Krista Hoek

Communication is an essential part of safe, effective, and person-centered care. In clinical practice, communication determines not only how information is transferred, but also how patients experience safety, trust, anxiety, pain, and comfort. Additionally, communication influences how care teams collaborate, make decisions, and deal with pressure, uncertainty, and hierarchy. The manner of communication can directly impact patient safety, patient experience, and team functioning.

Yet many communicative skills in healthcare are still only explicitly taught to a limited extent. A significant portion of professional communication behavior is learned implicitly: through observation, routines, modeling, and the culture of the workplace. Consequently, important aspects of communication, such as tone, timing, body language, non-verbal attunement, team norms, and power dynamics often remain invisible. This thesis proceeds from the idea that communication is not just an individual skill, but a relational and context-dependent competency that arises between people, within systems, and under the influence of clinical culture.

This thesis investigates how virtual reality (VR), simulation, and embodied experiences can be developed and used to train communication skills in healthcare. The emphasis is not on VR as a technology in itself, but on the question of how immersive and experiential learning environments can contribute to awareness, reflection, and potential behavioral change. The central idea is that communication must not only be cognitively understood but must also be experienced, recognized, and discussed.

The dissertation is built around three domains: communication in high-stress clinical situations, therapeutic communication for patient comfort, and communication and team culture in the operating room. Within three sections, eight chapters are presented, each focusing on a different aspect of communication education, VR development, validation, or implementation.

The first domain concerns communication in high-stress situations within anesthesiology. In acute perioperative situations, technical skills are indispensable, but safe action also depends on situational awareness, decision-making, leadership, task distribution, and team communication—namely, human factor skills. Chapter 1 outlines the educational and clinical background of simulation education within anesthesiology. The chapter shows that simulation is not primarily a technology, but an educational method through which healthcare providers can practice technical and non-technical skills in a safe environment. In this process, manikin simulation is compared with VR simulation, with attention to realism, cognitive load, debriefing, scalability, and practical feasibility.

Chapters 2A, 2B, and 2C build on this by describing the development and initial validation of a VR simulation for anesthesia training. Within these chapters, it was investigated whether an adaptive multiplayer VR simulation can play a complementary role in training crisis resource management (CRM) and communication under pressure. The VR simulation was developed through a user-centered design process, combined with an analysis of potential errors and risks. An important design principle was that the trainer must be able to adjust the scenario to the level and behavior of the participants, for example, by changing clinical parameters during the scenario. This adaptability is relevant because a scenario that is too simple has insufficient added value, while a scenario that is too complex can lead to cognitive overload. The introduction describes this development as a multiplayer, scenario-adaptive VR system for anesthesiology, developed through a user-centered process and researched using qualitative and quantitative methods. The evaluations in Section II showed that this form of VR simulation is feasible, acceptable, and educationally relevant. Participants experienced the scenarios as meaningful and recognized elements from clinical practice. They reported increased awareness of communication patterns, task distribution, team coordination, and decision-making under pressure. At the same time, these chapters primarily show early educational outcomes, such as satisfaction, perceived relevance, and self-reported learning. In terms of the Kirkpatrick model, the strongest results are primarily at levels 1 and 2: reaction and learning. There is still insufficient evidence that this VR training on its own leads to sustainable behavioral change in clinical practice or to better patient outcomes. VR should therefore not be seen as a replacement for existing simulation forms, but as a complementary educational form with specific advantages in terms of scalability, repeatability, and controlled exposure to complex scenarios.

The second domain focuses on therapeutic communication for patient comfort and the reduction of anxiety. Medical procedures, hospitalization, and surgeries can be associated with tension, uncertainty, and loss of control for patients. In such situations, the words, tone, attitude, and non-verbal behavior of healthcare providers can strengthen or soften the patient's experience. Chapter 3 introduces the core message of this section: good intentions are not enough. Communication has an effect, even when that effect is not consciously pursued. Verbal and non-verbal communication can influence expectations, anxiety, pain perception, and trust.

Chapters 4A, 4B, and 4C then investigate the development, validation, and application of patient-embodied VR to increase awareness of therapeutic communication. In these experiences, the healthcare provider does not look at a patient but experiences a clinical situation from the patient's perspective. This makes it tangible how language, tone, tempo, touch, attention, and the absence of attention can be received by someone who is dependent on care. This change of perspective makes the emotional impact of everyday communication more concrete than theoretical explanation alone. The studies within these chapters showed that patient-embodied VR can contribute to awareness, empathy, and reflection among healthcare providers. Participants recognized their own communication habits and indicated a desire to be more conscious of language use, non-verbal behavior, and the way they prepare patients for medical procedures.

Chapters 5A and 5B move these insights into clinical educational practice. These chapters describe and evaluate a blended therapeutic communication training for nurses in an acute admission ward. The training combined e-learning, a patient-embodied VR experience, and a didactic training day with experiential exercises. The qualitative findings pointed to perceived behavioral change and more attention to patient comfort in daily practice. These chapters thus show that therapeutic communication can not only be taught as a concept but can also be embedded in a practical training for healthcare providers.

Chapter 6 then examines the application of this training form within a broader intervention bundle in the preoperative holding area. This bundle consisted of therapeutic communication training for healthcare providers and non-pharmacological interventions for patients, including VR and music. The goal was to influence preoperative anxiety and patient comfort. The quantitative results showed modest and non-univoque effects, while the qualitative results suggested a positive influence on the work environment and patient experience. This discrepancy is important because it shows that the impact of communication is difficult to capture in a single outcome measure. Communication works in interaction with context, timing, workload, patient characteristics, organizational conditions, and the broader culture of care. This thesis therefore does not claim that VR-based training by itself demonstrably reduces patient anxiety, but shows that therapeutic communication is experientially trainable and that patient-embodied VR can provide a powerful entry point for awareness and reflection.

The third domain concerns communication and team culture in the operating room. The operating room is a complex and hierarchical environment in which different disciplines collaborate closely under time pressure. Communication there consists not only of spoken language but also of looks, silence, body language, spatial positioning, touch, routines, and implicit expectations. It is precisely these subtle forms of communication that contribute to cooperation, trust, safety, and the feeling of belonging somewhere.

Chapter 7 therefore investigates the non-verbal elements of rapport in the operating room and clinical practice. Using a video-ethnographic approach, it became visible how healthcare providers create attunement with patients and colleagues through eye contact, posture, distance, timing, and physical proximity. Such behaviors appear small but can have great significance for comfort, trust, team cohesion, and psychological safety.

Chapter 8 describes the development of VR-embodied experiences for medical students and junior doctors entering the operating room. The goal was not to prescribe a single correct way of communicating, but to help students and junior doctors recognize which norms, hierarchies, and expectations are present in the clinical environment. By experiencing the operating room from this perspective, implicit team dynamics can be made visible and discussable. Thus, VR offers an opportunity to make the unspoken in clinical culture part of education and guidance.

Across the three domains, this thesis shows that communication is not a separate technical skill, but a clinical, relational, and cultural competency. Communication arises between people, within systems, under the influence of roles, emotions, time pressure, hierarchy, and professional norms. VR can play a valuable role here because it can not only show situations but also allow them to be experienced. It makes perspective-shifting possible: from healthcare provider to patient, from team member to observer, and from outsider to participant. This allows aspects of communication that normally remain implicit to become visible, tangible, and discussable.

The integration between the chapters becomes visible in the triangle model of this thesis. In it, high-stress communication, therapeutic communication for patient comfort, and team culture in the operating room form the three domains, while VR-based embodied learning forms the overarching mechanism. From that thought, Chapters 2, 4, and 8 primarily show how VR-based learning environments can be developed; Chapters 4 through 8 show how immersive experiences can support perspective-shifting; and Chapters 5 and 6 show what happens when these experiences are embedded in clinical training and implementation contexts.

The most important contribution of this thesis is therefore not the conclusion that VR is better than existing educational forms. The contribution lies in showing how VR and embodied learning can be used as a catalyst for awareness, reflection, and conversation about communication.

At the same time, the use of VR calls for critical nuance. More realism does not automatically lead to better learning. A VR experience always remains a designed selection of reality and can never capture the full complexity of clinical practice. Furthermore, transfer to daily behavior is difficult. Future studies should therefore not only ask *if* VR works, but primarily for which learning objective, for which target group, under what circumstances, and with what form of guidance, debriefing, and implementation.

In summary, this thesis demonstrates that VR simulations and embodied experiences can be valuable tools to deepen communication education in healthcare. The chapters collectively show that VR can be powerful as part of a broader educational and implementation strategy. VR makes visible what often remains implicit, strengthens perspective-shifting, and offers space to approach communication not just as a skill but as part of professional culture and patient-centered care. In doing so, this thesis contributes to the further development of medical education in which healthcare providers not only learn what they must say or do, but also learn to understand what their communication brings about.