banovic et al., [<reflink idref="bib5" id="ref2">5</reflink>]; Warren, [<reflink idref="bib60" id="ref3">60</reflink>]). In addition, communication barriers between dementia patients and their family caregivers increase conflicts between them (Williams et al., [<reflink idref="bib62" id="ref4">62</reflink>]). Lack of effective communication may also prevent family caregivers from knowing the patient's health status in a timely and accurate manner, thereby affecting the patient's medical care (Taghizadeh et al., [<reflink idref="bib56" id="ref5">56</reflink>]; Zareii et al., [<reflink idref="bib65" id="ref6">65</reflink>]). Faced with these situations, family caregivers endure immense caregiving stress. When family caregivers lack understanding of the disease or have difficulty accepting and empathising with the patient, their care attitudes may become negative (Adewuyi et al., [<reflink idref="bib1" id="ref7">1</reflink>]; Banovic et al., [<reflink idref="bib5" id="ref8">5</reflink>]; Downs & Collins, [<reflink idref="bib19" id="ref9">19</reflink>]), causing them to frequently experience emotional distress such as anxiety, sadness and anger (Adewuyi et al., [<reflink idref="bib1" id="ref10">1</reflink>]; Downs & Collins, [<reflink idref="bib19" id="ref11">19</reflink>]). In the long run, these factors have adverse effects on the overall health and life quality of family caregivers (Karg et al., [<reflink idref="bib30" id="ref12">30</reflink>]).</p> <p>In order to overcome these challenges, family caregivers should receive professional communication training about dementia, to understand and empathise with patients' symptoms and feelings, and to provide appropriate care by reducing misunderstandings and unnecessary conflicts through effective communication. At present, most communication training courses adopt lectures and videos for teaching. Through interaction with dementia patients and case discussions, the courses teach learners the identification of dementia‐related symptoms and care knowledge, and strengthen their care attitudes (Chesneau et al., [<reflink idref="bib12" id="ref13">12</reflink>]; Fang et al., [<reflink idref="bib20" id="ref14">20</reflink>]; Naughton et al., [<reflink idref="bib40" id="ref15">40</reflink>]). Also, applying situational simulations to communication skills training enables learners to improve their confidence and skills in communication through actual participation in a safe environment (Harwood et al., [<reflink idref="bib22" id="ref16">22</reflink>]; O'Brien et al., [<reflink idref="bib42" id="ref17">42</reflink>]). However, traditional situational simulation courses mostly employ standard patients or peer role‐playing. Researchers have pointed out that role‐playing in the learning process is not authentic and cannot fully reproduce the emotional distress in real‐world contexts, which may affect learners' performance in real life (Helling‐Bakki et al., [<reflink idref="bib23" id="ref18">23</reflink>]; Shorey et al., [<reflink idref="bib50" id="ref19">50</reflink>]). Skill mastery requires continuous practice, rigorous evaluation and feedback (Rock, [<reflink idref="bib47" id="ref20">47</reflink>]), while lack of timely and specific feedback makes it difficult for learners to identify and correct mistakes (Huang et al., [<reflink idref="bib25" id="ref21">25</reflink>]; Lawaetz et al., [<reflink idref="bib32" id="ref22">32</reflink>]). Moreover, traditional situational simulations cannot ensure a consistent and repeatable learning environment. These factors limit the effects of communication skills learning.</p> <p>Virtual reality (VR) aims to enhance high‐fidelity patient simulation in nursing education through immersion in a virtual environment that mimics reality. With the advantage of a high degree of immersion, the realistic VR environment provides learners with an immersive experience that allows them to better understand the emotions and stresses of the caregivers in the situation (Caldas et al., [<reflink idref="bib9" id="ref23">9</reflink>]). VR facilitates understanding of the dementia care environment, understanding and sensing of the emotions of the person with dementia, helps learners develop empathy, and increases dementia knowledge and attitudes (Stargatt et al., [<reflink idref="bib52" id="ref24">52</reflink>]). Using computerised simulation scenarios, which reduces the learner's fear of making mistakes, training in communication skills by mimicking interactions with a person with dementia in a virtual reality simulation can reduce the learner's anxiety (Hirt & Beer, [<reflink idref="bib24" id="ref25">24</reflink>]). Learners receive immediate feedback and repeated practice to improve caregiving skills. It also allows them to acquire skills through continuous practice (Barsom et al., [<reflink idref="bib7" id="ref26">7</reflink>]; Huang et al., [<reflink idref="bib25" id="ref27">25</reflink>]; Lee et al., [<reflink idref="bib33" id="ref28">33</reflink>]).</p> <p>As a result, the present study developed a VR‐based simulated communication training (VRSCT) system based on experiential learning theory, and designed a VR simulated environment for dementia. Learners experienced and responded to the questions from the system to learn about dementia and its common symptoms and problems. By interacting with virtual characters, learners were faced with the life troubles of family caregivers and patients caused by physiological and psychological factors, and employed and practiced their communication skills to solve the common problems in daily life. In order to verify the effectiveness of the system, this study designed an experiment and applied it to the communication training course for family caregivers of dementia patients. It compared the knowledge, care attitudes, communication confidence and skills of learners using the VRSCT approach and the traditional communication training (TCT) approach. The research questions are presented as follows:</p> <p></p> <ulist> <item> Can the VRSCT approach improve family caregivers' care knowledge in comparison with the TCT approach?</item> <p></p> <item> Can the VRSCT approach enhance family caregivers' care attitudes in comparison with the TCT approach?</item> <p></p> <item> Can the VRSCT approach increase family caregivers' communication confidence in comparison with the TCT approach?</item> <p></p> <item> Can the VRSCT approach enhance family caregivers' communication skills in comparison with the TCT approach?</item> <p></p> <item> What are the relationships between family caregivers' care knowledge, care attitudes, communication confidence, and communication skills?</item> </ulist> <hd id="AN0183820127-3">LITERATURE REVIEW</hd> <p></p> <hd id="AN0183820127-4">Dementia communication skills training</hd> <p>Communication refers to the exchange of information between people through language, words, eyes, and gestures. Effective communication is a two‐way interactive process; the message sent by the sender is successfully received, understood and responded to by the receiver (Prabavathi & Nagasubramani, [<reflink idref="bib46" id="ref29">46</reflink>]). In the medical environment, through effective communication, we can understand the physical and psychological needs of patients and provide appropriate care to maintain high‐quality care for patients (Dithole et al., [<reflink idref="bib17" id="ref30">17</reflink>]). However, the memory and cognitive functions of dementia patients will decline, and their abilities to understand and express language will gradually be lost. Eventually, they may only use words or non‐verbal language, such as facial expressions and body movements to convey information (Alsawy et al., [<reflink idref="bib3" id="ref31">3</reflink>]; Nguyen et al., [<reflink idref="bib41" id="ref32">41</reflink>]). These communication limitations can make it difficult for family caregivers to properly assess the needs of patients (Taghizadeh et al., [<reflink idref="bib56" id="ref33">56</reflink>]; Zareii et al., [<reflink idref="bib65" id="ref34">65</reflink>]).</p> <p>The content of the communication training course includes introducing the course of dementia, teaching family caregivers to understand and recognise patients' symptoms, assessing patients' cognitive and language abilities, and using appropriate communication strategies according to patients' different conditions (Barnes & Markham, [<reflink idref="bib6" id="ref35">6</reflink>]; Chesneau et al., [<reflink idref="bib12" id="ref36">12</reflink>]; Troche et al., [<reflink idref="bib58" id="ref37">58</reflink>]). Accurate knowledge can help family caregivers understand and accept the symptoms exhibited by patients, and improve their care attitudes (Conway & Chenery, [<reflink idref="bib14" id="ref38">14</reflink>]). The use of situational simulations in the communication skills training course allows learners to deeply experience the communication barriers. This prompts them to reflect on their own skills and integrate relevant knowledge, thereby effectively applying these skills and knowledge in real life (Ditton‐Phare et al., [<reflink idref="bib18" id="ref39">18</reflink>]; Fifolt et al., [<reflink idref="bib21" id="ref40">21</reflink>]). In line with the constructivist learning theory, through active engagement and interaction with the environment, learners can improve their learning attitudes and understand complex concepts, which contributes to learning effectiveness (Chen et al., [<reflink idref="bib11" id="ref41">11</reflink>]). Past studies have pinpointed that applying situational simulations to learn to interact with dementia patients can help enhance learners' care attitudes and empathy with patients (Çetingök et al., [<reflink idref="bib10" id="ref42">10</reflink>]), and improve their communication knowledge and skills (Morris et al., [<reflink idref="bib39" id="ref43">39</reflink>]; Witt et al., [<reflink idref="bib63" id="ref44">63</reflink>]). Nonetheless, lack of realism in traditional situational simulations affects learners' feelings, making it difficult for them to empathise with simulated patients or peers (Helling‐Bakki et al., [<reflink idref="bib23" id="ref45">23</reflink>]; Naughton et al., [<reflink idref="bib40" id="ref46">40</reflink>]; Shorey et al., [<reflink idref="bib50" id="ref47">50</reflink>]). Additionally, traditional situational simulations are time‐consuming and costly, and it is difficult to re‐build scenarios (Lawaetz et al., [<reflink idref="bib32" id="ref48">32</reflink>]). Hence, it is necessary that researchers come up with pragmatic solutions for the situational simulation teaching plan to be executed effectively.</p> <hd id="AN0183820127-5">VR‐based simulations</hd> <p>VR‐based simulations are a method of creating simulated environments using virtual reality (VR) technology. These simulations provide an immersive experience that allows users to interact in a safe and controlled learning environment (Hwang & Chien, [<reflink idref="bib26" id="ref49">26</reflink>]; McDonald et al., [<reflink idref="bib37" id="ref50">37</reflink>]). According to constructivist learning theory, learning is a process of active construction in which learners build and integrate knowledge by interacting with teaching plans in real‐world or simulated environments (Piaget, [<reflink idref="bib45" id="ref51">45</reflink>]; Vygotsky & Cole, [<reflink idref="bib59" id="ref52">59</reflink>]). VR offers a secure learning environment that elevates learner engagement and effectiveness, especially in simulated scenarios that are hard to replicate in real life (Seprum & Wongwatkit, [<reflink idref="bib49" id="ref53">49</reflink>]). Its high customisability allows educators to tailor learning experiences to individual needs (Deuchler & Wölfel, [<reflink idref="bib16" id="ref54">16</reflink>]). Such personalisation means VR‐supported simulation‐based learning becomes notably potent in advancing knowledge and skills across diverse settings (Dai et al., [<reflink idref="bib15" id="ref55">15</reflink>]). Additionally, these VR simulations provide instant feedback, facilitating timely skill refinement for learners (Lee et al., [<reflink idref="bib33" id="ref56">33</reflink>]). Previous studies have shown that VR‐based simulations can provide an effective learning experience through the ability to create immersive and realistic experiences (McDonald et al., [<reflink idref="bib37" id="ref57">37</reflink>]). Especially in low‐risk, highly simulated learning environments, learners can practice tasks such as performing cardiopulmonary resuscitation (Barsom et al., [<reflink idref="bib7" id="ref58">7</reflink>]; Liu et al., [<reflink idref="bib36" id="ref59">36</reflink>]), difficult airway insertion skills (Samosorn et al., [<reflink idref="bib48" id="ref60">48</reflink>]), and fire safety training (Morélot et al., [<reflink idref="bib38" id="ref61">38</reflink>]). In this way, they can become familiar with the skills through practical experience and repeated practice, all in a safe environment.</p> <p>In addition, with its features of in‐depth immersion and high interactivity, VR technology allows users to deeply perceive others' emotions through visual, auditory and dynamic participation, thereby promoting the cultivation of empathy (Jang et al., [<reflink idref="bib28" id="ref62">28</reflink>]; Stavroulia & Lanitis, [<reflink idref="bib53" id="ref63">53</reflink>]). Wijma et al. ([<reflink idref="bib61" id="ref64">61</reflink>]) utilised virtual environments for caregivers to display daily situations from the perspective of dementia patients in 360 degrees, and to experience the feelings and restrictions of dementia patients, which helped increase their empathy for dementia patients. Also, Shorey et al. ([<reflink idref="bib50" id="ref65">50</reflink>]) indicated that VR‐based simulated learning could significantly enhance learners' communication skills and communication confidence. Above all, VR‐based simulations not only design the problems and challenges that learners may encounter in daily life so that they can have actual experience and coping strategies but also help correct their cognitive biases, deepen their reflection, and integrate their knowledge. Moreover, it motivates learners to apply their acquired skills and knowledge to real‐life situations.</p> <hd id="AN0183820127-6">THE VIRTUAL REALITY‐BASED SIMULATED COMMUNICATION TRAINING (VRSCT) SYSTEM</hd> <p></p> <hd id="AN0183820127-7">System structure</hd> <p>The present study employed CoSpaces Edu to develop a VRSCT system. CoSpaces Edu is an online creation platform featuring visual programming tools. Users create interactive and animated 3D virtual worlds with an intuitive drag‐and‐drop editor. They can also explore their creations through VR <bold>(</bold>Al‐Gindy et al., [<reflink idref="bib2" id="ref66">2</reflink>]<bold>)</bold>. In the administrator interface, the teacher integrated learning materials and scripts of dementia cases into the CoSpaces VR system to provide daily life scenarios of dementia patients as the teaching plan. On the other hand, in the VR learning interface displayed through Google Cardboard VR glasses, learners interacted with virtual patients and responded to the questions provided by the system. The learning trajectory was stored in the learning portfolio database (see Figure 1).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0001.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0001.jpg" title="1 VRSCT system structure." /> </p> <p></p> <hd id="AN0183820127-9">Simulated communication levels in VR</hd> <p>The VRSCT system was developed by two experts, a neurologist and a dementia case manager, with over 10 years of clinical experience. They considered the main factors contributing to the burden of caring for dementia patients, including the decline in their functional abilities and the deterioration in their communication skills (Small et al., [<reflink idref="bib51" id="ref67">51</reflink>]). In order to simulate realistic situations that family caregivers of dementia patients might face, seven different dementia cases of varying degrees of severity and a variety of everyday life scenarios were designed for inclusion in the VRSCT system (Table 1). The system uses the mini‐mental state examination (MMSE) to define the severity of dementia, including mild (MMSE ≥20), moderate (MMSE 10–19) and severe (MMSE ≤9) stages (Benoit et al., [<reflink idref="bib8" id="ref68">8</reflink>]). Additionally, the scenario design takes into account the most common types of conflict when communicating with dementia patients and their families, such as being unable to understand the patient or lacking the patience to listen. Moreover, conflicts most often occur during daily life events, such as using the bathroom, planning an agenda, locating an item and meal preparation (Small et al., [<reflink idref="bib51" id="ref69">51</reflink>]).</p> <p>1 TABLE Scenarios in the VRSCT system.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Scenario description</th><th align="left">Daily life events</th><th align="left">Communication strategy</th></tr></thead><tbody valign="top"><tr><td align="left">Case 1:Mrs. Yu, who is 82 years old, has moderate dementia (MMSE score: 18)Scenario: She experiences mild hearing loss and is very reluctant to see a doctorTask: Use effective communication to engage Mrs. Yu and persuade her to return to the hospital</td><td align="left">Planning an agenda:Taking a dementia patient to the hospital for a medical appointment</td><td align="left"><list list-type="Bullet"><list-item><p>Face‐to‐face, eye contact</p></list-item><list-item><p>Do not shout at older people with hearing loss</p></list-item><list-item><p>Avoid arguing or over‐correcting</p></list-item><list-item><p>Use specific nouns, not pronouns</p></list-item><list-item><p>Less background noise</p></list-item></list></td></tr><tr><td align="left">Case 2:Mr. Wang, who is 80 years old, has moderate dementia (MMSE score: 16)Scenario: Mr. Wang wants to wait for his wife, who passed away 5 years ago, before going for a walkTask: Use effective communication to encourage Mr. Wang and accompany him on a walk</td><td align="left">Planning an agenda:Going Out for a Walk</td><td align="left"><list list-type="Bullet"><list-item><p>Do not argue with dementia patients</p></list-item><list-item><p>Repeat key words and phrases</p></list-item><list-item><p>Change the subject appropriately</p></list-item><list-item><p>Avoid pronouns</p></list-item></list></td></tr><tr><td align="left">Case 3:Mrs. Li, who is 70 years old, has mild dementia (MMSE score: 22)Scenario: Mrs. Li is angry about losing her purseTask: Use empathetic communication to address Mrs. Li's lost purse situation</td><td align="left">Locating an item:Looking for a Purse</td><td align="left"><list list-type="Bullet"><list-item><p>Give time for understanding and response</p></list-item><list-item><p>Listen patiently</p></list-item><list-item><p>Repeat key words and phrases</p></list-item><list-item><p>Repeat for clarity</p></list-item><list-item><p>Do not argue with dementia patients</p></list-item><list-item><p>Stay relaxed and calm</p></list-item></list></td></tr><tr><td align="left">Case 4:Mr. Fan, who is 85 years old, has moderate dementia (MMSE score: 15)Scenario: Mr. Fan, forgetting he already ate, keeps asking for another meal after lunchTask: Use communication skills to manage Mr. Fan's eating confusion</td><td align="left">Meal preparation:Eating in the dining room</td><td align="left"><list list-type="Bullet"><list-item><p>Convey one message at a time</p></list-item><list-item><p>Listen patiently</p></list-item><list-item><p>Use gestures in conversation</p></list-item><list-item><p>Offer simple options</p></list-item><list-item><p>Avoid pronouns</p></list-item></list></td></tr><tr><td align="left">Case 5:Mr. Li, who is 86 years old, has moderate dementia (MMSE score: 10)Scenario: Mr. Li is in the kitchen, handling a knife unsafelyTask: Use communication to safely address Mr. Li's unsafe knife handling</td><td align="left">Meal preparation:Improper use of a knife</td><td align="left"><list list-type="Bullet"><list-item><p>Convey one message at a time</p></list-item><list-item><p>Stay relaxed and calm</p></list-item><list-item><p>Use gestures for clarity</p></list-item><list-item><p>Avoid baby talk</p></list-item><list-item><p>Use affirmative language</p></list-item></list></td></tr><tr><td align="left">Case 6:Mr. Chen, who is 88 years old, has severe dementia (MMSE score: 8)Scenario: Mr. Chen, limited to simple phrases, becomes agitated before bath time, repeatedly saying 'no' and 'not'...Task: Use communication skills to effectively comfort Mr. Chen and help him take a bath</td><td align="left">Using the bathroom:Assisting with bathing</td><td align="left"><list list-type="Bullet"><list-item><p>Ask structured questions</p></list-item><list-item><p>Use short, simple language</p></list-item><list-item><p>Give one instruction at a time</p></list-item><list-item><p>Allow time for responses</p></list-item><list-item><p>Guess the patient's intent</p></list-item></list></td></tr><tr><td align="left">Case 7:Mrs. Chang, who is 74 years old, has mild dementia (MMSE score: 24)Scenario: It is time to take medicine but Mrs. Chang does not want to take her medicationTask: Assist Mrs. Chang with taking her medicine</td><td align="left">Planning an agenda:Assisting with taking medicine</td><td align="left"><list list-type="Bullet"><list-item><p>Stay relaxed and calm</p></list-item><list-item><p>Give time for understanding and response</p></list-item><list-item><p>Change the subject appropriately</p></list-item></list></td></tr></tbody></table> </ephtml> </p> <p>Communication strategies for dementia were included in the case scenarios. These strategies included ensuring the attention of the person with dementia by using direct face‐to‐face communication and maintaining eye contact, using short, simple and familiar language, conveying only one message at a time, repeating keywords and sentences, providing the correct words and repeating what was understood appropriately, using structured questions and offering simple options. As shown in Table 1, the system contains seven dementia cases covering a range of severity from mild to severe. Symptom‐specific communication strategies accompany each case. For example, when talking to a person with mild dementia, it is important to communicate patiently and clearly; for a person with moderate dementia, one should use structured questions and simple choices; and for a person with severe dementia, concise language should be used, sufficient time for responses should be allowed, and pictures and gestures can be used. In addition, it is essential to maintain a relaxed and calm mood when talking with a person with dementia, and to reduce background noise by turning down the volume of the television or radio (Conway & Chenery, [<reflink idref="bib14" id="ref70">14</reflink>]; Downs & Collins, [<reflink idref="bib19" id="ref71">19</reflink>]; Troche et al., [<reflink idref="bib58" id="ref72">58</reflink>]).</p> <hd id="AN0183820127-10">Learning process based on the experiential learning theory</hd> <p>The experiential learning theory emphasises that learners develop concrete competences through four stages: concrete experience, reflective observation, abstract conceptualisation and active experimentation (Kolb & Wolfe, [<reflink idref="bib31" id="ref73">31</reflink>]; Sywelem et al., [<reflink idref="bib55" id="ref74">55</reflink>]). VR provides an immersive learning environment that enables learners to learn in simulated real‐world situations (McDonald et al., [<reflink idref="bib37" id="ref75">37</reflink>]), and has been recognised as a promising way to enable learners to experience, reflect on, and apply new knowledge and skills in authentic contexts (Barsom et al., [<reflink idref="bib7" id="ref76">7</reflink>]; Huang et al., [<reflink idref="bib25" id="ref77">25</reflink>]). Based on experiential learning theory, the VRSCT system consisted of four stages of the learning cycle, that is, concrete experience, reflective observation, abstract conceptualisation and active experimentation (Kolb & Wolfe, [<reflink idref="bib31" id="ref78">31</reflink>]; Sywelem et al., [<reflink idref="bib55" id="ref79">55</reflink>]). As shown in Figure 2, the case scenarios were provided for learners to observe, experience and get along with dementia patients. Faced with the impact of communication barriers in daily life, learners felt the difficulty of dementia patients who were unable to use language to express their needs in a timely manner due to the disease, and empathised with dementia patients who had symptoms such as emotional distress or delusions. Through cognition and understanding, learners held appropriate attitudes to respond peacefully to patients, and applied accurate communication skills to deal with common problems. Finally, with continuous reflection and practice, they transferred knowledge construction into skills application in daily life.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0002.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0002.jpg" title="2 Dementia VRSCT model." /> </p> <p></p> <p>In the "concrete experience" stage, there were seven dementia cases with different degrees of severity. Before entering each scenario, the system would introduce the case, including the age, the severity of dementia, the problems, and the task to be completed (see Figure 3). For each case, the patient had their own unique symptoms and communication barriers. The learners participated in the story in the role of caregiver and experienced various challenges of caring for dementia patients. For instance, in the first simulated case, an 82‐year‐old woman with dementia, who was hearing impaired, turned the volume on her TV up to the maximum. Learners would experience this high‐decibel TV sound in a virtual environment and needed to interact with the patient against a noisy background. In this simulated environment, learners must attempt to adopt appropriate strategies to communicate with the patient. In addition, they were required to complete the specific task assigned by the system, for example, accompanying the dementia patient who did not like to go to see the doctor.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0003.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0003.jpg" title="3 Interface of case introduction." /> </p> <p></p> <p>In the "reflective observation" stage, there were seven scenarios, each of which presented various common problems of dementia patients in daily life, such as unwillingness to see a doctor, refusal to take medicine, wanting to eat all the time, and unwillingness to take a bath. Learners had to analyse these problems in depth, and to think about the available resources and communication strategies according to the symptoms, language ability, emotions and current situation of the patient in the scenario, so as to effectively solve the problems. For instance, for the dementia patient who mistakenly believed that her purse had been stolen, learners should first understand and deal with the patient's anxiety, realise that the patient had delusional disorder, pacify her emotions rather than argue with her, and make use of skills to divert her attention in a timely manner (see Figure 4).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0004.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0004.jpg" title="4 Interface of common problems in daily life." /> </p> <p></p> <p>In the "abstract conceptualisation" stage, various questions were embedded in the VRSCT system for learners to answer. Learners should synthesise what they have learned, and choose an appropriate communication strategy as the answer (see Figure 5). If learners chose the wrong answer, the system would display "That's not correct!" (see Figure 6), show the correct answer, and provide communication principles and precautions related to the question. For example, when the dementia patient was angry and unwilling to take her medicine, she knocked over the water bottle. When communicating with her, learners should use a gentle tone and understand the needs of the patient. With the VR situational simulations, learners could deepen their understanding through repeated practice.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0005.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0005.jpg" title="5 Interface of answering a question." /> </p> <p></p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0006.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0006.jpg" title="6 Interface of immediate feedback." /> </p> <p></p> <p>In the "active experimentation" stage, an exclusive task was set for each scenario in the VRSCT system. Based on the abilities of the dementia patient and the life problems in each scenario, learners had to think about the communication skills and complete the tasks presented by the system. For instance, when communicating with the dementia patient who could only utter a single simple sentence and could not express himself smoothly in speech, learners should try hard to guess his intentions and use appropriate gestures or visual graphics to assist communication, thereby ensuring that the goal of the scenario could be successfully achieved (eg, assisting the patient in taking a bath) (see Figure 7).</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0007.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0007.jpg" title="7 Interface of completing a task." /> </p> <p></p> <hd id="AN0183820127-17">EXPERIMENTAL DESIGN</hd> <p></p> <hd id="AN0183820127-18">Participants</hd> <p>This study was approved by a joint institutional review board (JIRB No: N202212069), and was conducted in a medical centre in northern Taiwan. Family caregivers of dementia patients were recruited to participate in the course. They were informed that they would be randomly assigned to different learning approaches, and that the different learning approaches would not affect their learning goals or learning content. A total of 63 family caregivers agreed to participate in this experiment and signed the consent form. They were recruited through hospital outpatient clinics and were responsible for directly caring for the caregiver of a person with dementia. These caregivers lived in the same household as the person with dementia or visited them at least twice a week. Their average age of the caregivers was 52.56 years. Most of them were sons, daughters, or daughters‐in‐law of dementia cases (90.5%), while a few were spouses (9.5%); 79.4% were female. A significant portion had a college education (65.1%); moreover, the caregiving tenure for most was less than 5 years (87.1%). They were randomly divided into an experimental group (<emph>n</emph> = 32) and a control group (<emph>n</emph> = 31). Both groups were taught by the same teacher who had more than 10 years of teaching experience in dementia communication. The demographics of the two groups are homogeneous, as shown in Table 2.</p> <p>2 TABLE Demographic data.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Variable</th><th align="left">VRSCT (<italic>n</italic> = 32)</th><th align="left">TCT (<italic>n</italic> = 31)</th><th align="left">Total (<italic>n</italic> = 63)</th></tr></thead><tbody valign="top"><tr><td align="left">Age</td></tr><tr><td align="left">Mean (SD)</td><td align="char" char="(">53.31 (7.45)</td><td align="char" char="(">51.77 (8.08)</td><td align="char" char="(">52.56 (7.78)</td></tr><tr><td align="left">Sex</td></tr><tr><td align="left">Women</td><td align="char" char="(">26 (81.3%)</td><td align="char" char="(">24 (77.4%)</td><td align="char" char="(">50 (79.4%)</td></tr><tr><td align="left">Men</td><td align="char" char="(">6 (18.8%)</td><td align="char" char="(">7 (22.6%)</td><td align="char" char="(">13 (20.6%)</td></tr><tr><td align="left">Education</td></tr><tr><td align="left">High school</td><td align="char" char="(">11 (34.4%)</td><td align="char" char="(">11 (35.5%)</td><td align="char" char="(">22 (34.9%)</td></tr><tr><td align="left">College</td><td align="char" char="(">21 (65.6%)</td><td align="char" char="(">20 (64.5%)</td><td align="char" char="(">41 (65.1%)</td></tr><tr><td align="left">Caregiving years</td></tr><tr><td align="left"><1</td><td align="char" char="(">9 (28.1%)</td><td align="char" char="(">13 (41.9%)</td><td align="char" char="(">22 (34.9%)</td></tr><tr><td align="left">1–5</td><td align="char" char="(">18 (56.3%)</td><td align="char" char="(">15 (3.2%)</td><td align="char" char="(">33 (52.4%)</td></tr><tr><td align="left">6–10</td><td align="char" char="(">4 (12.5%)</td><td align="char" char="(">11 (48.4%)</td><td align="char" char="(">5 (7.9%)</td></tr><tr><td align="left">>10</td><td align="char" char="(">1 (3.1%)</td><td align="char" char="(">2 (6.5%)</td><td align="char" char="(">3 (4.8%)</td></tr><tr><td align="left">Family relationship</td></tr><tr><td align="left">Daughter</td><td align="char" char="(">19 (59.4%)</td><td align="char" char="(">19 (613%)</td><td align="char" char="(">38 (60.3%)</td></tr><tr><td align="left">Son</td><td align="char" char="(">5 (15.6%)</td><td align="char" char="(">6 (19.4%)</td><td align="char" char="(">11 (17.5%)</td></tr><tr><td align="left">Daughter in law</td><td align="char" char="(">4 (12.5%)</td><td align="char" char="(">3 (9.7%)</td><td align="char" char="(">7 (11.1%)</td></tr><tr><td align="left">Grandchild</td><td align="char" char="(">1 (3.1%)</td><td align="char" char="(">0</td><td align="char" char="(">1 (1.61%)</td></tr><tr><td align="left">Spouse</td><td align="char" char="(">3 (9.4%)</td><td align="char" char="(">3 (9.7%)</td><td align="char" char="(">6 (9.5%)</td></tr></tbody></table> </ephtml> </p> <hd id="AN0183820127-19">Experimental process</hd> <p>The experimental process is shown in Figure 8. The course lasted for 2 days, with 140 minutes of class time per day. On the first day, learners took a pretest, filled out the pre‐questionnaires, and then participated in classroom learning about symptoms and communication barriers of dementia. Afterwards, students in the experimental group carried out the dementia situational simulations for the first three cases. They adopted the VRSCT approach to interact with the virtual characters, answered the questions, and completed the specific tasks in the VR environment (see Figure 9). On the other hand, the control group adopted the TCT approach for learning. According to the cases and scenarios in the situational simulations, the students formed pairs to engage in peer role‐playing for conversational practice. On the second day, a lesson on dementia communication skills and strategies was given. Then, the experimental group adopted the VRSCT approach to practice the dementia situational simulations for the last four cases, while the control group employed peer role‐playing for practice. After each situational simulated practice, learners and the teacher discussed the case together, and shared the situations that occurred in their daily life and their coping strategies. At the end of the course, all the learners took a posttest and filled out the post‐questionnaires.</p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0008.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0008.jpg" title="8 Experimental process." /> </p> <p></p> <p> <img src="https://imageserver.ebscohost.com/img/embimages/rdk/58I/01jan25/bjet13497-fig-0009.jpg?ephost1=dGJyMNXb4kSepq84yOvqOLCmsE6epq5Srqa4SK6WxWXS" alt="bjet13497-fig-0009.jpg" title="9 The experimental group adopted the VRSCT approach for learning." /> </p> <p></p> <hd id="AN0183820127-22">Measuring instruments</hd> <p>This study adopted a mixed method to analyse the data. The quantitative method was used to compare the data collected from tests and questionnaires, including a pretest on dementia care knowledge, a posttest on dementia care knowledge, a dementia care attitudes questionnaire, a dementia communication confidence questionnaire, and a communication skills questionnaire. The qualitative method was used to analyse the case discussion and sharing content.</p> <p>The dementia knowledge assessment tool, version 2 (DKAT2) developed by Toye et al. ([<reflink idref="bib57" id="ref80">57</reflink>]) was adopted as the pretest in this study, in order to understand the two groups' basic care knowledge of dementia. The DKAT2 content included causes, characteristics and care of dementia. It consisted of 21 items, with a perfect score of 21. The Cronbach's alpha coefficient value was 0.79. In order to evaluate learners' learning effectiveness on dementia communication‐related knowledge, the dementia knowledge assessment scale (DKAS) developed by Annear et al. ([<reflink idref="bib4" id="ref81">4</reflink>]) was adopted as the posttest in this study. The DKAS content included causes, characteristics, communication skills and care of dementia. It consisted of 27 items, with a perfect score of 27. The Cronbach's alpha coefficient value was 0.89.</p> <p>The dementia care attitudes questionnaire was modified from O'Connor and McFadden's ([<reflink idref="bib43" id="ref82">43</reflink>]) dementia attitudes scale (DAS). It aimed to evaluate caregivers' care attitudes towards dementia patients, for example, "It is possible to enjoy interacting with people with dementia and related disorders," and "We can do a lot now to improve the lives of people with dementia and related disorders." It consisted of 20 items and adopted a 5‐point Likert scale (5 = <emph>strongly agree</emph>; 1 = <emph>strongly disagree</emph>). The higher the score, the more positive the caregiver's attitudes towards dementia patients. The Cronbach's alpha value was 0.83.</p> <p>The dementia communication confidence questionnaire was modified from Naughton et al. ([<reflink idref="bib40" id="ref83">40</reflink>]). It aimed to evaluate caregivers' confidence level when communicating with dementia patients, for instance, "I feel confident I have the skills to interact with a person with dementia," and "I know how to establish a connection with a person with dementia." It consisted of seven items and adopted a 5‐point Likert scale (5 = <emph>always</emph>; 1 = <emph>never</emph>). The higher the score, the higher the communication confidence. The Cronbach's alpha value was 0.87.</p> <p>The communication skills questionnaire was modified from Passalacqua and Harwood ([<reflink idref="bib44" id="ref84">44</reflink>]). It aimed to evaluate whether caregivers would use the specific communication strategies when talking to dementia patients, for instance, "I use gestures to engage residents when communicating with them," and "I use short sentences when talking to a person with dementia." It consisted of 13 items and adopted a 5‐point Likert scale (5 = <emph>very often</emph>; 1 = <emph>never</emph>). The higher the score, the more often the caregiver uses the correct communication strategy. The Cronbach's alpha value was 0.88.</p> <hd id="AN0183820127-23">EXPERIMENTAL RESULTS</hd> <p></p> <hd id="AN0183820127-24">Dementia care knowledge</hd> <p>To explore the effects of the VRSCT approach on learners' dementia care knowledge, we employed the analysis of covariance (ANCOVA) to compare the posttest scores of the two groups by excluding the possible impacts of the difference between their pretest scores. Before the analysis, the basic assumptions of the data were examined first. The result of Levene's test for equality of error variances did not show any significant difference in the two groups' pretest scores (<emph>F</emph> = 0.06, <emph>p</emph> > 0.05), indicating the homogeneity of variances between the two groups. In addition, the intra‐group regression coefficient homogeneity test revealed the homogeneity of regression coefficients within the group (<emph>F</emph> = 2.60, <emph>p</emph> > 0.05). As a result, ANCOVA could be performed. The ANCOVA results indicated that the experimental group adopting the VRSCT approach had significantly higher scores for dementia care knowledge than the control group adopting the TCT approach (<emph>F</emph>(<reflink idref="bib1" id="ref85">1</reflink>,<reflink idref="bib60" id="ref86">60</reflink>) = 53.93, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.47) (see Table 3). The results specified that the VRSCT approach was more conducive to enhancing dementia care knowledge in comparison with the TCT approach.</p> <p>3 TABLE ANCOVA results of dementia care knowledge.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Group</th><th align="left"><italic>N</italic></th><th align="left">Mean</th><th align="left"><italic>SD</italic></th><th align="left">Adjusted mean</th><th align="left">Adjusted <italic>SE</italic></th><th align="left"><italic>F</italic></th><th align="left"><italic>η</italic><sup>2</sup></th></tr></thead><tbody valign="top"><tr><td align="left">VRSCT</td><td align="left">32</td><td align="char" char=".">87.37</td><td align="char" char=".">5.62</td><td align="char" char=".">78.64</td><td align="char" char=".">0.74</td><td align="char" char=".">53.93<xref ref-type="fn" rid="tfn1" /></td><td align="char" char=".">0.47</td></tr><tr><td align="left">TCT</td><td align="left">31</td><td align="char" char=".">77.57</td><td align="char" char=".">6.53</td><td align="char" char=".">86.35</td><td align="char" char=".">0.73</td><td align="left" /><td align="left" /></tr></tbody></table> </ephtml> </p> <p>1 *** <emph>p</emph> < 0.001.</p> <hd id="AN0183820127-25">Dementia care attitudes</hd> <p>Before investigating the effects of the VRSCT approach on caregivers' dementia care attitudes, the result of Levene's test for equality of error variances did not show any significant difference in the two groups' pre‐questionnaire scores (<emph>F</emph> = 0.01, <emph>p</emph> > 0.05), implying the homogeneity of variances between the two groups. Also, the intra‐group regression coefficient homogeneity test disclosed the homogeneity of regression coefficients within the group (<emph>F</emph> = 0.01, <emph>p</emph> > 0.05). Hence, ANCOVA could be performed. The ANCOVA results uncovered that the experimental group adopting the VRSCT approach had significantly higher scores for dementia care attitudes than the control group adopting the TCT approach (<emph>F</emph>(<reflink idref="bib1" id="ref87">1</reflink>,<reflink idref="bib60" id="ref88">60</reflink>) = 15.25, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.20) (see Table 4). On the other hand, the VRSCT approach was more beneficial for improving dementia care attitudes in comparison with the TCT approach.</p> <p>4 TABLE ANCOVA results of dementia care attitudes.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Group</th><th align="left"><italic>N</italic></th><th align="left">Mean</th><th align="left"><italic>SD</italic></th><th align="left">Adjusted mean</th><th align="left">Adjusted <italic>SE</italic></th><th align="left"><italic>F</italic></th><th align="left"><italic>η</italic><sup>2</sup></th></tr></thead><tbody valign="top"><tr><td align="left">VRSCT</td><td align="left">32</td><td align="char" char=".">4.42</td><td align="char" char=".">0.27</td><td align="char" char=".">4.41</td><td align="char" char=".">0.04</td><td align="char" char=".">15.25<xref ref-type="fn" rid="tfn2" /></td><td align="char" char=".">0.20</td></tr><tr><td align="left">TCT</td><td align="left">31</td><td align="char" char=".">4.17</td><td align="char" char=".">0.28</td><td align="char" char=".">4.18</td><td align="char" char=".">0.04</td><td align="left" /><td align="left" /></tr></tbody></table> </ephtml> </p> <p>2 *** <emph>p</emph> < 0.001.</p> <hd id="AN0183820127-26">Dementia communication confidence</hd> <p>Before analysing the effects of the VRSCT approach on caregivers' dementia communication confidence, the result of Levene's test for equality of error variances did not indicate any significant difference in the two groups' pre‐questionnaire scores (<emph>F</emph> = 0.63, <emph>p</emph> > 0.05), showing the homogeneity of variances between the two groups. Moreover, the intra‐group regression coefficient homogeneity test revealed the homogeneity of regression coefficients within the group (<emph>F</emph> = 0.05, <emph>p</emph> > 0.05). Thus, ANCOVA could be performed. The ANCOVA results disclosed that the experimental group adopting the VRSCT approach had significantly higher scores in dementia communication confidence than the control group adopting the TCT approach (<emph>F</emph>(<reflink idref="bib1" id="ref89">1</reflink>,<reflink idref="bib60" id="ref90">60</reflink>) = 29.18, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.33) (see Table 5). That is, the VRSCT approach was more conducive to enhancing dementia communication confidence in comparison with the TCT approach.</p> <p>5 TABLE ANCOVA results of dementia communication confidence.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Group</th><th align="left"><italic>N</italic></th><th align="left">Mean</th><th align="left"><italic>SD</italic></th><th align="left">Adjusted mean</th><th align="left">Adjusted <italic>SE</italic></th><th align="left"><italic>F</italic></th><th align="left"><italic>η</italic><sup>2</sup></th></tr></thead><tbody valign="top"><tr><td align="left">VRSCT</td><td align="left">32</td><td align="char" char=".">4.09</td><td align="char" char=".">0.35</td><td align="char" char=".">4.07</td><td align="char" char=".">0.07</td><td align="char" char=".">29.18<xref ref-type="fn" rid="tfn3" /></td><td align="char" char=".">0.33</td></tr><tr><td align="left">TCT</td><td align="left">31</td><td align="char" char=".">3.53</td><td align="char" char=".">0.36</td><td align="char" char=".">3.56</td><td align="char" char=".">0.07</td><td align="left" /><td align="left" /></tr></tbody></table> </ephtml> </p> <p>3 *** <emph>p</emph> < 0.001.</p> <hd id="AN0183820127-27">Dementia communication skills</hd> <p>Before exploring the effects of the VRSCT approach on caregivers' dementia communication skills, the result of Levene's test for equality of error variances did not show any significant difference in the two groups' pre‐questionnaire scores (<emph>F</emph> = 0.20, <emph>p</emph> > 0.05), revealing the homogeneity of variances between the two groups. Also, the intra‐group regression coefficient homogeneity test indicated the homogeneity of regression coefficients within the group (<emph>F</emph> = 0.02, <emph>p</emph> > 0.05). Hence, ANCOVA could be performed. The ANCOVA results uncovered that the experimental group adopting the VRSCT approach had significantly higher scores for dementia communication skills than the control group adopting the TCT approach (<emph>F</emph>(<reflink idref="bib1" id="ref91">1</reflink>,<reflink idref="bib60" id="ref92">60</reflink>) = 14.96, <emph>p</emph> < 0.001, <emph>η</emph><sups>2</sups> = 0.20) (see Table 6). In other words, the VRSCT approach was more beneficial for improving dementia communication skills in comparison with the TCT approach.</p> <p>6 TABLE ANCOVA results of dementia communication skills.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Group</th><th align="left"><italic>N</italic></th><th align="left">Mean</th><th align="left"><italic>SD</italic></th><th align="left">Adjusted mean</th><th align="left">Adjusted <italic>SE</italic></th><th align="left"><italic>F</italic></th><th align="left"><italic>η</italic><sup>2</sup></th></tr></thead><tbody valign="top"><tr><td align="left">VRSCT</td><td align="left">32</td><td align="char" char=".">4.44</td><td align="char" char=".">0.30</td><td align="char" char=".">4.42</td><td align="char" char=".">0.05</td><td align="char" char=".">14.96<xref ref-type="fn" rid="tfn4" /></td><td align="char" char=".">0.20</td></tr><tr><td align="left">TCT</td><td align="left">31</td><td align="char" char=".">4.12</td><td align="char" char=".">0.29</td><td align="char" char=".">4.14</td><td align="char" char=".">0.05</td><td align="left" /><td align="left" /></tr></tbody></table> </ephtml> </p> <p>4 *** <emph>p</emph> < 0.001.</p> <hd id="AN0183820127-28">Correlations between dementia care knowledge, care attitudes, communication confidence, and c...</hd> <p>Table 7 shows the significant correlations between care knowledge, care attitudes, communication confidence, and communication skills. The correlation coefficients ranged from 0.40 to 0.69, indicating moderate correlations (Cohen, [<reflink idref="bib13" id="ref93">13</reflink>]). Care attitudes had a moderate positive correlation with communication confidence and communication skills, respectively. In addition, communication confidence had a moderate positive correlation with communication skills.</p> <p>7 TABLE Correlation analysis between care knowledge, care attitudes, communication confidence and communication skills.</p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left" /><th align="left">Care knowledge</th><th align="left">Care attitudes</th><th align="left">Communication confidence</th><th align="left">Communication skills</th></tr></thead><tbody valign="top"><tr><td align="left">Care knowledge</td><td align="char" char=".">1</td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left">Care attitudes</td><td align="char" char=".">0.53<xref ref-type="fn" rid="tfn5" /></td><td align="char" char=".">1</td><td align="left" /><td align="left" /></tr><tr><td align="left">Communication confidence</td><td align="char" char=".">0.62<xref ref-type="fn" rid="tfn5" /></td><td align="char" char=".">0.49<xref ref-type="fn" rid="tfn5" /></td><td align="char" char=".">1</td><td align="left" /></tr><tr><td align="left">Communication skills</td><td align="char" char=".">0.45<xref ref-type="fn" rid="tfn5" /></td><td align="char" char=".">0.56<xref ref-type="fn" rid="tfn5" /></td><td align="char" char=".">0.49<xref ref-type="fn" rid="tfn5" /></td><td align="left">1</td></tr></tbody></table> </ephtml> </p> <p>5 ** <emph>p</emph> < 0.01.</p> <hd id="AN0183820127-29">Case discussion and sharing</hd> <p>The case discussion and sharing process was recorded for analysis. Two researchers who had more than 10 years' experience of coding qualitative data analysed the records following Strauss's grounded theory (Strauss & Corbin, [<reflink idref="bib54" id="ref94">54</reflink>]). That is, the records were analysed and coded following three strategies to determine the coding results: open coding, axial coding and selective coding. Open coding refers to the process of examining and coding each respondent's statements; axial coding aims to combine concepts that are explicitly linked together. Selective coding is a process of integration and correction whereby the researcher goes back and forth between different coding stages in order to increase the credibility and reliability of the data analysis; it also establishes the rigour of the data analysis. During the coding process, two coders repeatedly read and named the records. They also shared and discussed their coding results until they reached agreement. As a result, five main perspectives were identified: VR realism, communication skills, knowledge learning, group interaction and classroom comparison. These perspectives are compiled in the Appendix.</p> <hd id="AN0183820127-30">DISCUSSION AND CONCLUSIONS</hd> <p></p> <hd id="AN0183820127-31">Discussion</hd> <p>Regarding the first research question, it was confirmed that the VRSCT improved family caregivers' knowledge more effectively than the TCT approach. The VR simulations helped learners observe and understand the symptoms associated with dementia. During the interaction with the simulated environment, learners could integrate what they had learned through interaction (Vygotsky & Cole, [<reflink idref="bib59" id="ref95">59</reflink>]). In addition, VR has an automatic feedback mechanism that allows family caregivers to correct errors in knowledge promptly. Through the discussion and sharing by family caregivers after the program, participants said, "I learned a lot from the VR interactions."</p> <p>As for the second research question, it was found that the VRSCT approach enhanced the family caregivers' care attitudes more than the TCT approach. Previous studies have pinpointed that immersive VR‐based learning can enhance learners' empathy and caring attitudes (Jones et al., [<reflink idref="bib29" id="ref96">29</reflink>]; Stargatt et al., [<reflink idref="bib52" id="ref97">52</reflink>]; Stavroulia & Lanitis, [<reflink idref="bib53" id="ref98">53</reflink>]). This result was also verified in this study. Facing the confusion and challenges of dementia patients in VR, family caregivers had strong feelings and cognitions, understood and accepted the symptoms of dementia patients, and thus strengthened their positive attitudes towards dementia care (Chesneau et al., [<reflink idref="bib12" id="ref99">12</reflink>]; Fang et al., [<reflink idref="bib20" id="ref100">20</reflink>]). Positive care attitudes could maintain a good interaction between family caregivers and patients; the patients felt understood and supported, thereby reducing communication barriers (Alsawy et al., [<reflink idref="bib3" id="ref101">3</reflink>]).</p> <p>Regarding the third and fourth research questions, it was confirmed that the proposed approach improved the family caregivers' communication confidence and skills more than the TCT approach. This was in accordance with past research, indicating that VR‐based simulations as a learning strategy could provide learners with a safe environment for repeated practice, reduce their anxiety, and increase their confidence and care skills (Hirt & Beer, [<reflink idref="bib24" id="ref102">24</reflink>]; Jallad & Işık, [<reflink idref="bib27" id="ref103">27</reflink>]; Wood et al., [<reflink idref="bib64" id="ref104">64</reflink>]). Dementia not only degraded the patients' communication abilities, but also led to emotional disorders and problematic behaviours, making communication between family caregivers and patients full of challenges. The present study designed seven dementia cases for family caregivers to discover the communication barriers of dementia patients with different degrees of severity through observation, and to practice using various communication skills to deal with common problems in daily life. In particular, the fluctuating emotions and behaviours of dementia patients highlighted the importance of flexible and individualised communication strategies. Researchers have pointed out that VR‐based simulations not only provide a variety of practice environments, but also help learners deal with various unpredictable situations (Hirt & Beer, [<reflink idref="bib24" id="ref105">24</reflink>]; Samosorn et al., [<reflink idref="bib48" id="ref106">48</reflink>]). Besides, VR training provides a greater sense of presence and agency compared to conventional technical training, and it enhances students' self‐efficacy when executing techniques in real‐world situations (Barsom et al., [<reflink idref="bib7" id="ref107">7</reflink>]; Liu et al., [<reflink idref="bib36" id="ref108">36</reflink>]). VR‐based simulations evaluated learners' skills in real time and provided specific feedback for them to reflect and modify (Huang et al., [<reflink idref="bib25" id="ref109">25</reflink>]; Lee et al., [<reflink idref="bib33" id="ref110">33</reflink>]), thereby enhancing their self‐confidence and communication skills.</p> <p>Regarding the fifth research question, positive correlations were found between dementia care knowledge, care attitudes, communication confidence, and communication skills. Family caregivers who had an accurate understanding of dementia would reduce their negative emotions such as anxiety and anger when communicating with patients. They were able to relax and understand the needs and emotions of dementia patients more deeply. Also, they were more confident in interacting positively with patients, which helped improve the relationship with the patients and helped them provide better care. During the case discussion and sharing stage conducted after the simulated practice, the family caregivers mentioned that the cases in VR were close to daily life, and that the sense of presence strengthened their learning effectiveness. Additionally, information feedback refers to the assessment of decisions made by learners in the learning process supported by digital learning systems, providing learners with relevant information to assist them in completing complex learning tasks (Lindell, [<reflink idref="bib34" id="ref111">34</reflink>]). The system offers personalised guidance on standardised concepts to users based on the errors they make in tests, which positively impacts their learning effectiveness (Liu et al., [<reflink idref="bib35" id="ref112">35</reflink>]). In the VRSCT system, when a participant responds incorrectly in VR, the system immediately offers feedback, outlining the correct communication principles. This feedback is both real‐time and personalised. During discussion and sharing, participants said that through the system feedback, they could recognise their previous incorrect communication methods. Therefore, participants could refine their communication strategies and enhance their self‐confidence. Still, there were five learners who complained about dizziness and discomfort when wearing the Google Cardboard VR glasses, so they needed to take a break. Also, a few family caregivers needed assistance since they were not familiar with VR technology. However, most family caregivers reported that the VR‐based simulated communication training course was very important and practical.</p> <hd id="AN0183820127-32">Limitations and future work</hd> <p>This study has some limitations. First, the proposed approach was applied to communication skills training for the family caregivers of dementia patients. The research results may not be generalised to other courses without further experiments. Second, the participants in this study used 2 days to learn dementia knowledge and its application; however, communication skills require continuous practice. Future research on VR‐based learning is recommended to investigate the changes in learners' care attitudes and communication skills after a longer period of time. Third, improving communication skills contributes to the quality of patient care (Taghizadeh et al., [<reflink idref="bib56" id="ref113">56</reflink>]). However, this study did not measure the quality of care for dementia patients. It is recommended that future research focus on assessing the relationship between communication skills and the quality of patient care. Also, we did not collect feedback from dementia patients themselves. It is recommended that future research include data from dementia patients in the analysis. The perspectives of dementia patients can provide valuable insights into the effectiveness of the training. Also, some participants reported dizziness and discomfort when using the VR glasses. According to these participants' statements, the dizziness did not affect their learning outcomes or experiences. As this study did not compare the perceptions and performance of those who reported dizziness or discomfort with those who did not, it is suggested that future research further examine if discomfort affects participants' VR learning outcomes. Furthermore, this study's use of self‐reported data may have introduced potential bias due to individuals' subjective perceptions and societal expectations. To mitigate such bias in future research, researchers can employ a mixed‐method approach that combines quantitative and qualitative research, or utilise behavioural analysis to enhance the objectivity and reliability of the data. Finally, it is suggested that the proposed approach be applied to other courses to increase learners' positive attitudes, empathy and skills, such as courses in the arts and humanities, environmental education, teamwork and leadership, and other healthcare programs.</p> <hd id="AN0183820127-33">Conclusions</hd> <p>In the present study, the experimental group adopting the VRSCT approach used VR technology to interact with virtual dementia patients, and obtained more realistic experiential learning, thereby improving their learning effectiveness. The results were in line with previous research, specifying that VR‐based simulations had significant effects on acquiring and deepening knowledge (Huang et al., [<reflink idref="bib25" id="ref114">25</reflink>]; Liu et al., [<reflink idref="bib36" id="ref115">36</reflink>]; Samosorn et al., [<reflink idref="bib48" id="ref116">48</reflink>]). In comparison with traditional training modes, VR‐based simulations allow learners to observe and understand how the disease affects the language expression and comprehension of dementia patients, as well as their psychiatric symptoms and behavioural changes due to the disease. Wijma et al. ([<reflink idref="bib61" id="ref117">61</reflink>]) pointed out that learners who used VR‐based simulations showed a deeper understanding of the subject matter. Through the presentation of VR, learners had a more specific and in‐depth understanding of some complex concepts, such as the course of dementia, its psychiatric symptoms and problematic behaviours. With the immediate feedback of the VR system, learners understood their own misconceptions and corrected them instantly. This was particularly crucial for learning dementia‐related knowledge as it required specific knowledge and skills to properly care for the patients.</p> <p>To sum up, the main contribution of this study is that it proposes a VR‐based simulated approach based on experiential learning theory. Through the experience of and interaction with the environment, it increased family caregivers' care knowledge and attitudes, thereby improving their communication confidence and skills.</p> <hd id="AN0183820127-34">ACKNOWLEDGEMENTS</hd> <p>This study is supported in part by the National Science and Technology Council of Taiwan under contract number NSTC 111‐2622‐H‐038‐002 and by the Taipei Medical University—National Taiwan University of Science and Technology Joint Research Program under contract number TMU‐NTUST‐112‐06.</p> <hd id="AN0183820127-35">CONFLICT OF INTEREST STATEMENT</hd> <p>There is no potential conflict of interest in this study.</p> <hd id="AN0183820127-36">DATA AVAILABILITY STATEMENT</hd> <p>The data can be obtained by sending request e‐mails to the corresponding author.</p> <hd id="AN0183820127-37">ETHICS STATEMENT</hd> <p>The participants were protected by hiding their personal information during the research process. They knew that the participation was voluntary and they could withdraw from the study at any time.</p> <hd id="AN0183820127-38">APPENDIX PARTICIPANTS' FEEDBACK</hd> <p></p> <p> <ephtml> <table><thead valign="bottom"><tr><th align="left">Perspectives</th><th align="left">Definition</th><th align="left">Example</th></tr></thead><tbody valign="top"><tr><td align="left">VR realism</td><td align="left">VR's situational simulation authenticity</td><td align="left"><p>"VR practice closely resembles my home situation, where I easily get angry over small things"</p><p>"I feel it's very realistic, just like the incidents I've had with my older relatives"</p><p>"VR provides a realistic, situational experience of actual scenarios"</p></td></tr><tr><td align="left">Communication skills</td><td align="left">Improve communication skills</td><td align="left"><p>"Through VR practice, I learned how to speak with older people"</p><p>"I realized the flaws in my previous communication methods"</p></td></tr><tr><td align="left">Knowledge learning</td><td align="left">Gain new knowledge</td><td align="left"><p>"I gained new insights in today's class about previously unknown topics"</p><p>"I learned a lot from the VR interactions"</p></td></tr><tr><td align="left">Group interaction</td><td align="left">Experience sharing and learning</td><td align="left"><p>"Mutual sharing improved my communication skills"</p><p>"Through sharing with classmates, I found many common problems and learned from others' methods"</p></td></tr><tr><td align="left">Classroom comparison</td><td align="left">Comparison of traditional learning and VR training effects</td><td align="left"><p>"VR provides a more realistic and effective experience than theoretical classes"</p><p>"VR learning, with its realistic simulations, is more engaging than traditional classes"</p></td></tr></tbody></table> </ephtml> </p> <ref id="AN0183820127-39"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref7" type="bt">1</bibl> <bibtext> Adewuyi, M., Morales, K., & Lindsey, A. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Improving the Quality of Communicating with Dementia Patients: A Virtual Reality-Based Simulated Communication Approach
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Hui-Chen+Lin%22">Hui-Chen Lin</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-8074-8884">0000-0001-8074-8884</externalLink>)<br /><searchLink fieldCode="AR" term="%22Hsin+Huang%22">Hsin Huang</searchLink><br /><searchLink fieldCode="AR" term="%22Chia-Kuang+Tsai%22">Chia-Kuang Tsai</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-7693-1408">0000-0001-7693-1408</externalLink>)<br /><searchLink fieldCode="AR" term="%22Shao-Chen+Chang%22">Shao-Chen Chang</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22British+Journal+of+Educational+Technology%22"><i>British Journal of Educational Technology</i></searchLink>. 2025 56(1):167-189.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 23
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Dementia%22">Dementia</searchLink><br /><searchLink fieldCode="DE" term="%22Patients%22">Patients</searchLink><br /><searchLink fieldCode="DE" term="%22Language+Impairments%22">Language Impairments</searchLink><br /><searchLink fieldCode="DE" term="%22Communication+Problems%22">Communication Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Speech+Therapy%22">Speech Therapy</searchLink><br /><searchLink fieldCode="DE" term="%22Computer+Simulation%22">Computer Simulation</searchLink><br /><searchLink fieldCode="DE" term="%22Training%22">Training</searchLink><br /><searchLink fieldCode="DE" term="%22Caregivers%22">Caregivers</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink><br /><searchLink fieldCode="DE" term="%22Communication+Skills%22">Communication Skills</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/bjet.13497
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0007-1013<br />1467-8535
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Dementia patients may have language barriers and decreased comprehension ability. Their family caregivers can feel frustrated when communicating with them. Poor communication hinders family caregivers from obtaining accurate health information about patients, and may also increase their emotional burden, affecting patient care quality. The present study developed a virtual reality-based simulated communication training (VRSCT) system and applied it to a training course for family caregivers of dementia patients. It allowed family caregivers to simulate real-world situations in a VR environment, experience the daily communication barriers and stress with dementia patients, and apply their acquired knowledge and skills to solve related problems. This study used a randomised control experimental design with mixed analysis methods. A total of 63 family caregivers were recruited and randomly divided into the experimental group (N = 32) learning with the VRSCT system to interact with virtual dementia patients and practice communication skills, and the control group (N = 31) using the traditional role-playing method for practice. Quantitative data were analysed to determine participants' knowledge of dementia care, attitudes, communication confidence and skills. In addition, the qualitative method was used to analyse the participants' discussion records. The results showed that by using the VRSCT approach, participants significantly improved their knowledge of dementia care, attitudes, communication confidence and communication skills compared to the control group. In addition, participants reported that through the real-time feedback of the VRSCT system, they could recognise their previous incorrect communication approach. As a result, they adjusted their communication strategies and increased their self-confidence.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1456975
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1456975
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  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/bjet.13497
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 23
        StartPage: 167
    Subjects:
      – SubjectFull: Dementia
        Type: general
      – SubjectFull: Patients
        Type: general
      – SubjectFull: Language Impairments
        Type: general
      – SubjectFull: Communication Problems
        Type: general
      – SubjectFull: Speech Therapy
        Type: general
      – SubjectFull: Computer Simulation
        Type: general
      – SubjectFull: Training
        Type: general
      – SubjectFull: Caregivers
        Type: general
      – SubjectFull: Outcomes of Treatment
        Type: general
      – SubjectFull: Communication Skills
        Type: general
    Titles:
      – TitleFull: Improving the Quality of Communicating with Dementia Patients: A Virtual Reality-Based Simulated Communication Approach
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            NameFull: Hsin Huang
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            NameFull: Chia-Kuang Tsai
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            NameFull: Shao-Chen Chang
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              Type: published
              Y: 2025
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            – TitleFull: British Journal of Educational Technology
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