CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING

Volume 14, Number 3, 2011

ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2010.0100

The Role of Immersion and Narrative in Mediated

Presence: The Virtual Hospital Experience

Alessandra Gorini, Ph.D.,1 Claret S. Capideville, Ph.D.,2 Gianluca De Leo, Ph.D.,3

Fabrizia Mantovani, Ph.D.,4 and Giuseppe Riva, Ph.D. 5

Abstract

The ‘‘mediated sense of presence’’ is a technology-induced illusion of being present in one (simulated) place
when one is actually present in another (physical) place. Typically experienced in virtual worlds, mediated
presence is generated by different technological, cognitive, and emotional factors. The aim of this study was to
test how to optimise the virtual experience by manipulating some of these factors. Specifically, we tested if an
immersive technology and/or a meaningful narrative context influence the users’ sense of presence, providing a
more compelling experience than a non-immersive and non-contextualized virtual space. Eighty-four students,
randomly divided into four groups, were asked to find a blood container inside a virtual hospital in an im-
mersive or non-immersive condition and with or without an emotionally related narrative. Two presence ques-
tionnaires and heart-rate variations were used to measure the effects of the four conditions on the users’ sense of
presence. Results showed a significant effect of narrative, F(8, 73) ¼ 30.346, p < 0.001, and level of immersion, F (8,
73) ¼ 10.913, p < 0.001, and a significant interaction between narrative and immersion, F(8, 73) ¼ 2.062, p ¼ 0.05,
both on the presence questionnaires and on the heart-rate variations. Moreover, considering the factors immersion
(I) and narrative (N) together, we found that the I–N condition generated the highest level of presence. We argue
that both immersion and narrative are important in creating an effective virtual reality experience because they
contribute differently to increasing the sense of presence. Immersion increases the place illusion, while the nar-
rative contributes to generating an emotional response and strengthening the subjects’ sense of inner presence.

Introduction user’s movements to the computer that continuously update

the virtual environments according to the user’s point-of-

V irtual Reality (VR) is a computer-simulated environ-

ment where users can explore and interact with an arti-
ficial reality whilst feeling that they are in a place different
view. Being the key element that distinguishes VR from the
other existing media,1 immersion provided by the HMD is
supposed to play an important role in creating a successful
from where they are physically. A VR system is made up of virtual experience.2
hardware, software, a user interface, and human factors such As stated by Dourish,3 VR is a technology that allows
as perceptions, cognition, and emotions. physical and virtual spaces to exist in parallel. But VR cannot
From a technological point of view, VR can be immersive, be considered just as a pure technology.4 VR is also an ex-
where the user interacts with it using a head-mounted dis- periential interface whose contents are three-dimensional
play (HMD) and a tracker position sensor, or non-immersive, environments (virtual worlds) where subjects interact be-
where the HMD is substituted by an external monitor. The tween themselves and with the environment as if they were
HMD is a display device that presents computer-generated really inside it.5 From a psychological point of view, the im-
images to each eye separately, giving the illusion of a three- pression of ‘‘being there’’ has been defined as a ‘‘sense of
dimensional space and depth of field. Worn on the head or as presence.’’6,7 When experienced in a VR setting, it is more pre-
part of a helmet, it covers the user’s eyes, isolating them from cisely termed ‘‘mediated presence,’’ indicating a technology-
the real world. When coupled with a tracker position sensor, induced illusion of being present in one (simulated) place
the HMD also becomes an input device that transmits the when one is actually present in another (physical) place.8

1
Department of Psychology, Istituto Auxologico Italiano, Milan, Italy.
2
Faculty of Communication and Arts, UNA University Centre, Lourdes, Brazil.
3
Virginia Modelling Analysis and Simulation Center, Old Dominion University, Norfolk, Virginia.
4
Dipartimento di Scienze Umane per la Formazione, Facolta’ di Scienze della Formazione, Università degli Studi di Milano-Bicocca, Milan, Italy.
5
Psychology Department, Catholic University of Milan, Milan, Italy.

99
100 GORINI ET AL.

Even if many researches have focused their attention on the hospital and asked to find some blood containers in an im-
concept of mediated presence, we still lack a clear definition mersive or non-immersive modality associated or not to an
of the factors that contribute to generating it. In particular, emotionally narrative context. In particular, we investigated
there are two main theoretical approaches to the definition if: (a) the immersive condition provides a higher sense of
of presence. The first one defines it as a ‘‘perceptual illusion of presence than the non-immersive condition; (b) the im-
non-mediation’’9 produced by means of the disappearance of mersive condition provides a higher emotional response (in
the medium from the conscious attention of the subject. In terms of physiological activation) than the non-immersive
this vision, the ‘‘place illusion,’’ that is, the sensation of being condition; (c) the narrative context increases the sense of
in a real place, is considered the main component that con- presence compared with the non-narrative condition; (d) the
tributes to the realistic response during a virtual experience. narrative context increases the emotional response (in terms
Place illusion is constrained by the sensorimotor con- of physiological activation) experienced in the environment
tingencies afforded by the VR system and is strictly related to compared with the non-narrative condition.
its level of immersion.2
The alternative approach in the definition of presence Materials and Methods
considers it as ‘‘inner presence,’’ a broad psychological phe-
nomenon, not necessarily linked to the experience of a me- Subjects
dium, whose goal is the control of the individual and social Eighty-four undergraduate students (42 males and 42 fe-
activity.7,10–23 This approach considers presence as the result males) between 19 and 25 years old (M ¼ 21.45 years;
of an evolved neuropsychological process,8 influenced by SD ¼ 2.91) participated in the study. All of them were familiar
cognitive and emotional factors, which play a crucial role in with technology and habitually used a computer at least 5
the way we differentiate between the internal and the exter- days a week. They were randomly assigned to one of the
nal, make our subjective judgments, react to the surrounding following experimental groups (see Table 1). Group 1: a vir-
world, attribute a meaning to our experience, and learn things tual hospital was presented to the subjects in an immersive
about it. Technical details, such as system resolution, im- condition associated to an emotionally related narrative (I–N
mersion, speed and kind of interface, as well as the ability of group). Group 2: a virtual hospital was presented to the
the designer, contribute to the quality of the virtual repre- subjects in an immersive condition without the narrative (I–
sentation, but the real author of the virtual experience is the NN group). Group 3: a virtual hospital was presented to the
user, who generates it driving its narrative flow through his/ subjects in a non-immersive condition associated to an emo-
her own cognitive and emotional interpretation of the tionally related narrative (NI–N group). Group 4: a virtual
events.1 When the user is emotionally and intellectually en- hospital was presented to the subjects in a non-immersive
gaged in the experience and perceives a significant sense of condition and without the narrative (NI–NN group).
control over the computer, his/her attention will focus on the Students with a history of neurological disease, head in-
interaction with the environment that generates an illusion of jury, learning disability, psychological disorders, and those
non-mediation, increasing his/her sense of presence.24 A key who used psychotropic medications were excluded from the
element of this process that combines form and content is study. All subjects were volunteers and did not receive any
given by the introduction of narratives in the virtual contexts. payment or credit for their participations. An informed con-
Narratives are stories that users can inhabit from a first- sent was obtained before starting the experiment.
person perspective. They create meaning for the individual’s
experiences, influencing the way people will appraise them,
The virtual hospital
and change the individual’s emotional states, modifying the
way people evaluate the experience. According to Sherman The virtual hospital, developed using the 3D Game Studio
and Craig,1 narratives are responsible for mental immersion, 6 software, was run on a portable computer (Sony Vaio No-
through which users can be deeply engaged and involved in tebook PCG-GRT 996ZP, Pentium 4 3.20 GHz) equipped with
the experience, increasing their sense of mediated presence. a graphic card NVIDIA GeForce FX Go5600 with 3D perfor-
In fact, when users identify themselves with the characters of mance and 64 MB of VRAM. The virtual environment re-
the story, their suspension of disbelief makes the content of presented a two-floor hospital connected by a lift (Figure 1).
the virtual experience seem real. Because emotions have a Many corridors and several rooms were located on each of
very peculiar way of controlling minds and influencing the two floors. A big park and an ambulance parking sur-
people’s actions, motivating learning and exploration be- rounded the hospital. All subjects explored the same envi-
haviors, narratives that attribute an emotional content to the ronment, but those included in the narrative conditions
virtual experience are supposed to contribute to a higher performed the task in the role of a doctor who had to find and
sense of presence and a better interaction with the environ- bring a container with a rare type of blood back to the main
ment than neutral ones.25,26 hospital where a child was waiting for a life-saving transfu-
Starting from these considerations, the aim of this study sion. Moreover, subjects in the narrative conditions were told
was to test experimentally how to optimize the virtual ex- that a mad murderer was wandering around the hospital
perience by manipulating its technological (level of immer- trying to kill them so that they could not reach the blood
sion) and psychological factors (narratives). In particular, we containers needed to save the child (see the Experimental
tested whether an immersive technology and/or a mean- procedure section). Subjects in the non-narrative conditions
ingful narrative context influence the users’ sense of presence, were just asked to find the blood containers exploring the
providing a more compelling experience than a non- virtual hospital, without any other specification that contex-
immersive and non-contextualized virtual space. In order to tualized their task. In order to make the environment in the
test our hypotheses, subjects were presented with a virtual two conditions (narrative and non-narrative) as similar as
IMMERSION AND NARRATIVE IN VIRTUAL REALITY 101

Table 1. Participants’ Distribution Among terms of level of immersion) measured with the ITC-SOPI and
the 4 Experimental Conditions the UCL self-reported questionnaires, and the physiological
emotional response assessed by the heart rate (HR) recording.
Narrative Non-Narrative

Immersive 21 participants 21 participants (I-NN) Presence evaluation

(IN) The dependent variables were assessed using the following
Non-Immersive 21 participants 21 participants (NI-NN) questionnaires:
(NI-N)
 UCL Presence Questionnaire27: a post-experience sub-
jective measure of presence. Participants were required
to provide ratings on a 1–7 Likert scale to the following
possible, they also met the virtual character representing the
questions: Q1 ‘‘ … rate your sense of being in the virtual
mad murderer but without knowing anything about him.
environment’’; Q2 ‘‘To what extent were there times
The environment was presented on an external computer
during the experience when the virtual environment
screen (Onyx-black LCD 16.1" UXGA) with a resolution of
was the reality for you?’’; and Q3 ‘‘When you think back
16001200 in the non-immersive condition, and through a
to the experience, do you think about the virtual envi-
HMD (V-Real Viewer PC) with a resolution of 640480 in the
ronment more as images that you saw or as places that
immersive condition. Participants navigated the environment
you visited?’’
using a joystick (non-immersive condition) or a joystick and
 Independent Television Company Sense of Presence
the motion tracker integrated in the HMD (immersive con-
Inventory (ITC-SOPI)28: this post-exposure presence
dition).
measure is divided in two parts. Part A consists of six
items and refers to the participants’ impressions/feelings
Experimental design
that follow the virtual experience. Part B consists of
The independent variables of the study were: narrative 38 items and refers to the subjects’ impressions/feelings
(exploration with a narrative context vs. exploration without during the virtual experience. A consistent scoring
a narrative context) and immersion (HMD: high degree of mechanism (1–5 point Likert scale ranging from
immersion vs. laptop screen: low degree of immersion). The ‘‘strongly disagree’’ to ‘‘strongly agree’’) is used for both
measured dependent variables were: the sense of presence (in parts. Factor analysis of this 44-item questionnaire

FIG. 1. The virtual hospital: (a) the hospital entrance; (b) the mad murderer wandering about the hospital; (c) the room with
the blood-container refrigerator; (d) one of the hospital rooms.
102 GORINI ET AL.

showed that it measures the following dimensions of variation (HR mean during the exploration of the environ-
presence: (a) spatial presence—how physically present ment minus HR mean at baseline), and the HR values re-
users feel in the virtual environment; (b) engagement— corded when the subjects encountered the mad murderer
how involved users feel toward the content of the vir- (HR-ENC) as dependent variables. Results showed a signifi-
tual environment; (c) ecological validity—the level of cant effect of narrative, F(8, 73) ¼ 30.346, p < 0.001, and level
realism and naturalness of the environment. of immersion, F(8, 73) ¼ 10.913, p < 0.001, and a significant
interaction between narrative and immersion, F(8,73) ¼ 2.062,
As stated by Slater,2 mediated presence is a qualia, and there is
p ¼ 0.051. Analyses of each individual dependent variable are
no way to measure it directly. However, indirect assessments
reported in Table 2. They show that the two narrative groups
based on questionnaires that compare responses with those
(N) and the two immersion (I) groups significantly differed in
that would have been expected in real experiences can be
almost all the analyzed dependent variables except in the
considered the most acceptable indirect measurement of it.
ITC-SOPI item ‘‘Ecological validity’’ (in the N groups) and in
the HR when subjects encountered the mad murderer (in the I
Psychophysiological evaluation groups). The ITC-SOPI and the HR values were also signifi-
The Procomp Infiniti Biofeedback system was used to re- cant in the interaction analysis (narrativeimmersion).
cord the heart rate at the baseline and during the exploration Looking at the mean values calculated in the four experi-
of the virtual hospital. mental groups and reported in Table 3, we notice that in all
the presence questionnaires, the means recorded in the I–N
Experimental procedure condition are the highest values, while the means in the
NI–NN condition are the lowest, except in the ITC-SOPI
Participants were asked to seat in a swivel armchair in Ecological validity item in which the I–N condition is not
front of a laptop screen. At the beginning of the session, they
received one of the two sets of instructions according to the
assigned group. Subjects in the non-narrative (NN) condition Table 2. Statistical Comparisons for Each Individual
were simply told their goal was to find a blood container kept Dependent Variable Measured in the Study
in the hospital refrigerator heedless of the other characters
eventually present in the environment. Subjects in the nar- Condition Dependent Variable df F p
rative (N) condition had the same goal, but it was contextu-
alized in the following narrative: Narrative UCL Q1 1,80 14,222 .000*
UCL Q2 1,80 12,738 .001*
A child has been involved in a car accident in front of the UCL Q3 1,80 21,878 .000*
hospital, and if she does not receive an urgent blood transfu- ITC-SOPI 1,80 15,563 .000*
sion, she will die. You are a doctor and you have to find the Spatial presence
blood containers as soon as possible in order to save the child’s ITC-SOPI 1,80 3,212 .077
life. Be careful, because a very dangerous mad murderer is Ecological
wandering around the hospital trying to kill you before you validity
reach the blood containers needed to save the child. When ITC-SOPI 1,80 17,464 .000*
you find him, run away to prevent him stopping you before Engagement
you find the blood. HR 1,80 20,341 .000*
(exploration - baseline)
Due to its emotional significance, the encounter with the mad HR-ENC 1,80 173,769 .000*
murderer was considered a significant moment of the virtual Immersion UCL Q1 1,80 14,349 .000*
exploration, and was marked during the HR registration UCL Q2 1,80 16,001 .000*
(HR-ENC). UCL Q3 1,80 9,885 .002*
The experiment was divided into two parts. The baseline ITC-SOPI 1,80 19,501 .000*
phase, in which participants were requested to stay com- Spatial presence
pletely relaxed while the HR was recorded for 2 minutes.29,30 ITC-SOPI 1,80 20,075 .000*
Immediately after that, participants read the experiment in- Engagement
ITC-SOPI Ecological 1,80 17,915 .000*
structions and were instructed about the use of the HMD
validity
equipment (if included in the I–N or I–NN groups) and how HR 1,80 4,187 .044*
to explore the virtual environment. The navigation phase, in (exploration - baseline)
which participants explored the virtual hospital until they HR-ENC 1,80 ,040 .841
found the blood containers while their heart-rate variations Narrative  UCL Q1 1,80 ,967 .328
were recorded. At the end of the task, participants completed immersion
the UCL and the ITC-SOPI questionnaires in order to assess UCL Q2 1,80 ,347 .557
the sense of presence elicited by the navigation in the vir- UCL Q3 1,80 2,612 .110
tual environment. Finally, a debriefing phase concluded the ITC-SOPI Spatial presence 1,80 1,199 .277
session. ITC-SOPI Engagement 1,80 ,688 .409
ITC-SOPI 1,80 5,327 .024*
Ecological validity
Results HR 1,80 ,007 .933
(exploration - baseline)
We performed a multivariate analysis of variance (MAN- HR-ENC 1,80 6,491 .013*
OVA) with immersion and narrative as independent factors,
and the three UCL items, the three ITC-SOPI items, the HR *Indicates a statistical significance.
IMMERSION AND NARRATIVE IN VIRTUAL REALITY 103

Table 3. Mean Values Calculated for Each used the HMD showed higher mean scores in all the UCL and
Independent Variable in the Four Experimental Groups ITC-SOPI items. In the immersive condition, characters and
objects, as well as the environment itself, were perceived as
Dependent variable Group (I) Group ( J) Mean SD Sig.
more real, and the experience was judged more interesting
Presence evaluation and involving than in the non-immersive condition. Wearing
UCL Q1 I-N I-N 5.48 1.17 - the HMD, participants felt more present inside the environ-
I-NN 4.76 1.51 .043* ment and believed they could change the events interacting
NI-N 4.48 1.33 .045* with characters and objects more than those in the non-
NI-NN 3.38 1.28 .000* immersive condition. Nevertheless, the level of immersion
UCL Q2 I-N I-N 5.57 1.12 - seems to be not sufficient to alter the subjects’ physiological
I-NN 4.14 1.65 .022* response, probably because it does not really contribute to the
NI-N 3.57 1.50 .009* contextualization of the events, which is a key factor of any
NI-NN 2.95 1.32 .000*
vivid emotional experience.
UCL Q3 I-N I-N 5.81 1.44 -
I-NN 4.19 1.46 .000*
NI-N 3.86 1.99 .006* The role of the narrative
NI-NN 2.67 1.24 .000*
ITC-SOPI I-N I-N 64.09 5.18 - Providing a context to the virtual hospital navigation, the
Spatial I-NN 55.57 9.32 .003* presence of the narrative had a significant effect both on the
presence NI-N 52.52 11.60 .001* presence self-reported questionnaires, and on the heart-rate
NI-NN 46.42 8.55 .000* variations, increasing what has been defined by Waterworth
ITC-SOPI I-N I-N 52.04 3.40 - as the users’ sense of inner presence.8 In particular, compared
Ecological I-NN 47.95 6.93 .256 to those in the non-narrative groups,and regardless the level
validity NI-N 47.23 7.00 .002*
of immersion, participants in the narrative conditions showed
NI-NN 43.33 8.83 .000*
ITC-SOPI I-N I-N 22.47 3.65 - a higher HR variation between the baseline and the virtual
Engagement I-NN 18.71 3.71 .000* exploration, and a higher heart-rate activation when they
NI-N 17.76 4.78 .000* encountered the virtual character representing the mad
NI-NN 15.42 4.69 .000* murderer. These results are consistent with the Healey’s
Psychophysiological theory on emotions,31 affirming that an increase in the heart-
evaluation rate response is an important physiological indicator of
HR I-N I-N 13.18 10.66 - arousal and valence activation. In fact, giving a specific role to
(exploration - the participants—being a doctor that must save a little child
baseline) by finding the blood containers—and attributing negative
I-NN 2.95 6.23 .009*
characteristics to the character found inside the hospital—he
NI-N 9.19 8.62 .438
NI-NN 2.08 2.66 .000* was described as a dangerous mad murderer—significantly
HR-ENC I-N I-N 114.64 10.78 - increased their emotional states. The narrative context leaded
I-NN 83.57 8.48 .000* the two groups of participants (N vs. NN) to a different
NI-N 107.41 12.73 .352 evaluation of the experience and modified their appraisal
NI-NN 86.84 8.25 .000* accordingly.32 In fact, even if all subjects were asked to per-
form exactly the same task (to find the blood containers), only
*Indicates a statistical significance. those in the narrative conditions had a motivation to find
them that gave more relevance to the experience. Similarly,
significantly different from the I–NN group. Regarding the even if all participants found a man inside the hospital, only
HR values, we also notice that the the I–N condition is not those in the narrative condition knew that he was a murderer
significantly different from the NI–N condition, but it is that could stop them reaching their goal. This information
higher than the I–NN and NI–NN both in HR and HR–ENC. caused a significant alteration in their emotional response,
according to Fridja’s theory,33 affirming that the emotion
Discussion elicitation depends on the way people appraise situations.
The only measured variable for which we did not find a
The main goal of the present study was to investigate
significant effect of the narrative was the ICT-SOPI Ecological
which elements enhance the users’ sense of mediated pres-
validity item that measures the level of realism and natural-
ence during a VR experience. To do this, we analyzed the
ness of the environment. This result can be reasonably ex-
contribution of technological (i.e., the physical immersion
plained by the fact that the realism and naturalness of a
through the use of the HMD) and cognitive factors (i.e., the
virtual environment are physical characteristics more related
narrative) during the exploration of a virtual hospital.
to the way in which we perceive the environment than to the
way in which we contextualize it.
The role of immersion
Considering the factors immersion and narrative to-
Consistent with our hypotheses, the results show a sig- gether and combining the four conditions (immersion, non-
nificant influence of physical immersion on all the presence immersion, narrative, non-narrative), we found that the I–N
self-reported questionnaires, suggesting its role in increasing condition is the one that generates the maximum level of
one of the aspects of presence, defined by Slater2 as place mediated presence, both in terms of place illusion and inner
illusion. Compared to those who experienced the virtual en- presence. On the contrary, the condition that produces the
vironment in a non-immersive condition, participants who minimum level of presence is the NI–NN. Given these results,
104 GORINI ET AL.

we argue that both immersion and narrative are important 5. Riva G, Waterworth JA, Waterworth EL. The layers of
features that must be taken into account in order to create an presence: A bio-cultural approach to understanding pres-
effective VR experience because they contribute differently to ence in natural and mediated environments. CyberPsychol-
the theoretical construct defined as ‘‘sense of presence.’’ Im- ogy & Behavior 2004; 7:405–19.
mersion increases the place illusion, that is, the strong illusion 6. Coelho CM, Tichon JG, Hine TJ, et al. (2006) Media presence
of being in a place in spite of the certain knowledge that one is and inner presence: The sense of presence in virtual reality
not there, while a narrative that contextualizes the virtual technologies. In Riva G, Anguera MT, Wiederhold BK,
experience generates an action based and controlled by the Mantovani F (eds). From communication to presence. Am-
subject’s needs, motives, and goals that significantly con- sterdam: IOS Press, pp. 25–45.
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Disclosure Statement
Virtual Environments 2001; 10:266–81.
No competing financial interests exist. 20. Spagnolli A, Gamberini L, Gasparini D. Breakdown analysis
in virtual reality usability evaluation. PsychNology Journal
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