In the light of substantial improvements to the quality and availability of virtual reality (VR) hardware seen since 2013, this review seeks to update our knowledge about the use of head-mounted displays (HMDs) in education and training. Following a comprehensive search 21 documents reporting on experimental studies were identified, quality assessed, and analysed. The quality assessment shows that the study quality was below average according to the Medical Education Research Study Quality Instrument, especially for the studies that were designed as user evaluations of educational VR products. The review identified a number of situations where HMDs are useful for skills acquisition. These include cognitive skills related to remembering and understanding spatial and visual information and knowledge; psychomotor skills related to head-movement, such as visual scanning or observational skills; and affective skills related to controlling your emotional response to stressful or difficult situations. Outside of these situations the HMDs had no advantage when compared to less immersive technologies or traditional instruction and in some cases even proved counterproductive because of widespread cybersickness, technological challenges, or because the immersive experience distracted from the learning task.

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A review of the use of virtual reality head-mounted displays in education and training

The merger of game-based approaches and Virtual Reality (VR) environments that can enhance learning and training methodologies have a very promising future, reinforced by the widespread market-availability of affordable software and hardware tools for VR-environments. Rather than passive observers, users engage in those learning environments as active participants, permitting the development of exploration-based learning paradigms. There are separate reviews of VR technologies and serious games for educational and training purposes with a focus on only one knowledge area. However, this review covers 135 proposals for serious games in immersive VR-environments that are combinations of both VR and serious games and that offer end-user validation. First, an analysis of the forum, nationality, and date of publication of the articles is conducted. Then, the application domains, the target audience, the design of the game and its technological implementation, the performance evaluation procedure, and the results are analyzed. The aim here is to identify the factual standards of the proposed solutions and the differences between training and learning applications. Finally, the study lays the basis for future research lines that will develop serious games in immersive VR-environments, providing recommendations for the improvement of these tools and their successful application for the enhancement of both learning and training tasks.

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A review of immersive virtual reality serious games to enhance learning and training

Background Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work-related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience-promoting training programmes. Objectives To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists). Search methods We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results. Selection criteria Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, wait-list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well-being or quality of life. Secondary outcomes were resilience factors. Data collection and analysis Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only). Main results We included 44 RCTs (high-income countries: 36). Thirty-nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies). Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face-to-face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive-behavioural therapy) versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support. Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD -0.29, 95% CI -0.50 to -0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD -0.61, 95% CI -1.07 to -0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD -0.06, 95% CI -0.35 to 0.23; 5 studies, 231 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.14, 95% CI -0.01 to 0.30; 13 studies, 1494 participants; very-low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very-low certainty evidence). Authors' conclusions For healthcare professionals, there is very-low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post-intervention. The paucity of medium- or long-term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high-quality replications and improved study designs.

Psychological interventions to foster resilience in healthcare professionals

Serious games and gamification to engage consumers in pro-environmental behaviours for energy efficiency are in their infancy To date, despite growing interest and some initial attempts, their potential to engage consumers in energy efficiency behaviours has been understudied To provide an overview of serious games and gamification to engage individuals in pro-environmental behaviours for energy efficiency, a computer-based search for relevant publications was performed in several databases After applying the inclusion criteria and removing duplicates, 10 papers were included in this systematic review Results showed that serious games and gamification have been used in three different areas related to energy efficiency: environmental education, consumption awareness, and pro-environmental behaviours This review also showed that applied gaming interventions can be used in more than one of these three areas (comprehensive interventions) The main observation to be drawn from this review is that both serious games and gamification can foster energy-saving behaviours and vary widely in terms of type of games and of features that might be appealing and motivating

Gaming for Earth: Serious games and gamification to engage consumers in pro-environmental behaviours for energy efficiency

Industry 4.0 aims at integrating machines and operators through network connections and information management. It proposes the use of a set of technologies in industry, such as data analysis, Internet of Things, cloud computing, cooperative robots, and immersive technologies. This paper presents a training system for industrial operators in assembly tasks, which takes advantage of tools such as virtual reality and process mining. First, expert workers use an immersive interface to perform assemblies according to their experience. Then, process mining algorithms are applied to obtain assembly models from event logs. Finally, trainee workers use an improved immersive interface with hints to learn the assemblies that the expert workers introduced in the system. A toy example has been developed with building blocks and tests have been performed with a set of volunteers. The results show that the proposed training system, based on process mining and virtual reality, is competitive against conventional alternatives. Furthermore, user evaluations are better in terms of mental demand, perception, learning, results, and performance.

A training system for Industry 4.0 operators in complex assemblies based on virtual reality and process mining

INTRODUCTION Stress Management Training programs are increasingly being adopted in the military field for resilience empowerment and primary stress prevention. In the last several years, advanced technologies (virtual reality in particular) have been integrated in order to develop more innovative and effective stress training programs for military personnel, including soldiers, pilots, and other aircrew professionals. This systematic review describes experimental studies that have been conducted in recent years to test the effectiveness of virtual reality-based Stress Management Training programs developed for military personnel. This promising state-of-the-art technology has the potential to be a successful new approach in empowering soldiers and increasing their resilience to stress. METHODS To provide an overview from 2001 to 2016 of the application of virtual reality for Stress Management Training programs developed for the military, a computer-based search for relevant publications was performed in several databases. Databases used in the search were PsycINFO, Web of Science (Web of Knowledge), PubMed, and Medline. The search string was: ("Virtual Reality") AND ("Military") AND ["Stress Training" OR ("Stress Management")]. RESULTS There were 14 studies that met the inclusion criteria and were included in the review. DISCUSSION The main observation to be drawn from this review is that virtual reality can provide interactive Stress Management Training to decrease levels of perceived stress and negative affect in military personnel. This technology appears to be a promising tool for assessing individuals' resilience to stress and for identifying the impact that stress can have on physiological reactivity and performance.Pallavicini F, Argenton L, Toniazzi N, Aceti L, Mantovani F. Virtual realtiy applications for stress management training in the military. Aerosp Med Hum Perform. 2016; 87(12):1021-1030.

Virtual Reality Applications for Stress Management Training in the Military.

The use of Virtual Reality (VR) for training is increasingly common in the military and in emergency operator fields. One of the main problems with the use of VR for training is the fact that the technology, although advanced, is not enough on its own. Technological aspects like fidelity and sensorial realism are certainly important in developing effective training techniques, but there are others that need to be considered. Focusing on human factors from the earliest stages of designing VR training can increase effectiveness and reduce the possibility of ineffective or even harmful effects of the training. This approach, called “Human-Centered VR Training Design,” is characterized by being both multimodal (i.e., oriented to several aspects of user experience) and multilevel (i.e., based on the integrated use of technical and methodological solutions); it has undergone preliminary testing by Selex ES within the project Minerva in collaboration with psychological researchers at the University of Milano-Bicocca. Keywords: Virtual Reality, Training, Military, Emergency Operators, Human Factors 1. VIRTUAL REALITY FOR THE TRAINING OF MILITARY FORCES AND EMERGENCY OPERATORS The use of Virtual Reality (VR) for training is increasingly common in the military (Koźlak, Kurzeja, & Nawrat, 2013; Reist et al., 2013; Rizzo et al., 2011; Rizzo et al., 2013; Seidel & Chatelier, 2013; Summers, 2012) and in the emergency operator fields (Brady, Lee, Pearce, Shintaku, & Guerlain, 2015; Farra, Miller, Timm, & Schafer, 2013; Hsu et al., 2013; Pucher et al., 2014). This level of endorsement is linked mainly to the possibility offered by VR to simulate complex, highly stressful scenarios in a safe, customizable and dynamic environment (e.g., flight simulator, simulations of battlefields or emergency scenarios) (Seidel & Chatelier, 2013; Wilkerson, Avstreih, Gruppen, Beier, & Wooliscroft, 2008). In addition, training in a virtual world has been reported to be a good compromise between the traditional alternatives of classroom-based training and real-world training exercises (Hsu et al., 2013; Rizzo et al., 2011). VR has been adopted by both the military and emergency operators for the training of physical (e.g., the repetition of the steps to follow during an emergency helicopter landing) and mental skills (e.g., managing a health-related emergency situation). The three main areas of application of VR within these fields can be summarized as follows: 1) Procedural training: focuses on the training of single procedural skills. Some examples are military flight simulation (An, Li, Xu, & Shi, 2011; Zhao, Xu, Ye, & Li, 2011) and emergency medicine simulations (Bartoli et al., 2012; Ferracani, Pezzatini, Seidenari, & Del Bimbo, 2014); 2) Management of complex situation training: relates to contextual or relational skills, including team communication and decision making (Hoch & Kozlowski, 2014; Pucher et al., 2014), battlefield simulations (Rizzo, Parsons et al. 2011) and disaster preparedness training (Freeman et al., 2001; Kizakevich et al., 2007; Wilkerson et al., 2008); 3) Emotion and stress management training: concerns coping with stress. Examples include stress management training for military forces (Cosenzo, Fatkin, & Patton, 2007; Rizzo et al., 2012) and PTSD management training (Rizzo et al., 2015; Rizzo et al., 2012; Cosenzo, Fatkin, & Patton, 2007) and PTSD management training (Rizzo et al., 2015). 2. IS TECHNOLOGY REALLY ENOUGH? THE IMPORTANCE OF HUMAN FACTORS A few years ago there was a “technology rush”, with the aim of developing the most effective VR system for training; in particular, a VR system with the maximum level of sensory realism, or “physical fidelity,” which is Proc. of the Int. Conference on Modeling and Applied Simulation 2015, 978-88-97999-59-1; Bruzzone, De Felice, Frydman, Massei, Merkuryev, Solis, Eds. 206 the objective level of sensory realism that a VR system provides. More specifically, physical fidelity refers to the degree to which the physical simulation looks, sounds and feels like the operational environment in terms of the visual displays, controls, audio and haptic devices, as well as the physics models driving each of these variables (Becker, Warm, Dember, & Hancock, 1995; Rinalducci, 1996). But how realistic does a VR system need to be in order to fulfill its training goals? On the one hand, it is possible that unrealistic situations may lead to ineffective or even harmful effects of training. For example, the enhancement of haptic fidelity has been shown to be a fundamental element for surgical training when fine motor skills, accuracy and delicate tool control are required (Basdogan et al., 2004).  On the other hand, because of the learning abilities and perceptual limitations of the sensory, motor and cognitive systems of users, a perfect VR system is not always necessary (Scerbo & Dawson, 2007). A number of studies have even demonstrated that a high transfer of learning can be achieved with simple simulators when training soft and hard skills (Scerbo & Dawson, 2007). Physical fidelity and sensorial realism are certainly important elements to be considered during the design and development of a VR training system, but there is more to the story. The concept of fidelity, in fact, is not limited to that of sensorial realism; more generally, it refers to the extent to which the virtual environment emulates the real world (Alexander, Brunyé, Sidman, & Weil, 2005; Lintern, Roscoe, Koonce, & Segal, 1990). The level of fidelity of a VR system includes a large number of subcategories (Stoffregen, Bardy, Smart, & Pagulayan, 2003) related not only to its technological features, but also to the users’ subjective characteristics, or “human factors” (Riva & Mantovani, 1999; Wann & Mon-Williams, 1996). Due to the close bond between the user and the system within virtual environments, it may be impossible to segregate human factors from design issues when striving to achieve the potential of VR technology. It is the capabilities and limitations of the user that often times will determine the effectiveness of virtual worlds. 3. DEVELOPING VIRTUAL REALITY TRAINING THROUGH A “HUMANCENTERED DESIGN” Designing usable and effective interactive virtual worlds is a new challenge for system developers and human-factors specialists. An understanding of humanfactors issues can thus be used to provide a systematic basis by which to direct future VE research efforts aimed at advancing the technology to better meet the needs of its users. This need is best articulated by Shneiderman, 1992), who stated that "analyses of VR user-interface issues may be too sober a process for those who are enjoying their silicon trips, but it may aid in choosing the appropriate applications and refining the technologies” (p. 224). Thus, an interdisciplinary approach including users, trainers, designers, psychologists and technology experts can define concrete guidelines that may support strategic choices and training design activities evaluation. Human-factors practitioners such as psychologists and trainers can assist in making significant contributions to the theoretical understanding of human-virtual environment interaction (HVEI). Focusing on the users’ characteristics and needs from the earliest stages of the design of a VR can increase its effectiveness. This can be done by adopting a “Human-Centered VR Training Design” that provides an understanding of issues related to the subjective experience of the user and to the particular aims of the training from the early stages of development. Knowing the different elements involved in the task means that VR scenarios are tailored to the user, adopting the most suitable technology selected according to the needs of fidelity dictated by the specific task. This is possible through an analysis of the specific task to be trained, not only from a procedural point of view but also from a cognitive one (see Figure 1). Figure 1: “Human-Centered VR Training Design Model” (adapted from Pantelidis, 1995) 4. A PRELIMINARY INVESTIGATION OF THIS APPROACH AND FUTURE DIRECTIONS This approach, that could be defined as a “HumanCentered VR Training Design,” is characterized by being both multimodal (i.e., oriented to several aspects of user experience) and multilevel (i.e., based on the integrated use of technical and methodological solutions). It has undergone preliminary testing by Selex ES within the project Minerva in collaboration with psychological researchers at the University of Milano-Bicocca. The interdisciplinary approach proposed could contribute to the definition of concrete guidelines that may support future strategic choices and training design activities in the development of VR Proc. of the Int. Conference on Modeling and Applied Simulation 2015, 978-88-97999-59-1; Bruzzone, De Felice, Frydman, Massei, Merkuryev, Solis, Eds. 207 training for military and emergency operators. Future studies will replicate the preliminary test conducted in order to thoroughly investigate the usefulness of this new integrated approach in the design and development of effective VR training. This innovative approach has been tested by Selex ES within the project Minerva in collaboration with psychological researchers at the University of MilanoBicocca and five staff members at the Scuola Interforze di Aerocooperazione di Guidonia. Testing sessions were the first opportunity to give a preliminary demonstration of how academic methods and know-how can be adopted to improve the efficacy of specific VR training scenarios. Each scenario has been evaluated from a multilevel point of view, and in particular: 1) Subjective user’s experience level: interviews, focus groups and the administration of self-report questionnaries (e.g., SUS, STAI-Y1). In particular, the following aspects of the VR experience were evaluated: • Sense of presence (i.e., user’s subjective sensation of “being there” in the scene depicted) (Riva 

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Luciana Aceti

Papers

Virtual Reality Applications for Stress Management Training in the Military.

Developing effective Virtual Reality training for military forces and emergency operators: From technology to human factors