A caring-perception model for ethical competence in virtual reality environment

Virtual reality in education and clinical practice

VR is a technology that creates environments which mimic human experiences through auditory, visual, and tactile feedback (including sight, sound, and touch), contributing to immersive and realistic scenarios.^13,14 It allows users to interact with various dilemmas and scenarios in environments that are perceived as real, potentially enhancing a sense of presence. VR is used in education where students can practice different skills in various care environments, enabling more personalized education and a safe environment to learn and reflect, explore perspectives, and make risk-free decisions without exposing patients to harm. ¹⁵ According to Wang et al., ¹⁶ VR provides the opportunity to experience a sense of presence and Vanlaere et al. ¹⁷ highlight the relevance of VR for strengthening reflection in care practice and view vulnerability as a starting point for ethically responsible care. Technologies can be effective in enhancing empathy, presence, and immersion and in influencing the degree to which users can experience a sense of “being there” and how facial expressions can be immersive and evoke stronger emotional reactions. ¹⁴

Studies^18–23 show that VR increases engagement, improves learning outcomes, and promotes the development of critical thinking both in education and clinical practice within the healthcare sector. Research^{16,19,24–27} further reveals that the use of VR improves patient safety as training promotes communication, empathy, trust, and caregiving competence, which is the ability to understand others’ situations and to take care of others. According to Torda, ²³ VR that replicates real life makes it possible for users to fully focus on the scenario and stimulates both intellectual and emotional dimensions, thus contributing to the understanding of ethical issues that affect clinical decision-making. According to Wong et al., ²⁸ the main advantages of virtual spaces are that they can make the invisible visible or at least highlight aspects that would otherwise receive little attention and alert caregivers to the most relevant issues when dealing with patients.

Despite the potential of virtual reality in education, there are ethical issues that must be considered. Fundamentally, scenarios in virtual reality should reflect real situations and portray people ethically and true to reality, without affecting the patient’s autonomy and the principle of not causing harm to others. ²⁹ The use of virtual reality can also induce psychological stress in participants, which should be carefully considered. High-flying virtual environments often provide diverse sensory impressions that can lead to overload, as they are directly connected to or near the participants’ senses. ³⁰ Additionally, there are recognized safety risks with virtual reality, such as motion sickness or “cyber sickness,” which can cause nausea, fatigue, dizziness, and eye strain.^14,22

The rationale for theory development

Integrating VR into education can promote a deeper understanding of ethical issues, strengthen the ability to make well-founded decisions, and prepare healthcare personnel for a complex reality in clinical practice. Rudschies and Schneiders’ ²² study shows that VR can evoke feelings of empathy, trust, and compassion in the same way as in genuine encounters. However, according to Salzmann-Erikson and Eriksson, ³¹ and Fronczek, ³² the transition to the digital age needs further research to avoid the neglect of a holistic human view and ensure that the use of VR is rooted in care and caring theories. Fronczek ³² highlights the importance of a clearer and expanded theoretical focus in technology use, one that is anchored in nursing and caring theories and concepts to better capture the values of “being there” and “presence.” According to Francis, ³³ only scant research has focused on the importance of VR for ethical education, ethical competence, and decision-making. We have, therefore, considered it important to expand and anchor values of “being there” and “presence” to caring theories and ethical concepts as a theoretical basis when enhancing the ethical competence of health professionals’ education using VR.

Meaningful fragments from Eriksson’s texts: The ethics of caring in the face of the suffering human being

According to Eriksson, ³⁶ technology has often been perceived as a threat to human values in human care, but there are no contradictions between charitable care and a high-tech care culture regarding the assumption that technology creates new opportunities for a richer existence for humans; nor does it reduce humans to a tool as long as the technology is based on ethical values and does not allow itself to be controlled by technological and economic interests. What is important is that the patient’s face is not hidden behind technology but that the face and the call of the face remain visible. Ethics becomes a reality only in moments where the other person’s face appears, and technology takes on a deeper meaning when the human face is seen, listened to, and allowed to emerge and awaken ethical responsibility. Hence, whether technology contributes to good care depends on how well health personnel master the art of caring itself. Ethics, seeing the patient, carrying responsibility, and having compassion, all become visible as a fundamental attitude, as an invitation, a presence, and being emotionally affected in a caring relationship. In encounters with the other, the healthcare personnel always have the greater responsibility.

Eriksson ³⁷ emphasizes that the words to see and to know have the same etymological origin in the Latin video which signifies “I see.” She also uses the term revision which means having a sharp eye to see reality for what it is and putting one’s own understanding and prejudices on the line. When seeing and gaining insight into different realities, pictures of the caring reality and a concrete situation can emerge. The word attest means to express and put into words what has been seen. Attestation, again, is an assessment of whether something is true. Thus, the person who has seen becomes a witness, a person who knows something and can make an attestation about something based on an extended understanding of what has been observed. Ethical testimonies correspond to the true, the good, and the beautiful. ³⁸ According to Eriksson, ³⁷ seeing and knowing involves a hermeneutic movement between understanding, interpretation, wholeness, and the unique and the special. For this movement to occur, the will to understand and absolute presence in the situation is necessary. Eriksson’s ³⁸ basic view of ethics leads to the importance of an inner value base or the human being who carries an ethos. Ethos becomes visible here and now as an ethical bearing. It is ethos that helps us to see and be responsive both to our innermost voice and to having the courage to meet the suffering human being in what Eriksson ³⁹ describes as the ethical mantra of care: I was there, I saw, I recognized, and I became responsible. It is thereby an ethical duty to be present, see, acknowledge, and take responsibility for providing good care to the suffering human being.

Meaningful fragments from Martinsen’s texts: Seeing with the eye of the heart in patient encounters

Martinsen ⁴⁰ emphasizes the concept of seeing in a profound sense and uses the term “the eye of the heart,” in the sense of seeing with the eye of the heart, which is grounded in a heartfelt love for fellow human beings and the safeguarding and care of life. The eye of the heart has an active force and is a seat for emotions, thoughts, will, imagination, and compassion. The heart is the site of a human being’s ethical orientation and represents a call to compassion and effort; to perceive the other is already to be in an ethical relationship with the other. When one empathizes with the other, one is invited to follow along in the other’s world, meeting the other with a seeing-listening heart. The eye of the heart as seeing-listening also encompasses restraint so that the other can emerge in their integrity and vulnerable life context. ⁴⁰

Martinsen ⁴⁰ further describes the understanding of seeing-listening as a battle between seeing with a participating eye and seeing with a registrating eye. Ethics and professional judgment become central in this battle between seeing with the participating and registering eye. Martinsen ⁴⁰ also highlights the importance of seeing the face of the other. When we see the face of the other, we see the significance and vulnerability in every human being. We see the similarity, but also that the other emerges as themselves, in their difference. Seeing the face of the other is sensing and seeing with heartfelt, participatory eyes. Similarity and difference are not opposites, but fundamental conditions. Therefore, we must continually turn back to our everyday experiences and be attentive to what we have overlooked and already seen. When we see that another human being needs help, we must trust and allow ourselves to be set in motion. We must see with open eyes for it is the other who will emerge as significant and the one in need of help. We must let the other’s suffering touch our hearts and body. To see with the eye of the heart therefore means to see with one’s whole being and with a “listening gaze,” a gaze that is attentive and alert, characterized by calmness and presence, and that allows the ethical demand to become practical action and precede prejudices. ⁴⁰

Martinsen^2,40 connects perception with professionalism. Senses and perception are open for seeing with emotions and when the suffering of the other matters, we obtain understanding. Seeing requires concentration in time and space, an intense presence with emotions, intellect, and the urge to act. This presence in time and space is called spaciousness; being touched and dynamically present, where time on the one hand is the societal clock time and on the other the time of life experience. ² Through dynamic and continuous self-formation, healthcare professionals can learn to know themselves and dare to stand in the presence of the other and not merely objectify; the evaluative and objectifying gaze of knowledge must be combined with being present, listening, and seeing. Furthermore, Martinsen ⁴⁰ uses the term slow eyes, in the sense of being participatory and attentively present, and combines this with professional observations and a “look for” gaze. Therefore, the eye of the heart is both perceptive and exploratory at the same time, evaluative and professionally open, and simultaneously open and unconditional, seeing the significance in all human life and allows it to be as it is. This openness to the diversity of experiences, where nurses listen to the tone of patients, forms the basis for knowledge acquisition. The inner ethics is about finding oneself together with others, being made responsible in community, in patient encounters. ²

Meaningful fragments from Koskinen’s texts: Listening as an ethical foundation in the encounter with the vulnerable human being

According to Koskinen, ⁴¹ vulnerability and the ability to be affected by another human being are fundamental to caring. Therefore, it is important to dare to let oneself be affected and accept one’s own feelings and shortcomings. Koskinen’s ⁴¹ clarification of the concept of listening shows that listening is connected with seeing, realizing, perceiving, observing, contemplating, and witnessing. The eyes and ears always intersect with, rely on, shape, and feed sounds and images to each other without excluding one or the other, while both are prepared for new understanding. Conceptually, listening can be understood as a mindset and a bearing, a willingness to dutifully see, witness, love, and empathize with the patient. According to Koskinen,^41,42 listening is caring in itself. Every human being needs someone in their life to turn to, someone who will listen to their life story. People longing for someone who sees, takes time, is close, encourages, and supports the shaping of the spoken life narrative. Listening to life narratives requires time and consideration of one’s own feelings while receiving the narrative and making room for the dark and the light, both fear and hope. According to Koskinen, ⁴² it is essential not to ignore the patient’s experiences and feelings, and to listen in silence, show availability and time, and openly receive the patient’s narrative in order to try to understand their suffering and vulnerability.

Koskinen^41,42 describes how humans are inherently listening beings, and that listening is a human trait that encompasses listening to oneself, to others, and to existence or some form of higher power. Listening is also ethically grounded and is often seen as an ethical virtue and an ethos in terms of ethical choices and an ethical attitude toward self, the other, and the world. This ethical attitude is associated with silence, invitation, showing hospitality, and openness to the other’s otherness and vulnerability, feeling compassion for the other’s suffering. It is an insight into the other as otherness and as a mystery that calls for openness and making room for not knowing how the other feels or is. The other cannot be fully understood, but the other and the unique narrative can be opened and given meaning when the listener steps into the background. Listening thus involves being in this movement and tension between the unknown and the known. In such a listening encounter between individuals, it can feel as if time and space are erased, and we experience a sense of presence and participation in a larger shared narrative. Koskinen ⁴² also underscores the importance of listening in relation to the other’s face, as it is the face that expresses suffering and asks and begs us not to be left alone. The eyes can plead urgently and call on our responsibility to see and listen.

Koskinen ⁴² discusses listening in relation to the caregiver and practice. Listening requires self-critical reflection on one’s own interpretations and viewpoints to challenge one’s own understanding. Reflecting on one’s own practice necessitates a thinking through and willingness to understand rather than having a ready answer. Listening to others’ life narratives can therefore be described as a gift that can provide an opportunity to gain new insights, thereby growing as a person. To be able to invite the other into a relationship also involves being at home with oneself and one’s ethical core values. Listening is therefore an ethical choice and a responsibility, wonder, and also entails courage to be affected, especially when the patient’s narrative of vulnerability and suffering is experienced as challenging or threatening. Koskinen ⁴² points out that it is only when the caregiver is touched by the other’s vulnerability and suffering that care can become caring.

Creation of a caring-perception model for ethical competence education

Based on the understanding of the meaningful fragments from Eriksson (KE), Martinsen (KM), and Koskinen (CK), descriptive patterns were formulated and, finally, basic elements were abstracted for the creation of a theory model (see example in Table 2). Ultimately, a caring theory-based model for ethical competence was developed (see Figure 1) and interpreted in relation to enhancing ethical competence in a VR environment.

Interpretation of the model for the development of ethical competence in a virtual reality environment

Ethical competence in healthcare professionals within virtual environments takes the form of a movement between “I am here,” “I see and listen,” “I’m affected,” “I realize,” “I’m responsible” to a synthesis in “ethical bearing and acting.”