Virtual World Interview Skills Training for Students Studying Health ...

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Virtual World Interview Skills Training for Students Studying Health Professions a

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Andrew J. Campbell , Krestina L. Amon , Melanie Nguyen , Steven a

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Cumming , Hugh Selby , Michelle Lincoln , Victoria Neville , Navjot d

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Bhullar , Lynne Magor-Blatch , Lisa Oxman , Toni Green , Amanda e

George & Andrew Gonczi a

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The University of Sydney, Sydney, Australia

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Australian National University, Canberra, Australia

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University of Wollongong, Sydney, Australia

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University of New England, Armidale, Australia

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University of Canberra, Canberra, Australia Published online: 26 May 2015.

To cite this article: Andrew J. Campbell, Krestina L. Amon, Melanie Nguyen, Steven Cumming, Hugh Selby, Michelle Lincoln, Victoria Neville, Navjot Bhullar, Lynne Magor-Blatch, Lisa Oxman, Toni Green, Amanda George & Andrew Gonczi (2015) Virtual World Interview Skills Training for Students Studying Health Professions, Journal of Technology in Human Services, 33:2, 156-171, DOI: 10.1080/15228835.2015.1022682 To link to this article: http://dx.doi.org/10.1080/15228835.2015.1022682

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Journal of Technology in Human Services, 33:156–171, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 1522-8835 print=1522-8991 online DOI: 10.1080/15228835.2015.1022682

Virtual World Interview Skills Training for Students Studying Health Professions ANDREW J. CAMPBELL, KRESTINA L. AMON, MELANIE NGUYEN, and STEVEN CUMMING Downloaded by [University of Sydney Library] at 17:18 28 May 2015

The University of Sydney, Sydney, Australia

HUGH SELBY Australian National University, Canberra, Australia

MICHELLE LINCOLN The University of Sydney, Sydney, Australia

VICTORIA NEVILLE University of Wollongong, Sydney, Australia

NAVJOT BHULLAR University of New England, Armidale, Australia

LYNNE MAGOR-BLATCH, LISA OXMAN, TONI GREEN, and AMANDA GEORGE University of Canberra, Canberra, Australia

ANDREW GONCZI The University of Sydney, Sydney, Australia

This study examined the effectiveness of a health professional virtual world interview skills trainer (IST), in comparison to classroom training via interview role-plays with peers. Students of psychology, physiotherapy, and general health science learned interviewing skills through role-play and virtual world training. Students were randomly allocated to a role-play-first, or IST-first condition. Interviewing self-efficacy was measured at baseline Received March 24, 2014; accepted February 20, 2015. Address correspondence to Andrew J. Campbell, PhD, Faculty of Health Sciences, The University of Sydney, P.O. Box 170, Lidcombe, NSW 1825, Australia. E-mail: andrew. [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wths. 156

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and after each of the learning experiences. In total, 72 students completed all surveys. Students’ reported an increase in interviewing self-efficacy significantly after the IST experience than after role-play.


KEYWORDS health professionals, interviewing skills, simulated learning, virtual worlds

Health professional interview skills are a core element of effective, client-centered healthcare. Effective communication in an interview establishes rapport and cooperation with a client, provides insight into a client’s concerns, obtains information necessary for diagnosis and treatment, and is responsive to the client’s need for information (Baumal & Benbassat, 2008). Effective communication between client and clinician has been shown to affect patient outcomes. Street, Makoul, Arora, and Epstein (2009) found that communication enhances patient access to healthcare by increasing awareness of services and willingness to participate. It also increases patient knowledge, empowerment, and ability to manage emotions. According to Street et al. (2009), the consequences of more open communication between the patient and health professional include enhancing the therapeutic alliance, increasing social support, and creating patients who are informed to make higher quality decisions. Weiland et al. (2012) also showed that doctor-patient communication with patients exhibiting medically unexplained physical symptoms enhanced satisfaction, daily functioning, and healthcare use. Communication can reduce symptoms and anxiety in these patients. The complexity of healthcare and diversity of clients means that health communication cannot occur in a fixed sequence. Effective health interviewing, therefore, is the flexible and appropriate use of communication tools in a variety of situations. These tools can include asking questions in an appropriate manner and sequence, strategies for responding to emotions, and the principles of active listening. With demonstrated links between communication and patient=client health outcomes, it is important to ascertain the most effective methods for teaching health students these skills. As part of their education, health students are provided with opportunities to practice and develop communication skills. Often, however, this learning occurs during clinical placement. Here, students are assigned to healthcare practices (both private and public) to receive training by a clinician (clinical educator). The student would be trained in, and assessed on, a number of discipline-specific skills relevant to their stage in the degree program. Professional skills, such as interviewing and client communication, are also taught. However, on clinical placement students are interviewing real patients. For some students, this may be their first exposure to health


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interviewing. An additional limitation of this learning context is that communication skills are not explicitly attended to (unless students make a glaring mistake). The focus of clinical education is on discipline specific treatment based skills (Levinson, Lesser, & Epstein, 2010). As such, further opportunities to practice these skills and explicit instruction and feedback would appear to be an important addition to the curricula. Research has shown that simulated training in clinical skills (including communication skills) provided prior to clinical placement, can enhance student self-efficacy and performance while on practicum. At present, this training is primarily delivered through in-class role-plays. In these role-plays students alternate between the roles of client, clinician, and observer. The use of role-plays in several health professions have demonstrated success in developing active listening skills, empathy, problem solving, acquiring knowledge, and refinement of interview skills (Barney & Shea, 2007; Joyner & Young, 2006; Nestel & Tierney, 2007; Rao, 2011). However, the diversity of patients that students will encounter in their workplace suggests that more authentic learning scenarios than role-plays between peers are required. Moreover, there is limited time for students to continue to practice their interviewing skills within and outside the timetabled lecture or tutorial. As such, an alternative and=or adjunct learning experience would arguably be beneficial. Another argument for additional opportunities for students to practice their interviewing and health communication skills is logistical. With increasing enrollments of health professional students (particularly in first year) attending limited numbers of clinical placements and finite tutorial hours, learning opportunities and spaces are required to allow students time to refine and enhance their communication with clients=patients. The authors wish to highlight that this project aimed to extend students’ opportunities to learn about health interviewing, not to replace clinical placement client interview experience. We acknowledge the importance of clinical placement training and wish to enhance the skills learned during practicum by providing further practice (for senior students) and preparation opportunities (for junior students).

VIRTUAL WORLD INTERVIEWING AND HEALTH EDUCATION Recently, virtual worlds have been used in delivering health services and developing understanding of verbal and nonverbal clinical communication (Bordnick, Traylor, Carter & Graap, 2012; DeVault, et al., 2014). Bordnick et al., (2012) compared the feasibility and effectiveness of delivering cognitive-behavioral therapy and cues exposure skills training through virtual worlds. Researchers found that participants—smokers—who received virtual worlds training in addition to nicotine replacement therapy smoked fewer cigarettes per day and reported lower cravings than participants who received nicotine replacement therapy alone. Virtual worlds, it seems, can



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create authentic environments for interactions with health professionals. This authenticity is such that participants are more willing to disclose to a virtual interviewer when they believe that the interviewer was an automated system compared to when it was controlled by a human (Lucas, Gratch, King, & Morency, 2014). This research suggests great potential for virtual worlds to be engaging learning environments for health students, particularly in tasks focusing on client-professional interactions. In contrast to the previous work where the interviewer is the virtual element, recent research has also examined the effectiveness of training participants using virtual patients (Bearman, 2003; Cook & Triola, 2009; Hayes-Roth, Saker & Amano, 2009; Parsons, Kenny & Rizzo, 2008). Virtual patients are avatars playing the role of a patient in a virtual world. Students conduct health interviews by selecting from a range questions provided on screen. The exact questions will reflect the intended learning outcomes, for example, medical history taking or diagnosis. The virtual patient will then respond with statements and expressions from a bank of predetermined replies for the selected question. The outcome of the session with the virtual patient is determined by the line of questioning the student pursues. However, a clear storyline exists for each line of questioning (Bearman, 2003; Cook & Triola, 2009). With the technological advances of enabling the integration of dynamic visual and auditory stimuli, virtual patients are designed to resemble human patients through a range of facial expressions, gestures, and voice responses. Accessible where a computer is available, it does not require teachers or trainers to be present. This addresses concerns about accessibility and affordability. These interactive characters have demonstrated uses in the health industry to teach and refine interview skills and basic communication, history taking, decision making, therapy and rehabilitation, and medical examinations (Botezatu, Hult, & Fors, 2010; Parsons et al., 2008). Hayes-Roth et al. (2009) evaluated a virtual world training program (STAR) where students, guided by a Coach avatar (online character that plays a teacher-like role), interview virtual patients. Compared to students learning from an e-Book in the control group, students engaged in virtual world training demonstrated significantly greater improvements in interviewing skills two weeks after the program concluded. Researchers particularly emphasize that students in both training conditions (e-Book and STAR) reported high self-efficacy, even though skills performance statistically improved for STAR participants only. Hayes-Roth et al. (2009), however, did not report the specific type of self-efficacy measured. Studies using measures of interviewing skills, self-efficacy in particular, would be important for enhancing the current understanding of virtual world training programs in comparison to face-to-face activities. Self-efficacy for a specific task may be affected differently by training medium than general self-efficacy.


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Despite the ‘‘confidence-competence gap’’ demonstrated by Hayes-Roth et al. (2009), research has shown that self-efficacy remains a factor in performance success. Self-efficacy is the perceived confidence an individual has in performing a specific task (Bandura, 1977). It has been shown to predict improvements in healthcare training (Opacic, 2003; Parle, MacGuire, & Heaven, 1997). Specifically, self-efficacy predicts an individual’s motivation to learn and engage with training (Colquitt, LePine, & Noe, 2000). Chiaburu and Marinova (2005) investigated factors predicting skill transfer as an outcome of training in employees of a corporate organization. They found that training self-efficacy (a participant’s confidence in their ability to successfully engage with training activities) predicted pretraining motivation which in turn predicted skill transfer. So, self-efficacy can be measured as a potential indicator of performance. It is also important to note that there is no one correct way of interviewing all patients and clients. Instead, students should be equipped with a variety of tools and be able to assess situations and use those tools appropriately. Part of this learning is developing confidence in knowing each of these tools and when to employ them. Thus, interviewing self-efficacy should be explored. This refers to an individual’s confidence in their ability to select the appropriate tools=responses for each client in a specific situation. Previous research on virtual interviewing (e.g., Hayes-Roth et al., 2009) have not explicitly examined the effects of training type on interviewing self-efficacy in particular. Functional and physical fidelity have also been identified as factors important to the success of virtual world interventions (Alexander, Brunye´, Sidman, & Shawn, 2005). The extent to which virtual world interactions correspond with face-to-face communication can affect immersion in the task and learning outcomes. Functional fidelity (behavior) refers to how well a virtual patient acts and reacts to the student as a real patient would, whereas physical fidelity (visual) is concerned with how realistic the virtual patient looks and sounds. Hayes-Roth et al. (2009) stated that high physical fidelity would stimulate a strong sense of physical presence, and as such, be more beneficial for physical clinical skills. Comparatively, high functional fidelity would facilitate cognitive skills such as interview expertise adaptive to the client’s behavior. From their study, they inferred that functional fidelity had a greater impact on learning how to conduct health interviews than physical fidelity, however, this was not explicitly measured.

THE CURRENT STUDY The current study aimed to create and evaluate a virtual environment that students can access at their convenience (both regarding time and location) to practice their health interviewing skills. It extends on research by



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FIGURE 1 Image of virtual patient, Edith.

Hayes-Roth et al. (2009), by evaluating a virtual world interviewing tool where the student interacts with the patient without a teacher (or coach) present. This is to enhance the functional fidelity of the experience, that is, student health professionals would interview their patients without the perceived ‘‘safety net’’ of a teacher present. Simmersion Holdings from Canberra, Australia, have created MyCosm1 technology which allows 3D virtual environments with rich real-time graphics to be created. A Virtual World Interview Skills Trainer (IST) for health professionals was created using MyCosm technology. As part of this project, four avatars were designed: a young boy, an indigenous man, a middle-aged female and an elderly female. Two were used as virtual patients for this study named ‘‘Melinda,’’ who is the middle-aged female, and ‘‘Edith,’’ who is the elderly senior (Figure 1). The virtual world environment was created from photographs taken in clinic rooms at The University of Sydney, Faculty of Health Science Campus, and The University of Canberra, as the project was trialed with students from these institutions. Three units of study were identified as suitable for providing the Virtual World learning experience to health professional students. Teachers within these units of study created a story and accompanying script for the avatar of their choice. Disciplines included Health Sciences, Psychology, and Physiotherapy. Students would conduct interviews with the avatar by selecting a question from the teacher-generated question bank. The IST program randomly selected a response created by the teacher to answer the student’s chosen question, both verbally and with the use of facial expressions and general body language. The IST was designed with a feedback function. Feedback would appear in text form to the student following the avatar’s response. This


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feature allowed the teacher to program a variety of questions, answers and feedback on why particular strategies are more appropriate than others when interviewing their client. Providing feedback in this virtual world allowed for individualized one-on-one feedback that is often limited during in-class role-plays. The current study evaluated the Virtual World Interview Skills Trainer program developed by Simmersion Holdings with university students studying health professions. The aim was to compare student’s self-efficacy of interviewing skills between existing teaching techniques and simulated learning. It was hypothesized that (a) students will report higher change in self-efficacy of interviewing skills following the virtual world simulation activity, than the in-class role-play activity; and (b) virtual world interviewing would be more effective with high functional, rather than physical, fidelity.

METHODS Participants Participants were students studying Health Sciences at The University of Sydney, as well as Psychology and Physiotherapy students at The University of Canberra. Interviewing-skills training is a core component of these degree programs. As such, all students participated in role-play and virtual-world learning as part of their unit of study. Participation in the study by completion of three questionnaires (baseline, postrole play, postvirtual world learning) was voluntary.

Measures Three questionnaires and surveys were used to evaluate the effectiveness of virtual learning compared to role-play learning for interview skills. DEMOGRAPHICS QUESTIONNAIRE This nonstandardized, 15-item questionnaire, was created by the researchers to examine student’s background and experiences with technology. The survey included items about gender, age, year of study, and experience with computers, the Internet and technology. INTERVIEWING SELF-EFFICACY SURVEY (ISES) The ISES was adapted from the Counselling Self-Estimate (COSE) Inventory (Larson et al, 1992). The COSE was developed for use in training, supervision, and research towards the development of self-efficacy in counselling among trainees (Daniels & Larson, 2001; Larson, Suzuki, Gillespie, Ptenza,



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& Beschtel, 1992; Larson et al., 1999; Yuen, Chan, Lau, Lam, & Shek, 2004). According to the guidelines set out by George and Mallery (2003), internal consistency for the COSE is excellent (a ¼ 0.93; Larson et al., 1992). Convergent and discriminant validity is reported by Larson et al. (1992). Twenty-eight items were selected from the COSE for adaptation to the ISES. Items that explicitly addressed clinical counselling skills were excluded. The object of this project was to examine ways of supporting the development of interviewing, not diagnostic skills, in students. Items were randomly listed, and the word ‘‘counselling’’ was changed to ‘‘interviewing’’ to better align with the project. Students were asked to rate the degree they agreed with the item statements on a Likert-scale from 1 (strongly disagree) to 6 (strongly agree). Negatively worded items were reverse scored; therefore, higher total scores would represent higher perceptions of interviewing self-efficacy. Internal consistency for the ISES was good (a ¼ 0.88). STUDENT EXPERIENCE OF VIRTUAL LEARNING QUESTIONNAIRE The Student Experience of Virtual Learning questionnaire is a nonstandardized, 16-item survey, of students’ perceived enjoyment, learning, and motivation to learn more about interviewing skills following virtual world learning. Students also answered questions about their experiences with the technology and avatar. Questions included 5-point Likert scales and free response text. Specific questions regarding the virtual learning were also asked. These included items such as ‘‘Did you encounter any technical difficulties with the simulation?’’ and ‘‘What are your suggestions for improving the simulation learning tool?’’

Procedure A crossover design was used to examine changes in student interviewing self-efficacy following learning via role-plays and virtual world interactions. Students completed a demographics questionnaire once and the ISES three times during semester. Students completed the first ISES at the beginning of the semester to establish a baseline score. This survey was administered in class, either through paper-and-pencil at The University of Sydney, or online at The University of Canberra. Tutorial groups of students were then randomly allocated to either a role-play first or virtual world training first condition. Three hundred and seven students completed the virtual world training in the first week and 284 students completed the role-play training in the first week. After one week, students participated in the alternate task. The role-play training was conducted in class for both University of Sydney and University of Canberra students. Students were divided into pairs or groups of three to take turns interviewing each other about particular


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scenarios. The role-play tutorial was structured around core interviewing techniques students were introduced to in an earlier lecture. At the conclusion of the tutorial, students were invited to complete the ISES either online (The University of Canberra) or via paper-and-pencil (The University of Sydney) in the tutorial. At The University of Canberra, students completed the virtual world training during their tutorials. Students at The University of Sydney completed the virtual world training in specific weeks (as allocated to them at the commencement of the project). Students could elect to complete this task on their personal computers (i.e., the program was downloaded from the central server to their personal machines), or at the computer labs on campus outside tutorial times. The difference between delivery mode is due to the larger numbers of students at The University of Sydney (417 students enrolled). Meaningful comparisons between the delivery modes cannot be made due to the small sample size. As such, discussions about the implications of this difference in delivery mode cannot be supported by evidence from our study. In the virtual world condition, students would log onto the virtual world and interview the avatar by choosing from one of a number of question options. The avatar would respond and the interview would continue for between 1–5 min (the equivalent length of a role play scenario) depending on the questions the student asked. For example, the interview may conclude on an unsuccessful note if the student has asked something inappropriate or behaved in an inappropriate manner (e.g., selecting to touch the patient=client as an option provided to them). It may also conclude on a successful note, for example, if the client=patient stated they had received the help that they sought from their health professional. Upon completion of this task, students were invited to complete the ISES and a Student Experience of Virtual Learning survey online via Survey Monkey. Instructions to complete the virtual world training were sent out by the unit coordinators. Students who experienced technical difficulties were instructed to contact the project manager as they worked with the Simmersion Holdings technical team and the University’s information and communications technology (ICT) personnel. E-mails received by the unit coordinators regarding technical difficulties were forwarded to the project manager to resolve.

RESULTS Two hundred and seventy two students completed the baseline survey, 322 students completed a survey following their role play learning and 186 students completed the survey after their virtual world learning. However, only 72 students completed all three surveys. The data reported in this article will be from students who had completed all surveys.



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The 200 students who completed the baseline survey but not the subsequent surveys were compared to the 72 completed cases on gender distribution, comfort with using the computer, frequency of Internet use and age. This was to determine whether there were any statistical differences between the samples. The 200 excluded surveys were mostly incomplete so baseline interviewing self-efficacy scores could not be compared. The two groups (included and excluded) did not differ significantly on gender distribution (v2 (1, N ¼ 270) ¼ 3.65, p ¼ 0.06). Mann-Whitney U tests showed no statistically significant differences between the groups on how comfortable they were using the computer (p ¼ 0.98) or frequency of internet use (p ¼ 0.19). However, participants who were included were significantly older (Median ¼ 23 years) than those who had only completed the baseline survey (Median ¼ 18 years). This may reflect greater conscientiousness in more mature students. However, because age was not systematically examined in this study, conclusions cannot be drawn about the impact of age on interviewing self-efficacy. This is discussed further in the limitations and future research section of this article. Students (86.1% female) ranged in age from 17–65 years (Median ¼ 23 years). Students were enrolled in the following units of study: Foundations of Health Sciences (38.9%); Professional Practice (30.6%), Advanced Counselling (20.8%), and Musculoskeletal Interventions (9.7%). The majority of students were in their first year (70.8%). An Independent Samples Kruskal-Wallis test showed no significant differences between students of the different year groups (p ¼ 0.5). All students indicated that they were comfortable with using a computer and 95.8% used the Internet a few times a day. Internet was accessed daily at home (94.4%), daily at work (34.7%), and weekly at school (44.4%). Social networking was the main reason for logging online (88.9%), followed by educational purposes (61.1%), work related (47.2%), for shopping (41.7%), and for gaming (11.1%). The ISES was created to measure the student’s perceptions about their interviewing abilities, prior to any interview training (baseline), after participating in the in-class role-play activity, and following their experience with the IST. Each participant had three interviewing self-efficacy scores based on their responses in the three surveys. A higher score indicated higher self-efficacy. To evaluate changes in self-efficacy following the training, each student’s baseline score was subtracted from their posttest score. Therefore, each participant had a change in self-efficacy score following virtual world learning and role-play experiences. A paired samples t-test showed significantly greater improvement in interviewing self-efficacy following virtual world learning (Mchange ¼ 8.80, SD ¼ 16.43) compared to role-play experiences (Mchange ¼ 5.48, SD ¼ 11.03; t (71) ¼ 2.04, p ¼ 0.04). Due to the small sample size, the Wilcoxon Signed Ranks test was also conducted. Here, there was also significantly greater

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TABLE 1 Mean (Standard Deviation) for the Extent to Which Students Believed Each Tool Facilitated Their Enjoyment, Motivation for Learning and Their Learning of Interviewing Skills Itself

Enjoyment Motivation Enhanced my understanding

Role-play (SD)

Virtual world IST (SD)

3.88 (0.79) 3.57 (0.89) 3.82 (0.79)

3.56 (0.92) 3.18 (1.05) 3.29 (1.04)


Note. IST ¼ Interview Skills Trainer.

self-efficacy following virtual world training compared to role plays, z ¼ 2.09, with a small effect size (r ¼ 0.2). Students also reported on their experiences interacting with virtual patients through the Student Experience of Virtual Learning Questionnaire. Their mean responses are presented in Table 1. Paired-samples t-tests were used to compare student preferences for role-play and IST learning. Students reported significantly greater enjoyment (t (71) ¼ 2.70, p ¼ 0.01), motivation (t (71) ¼ 3.30, p ¼ 0.002), and learning (t (71) ¼ 4.45, p < 0.01) from role-play experiences compared to Virtual World simulated learning. Correlations were conducted to explore the relationship between physical fidelity, functional fidelity, and student outcomes. There was no significant relationship (all p > 0.35) between how realistic the avatar’s expressions seemed and students’ self-reported enjoyment of the virtual world experience (r ¼ 0.11), their motivation to learn interviewing skills using the IST (r ¼ 0.11), and their belief that virtual world interviewing enhances their learning (r ¼ 0.09). However, there was a significant positive relationship between how realistic the interview questions were and students’ enjoyment of the IST (r ¼ 0.38, p ¼ 0.001) and their belief that virtual world training enhanced learning (r ¼ 0.45, p < 0.001). Thirty four point seven percent of participants agreed or strongly agreed (59.7% broad agreement) that the avatar’s facial expressions were realistic. In contrast, 56.9% of respondents agreed or strongly agreed (80.5% broad agreement) that the interview questions seemed authentic. Approximately half the students (51.4%) reported technical difficulties with the IST. These included problems with accessing the program (56.8% of students reporting ICT issues), launching the program (13.5%), and problems with sequencing within the program (29.7%). Access issues encompassed problems downloading and installing the program.

DISCUSSION The current study supported the hypothesis that there would be significantly greater improvement in interviewing self-efficacy following virtual world



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training, when compared to in-class role-plays. Additionally, while not as immersive as human role-playing interviewing, virtual world interviewing was perceived by students to be more effective with high functional physical movement (fidelity) inclusive of realistic interview question lines, avatar conversation, and behavioral cues to such questions. Each of the studies reviewed in the literature (Bearman, 2003; Cook & Triola, 2009; Hayes-Roth et al., 2009; Parsons et al., 2008) specified that simulated clinical communication, education skill set acquisition, and engagement in simulation experience needs to align with the realism of face-to-face experiences of training. Students in the current study did perceive role-plays to be more motivating and enjoyable, as well as better able to enhance their understanding of interviewing when compared to virtual world simulation, but this could arguably be because of the level of familiarity toward the interaction of the offline world, or the technical difficulties experienced by the students. Notably though, the current study supported the research of Hayes-Roth et al. (2009), with evidence of effective simulated training, for which students reported comparable learning experiences between virtual world training and role play. Furthermore, students reported that the presence of greater immersion (i.e., behavioral realism of the Avatar through emotion display and movement), strongly aided in their connection to the simulated interview experience. This strongly aligns with the review of Alexander et al. (2005), emphasizing the importance of immersion (clarity of behavior=communication cues of the Avatar) and fidelity (a realistic looking Avatar). It would be beneficial for future research to determine whether the effects are similar when the conditions are compared as a combination of the two, and singly. A core focus of this research into interview skills training for health professionals is developing confidence in students in knowing each of the interview ‘‘tools and techniques’’ and when to employ them with specific clients. Thus, self-efficacy should be explored in future research because Hayes-Roth et al. (2009) did not describe their measure of self-efficacy. Given this, future studies should prioritize determining which of the different types of self-efficacy best indicates health interviewing performance. Hayes-Roth, Saker, and Amano (2010), report that the confidencecompetence gap exists when training tasks are easy. If students are successful in their practice experiences, they may incorrectly infer that they are more able than they actually are. The authors argue that the virtual interviewing script was challenging for students. Anecdotal evidence suggests that although students could choose from a range of questions to ask the avatar, the ‘‘correct’’ response was not obvious (for example, many students stated that they learned not to touch patients even if they were crying, especially in the early stages of rapport building). On the other hand, role-plays were conducted with peers. It is possible that students did not challenge their peers to the same extent. Or, they were unable to present high (physical


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and functional) fidelity scenarios as their personal experience (particularly the large cohort of first year students) may have been limited. What may have also limited the study was that student perceived self-efficacy, and not actual interviewing skills, was measured in this study. Research examining the relationship between perceived learning, self-efficacy, and actual learning is required to further clarify, and extend upon this study. This research also examined the contribution of physical and functional fidelity to student learning. Results showed a significant positive relationship between functional fidelity and student enjoyment of the IST and their perceived learning. However, no relationship existed between how realistic the students perceived the avatars to look and ‘‘feel,’’ and their motivation to learn from, as well as enjoyment of the IST. This is consistent with the hypothesis and lends further credence to claims made by Hayes-Roth et al. (2009). For cognitive tasks such as interviewing, it is more important that the questions and conversation seemed realistic rather than the physicality of the avatar. The nature of the IST experience also highlighted to students that the focus was on their interactions with the virtual patient, rather than their interactions with the tool. Aside from changing their view of the avatar and interviewing the patient, there were no other interactive elements to the IST. It was clear that the interaction, rather than the tool, was the focus of this experience. Studies examining different variations of the IST could shed further light on this explanation.

Limitations of the Current Study Of the 272 students involved in the study, only 72 completed all surveys for learning experience and simulation evaluation. The researchers believe this was due to the voluntary nature of the surveys and potentially from the students’ experience surrounding access and technical problems including installation and=or launching the program. Each of the technical issues were resolved once the student had contacted the project manager to ensure they attempted the IST task. It was important that the students had access to, and had support from the research team with the technical issues they faced. Without this, students may have been further deterred from completing the task. Participants’ survey responses were de-identified and could not be linked back to which tutorial they were enrolled in. As such, it cannot be determined how many students completed each condition first. This is a limitation of the current study. As stated earlier, participants who had completed all three surveys (and therefore included in the study) were significantly older than participants who had only completed the baseline survey. In this study, age does not affect Internet use or comfort with using a computer. However, it may reflect a sense of maturity or conscientiousness. This, in turn, could have affected


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students’ responses to the different learning experiences. For instance, students who are older might prefer functional over physical fidelity or at least see the value of functional fidelity in the absence of physical fidelity. However, this study did not systematically examine the effect of age on responses to training and virtual worlds. Future research systematically examining the role of age would enhance understanding of the current findings and extend current discussions regarding virtual worlds.


CONCLUSION The relationships between self-efficacy, functional and physical fidelity, student perceptions of learning, and students’ actual learning need to be further clarified. However, this research suggests a place for virtual world training. It may be a cost effective way for increasing opportunities to practice interviewing skills outside of the classroom. Moreover, this practice occurs in an environment where students are allowed to make mistakes. With improvements in the technology (including incorporating feedback and compatibility with university information communication technology systems), this form of training is argued to be a valuable tool for health students.

FUNDING The authors wish to thank the Australian Government Office for Learning and Teaching (Grant ID11-2096) for funding this research project.

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