The influence of augmented gaze on nursing telehealth appointments: an experiment

Introduction

Telehealth in nursing utilizes videoconferencing technologies such as Zoom or Microsoft Teams to provide remote home monitoring, consultation, and patient education (1). Though telehealth nursing was widely implemented before the coronavirus disease 2019 (COVID-19) pandemic, it has become a sustained part of modern nursing practice post-pandemic. Success of telehealth experiences is contingent on nurse practitioners’ abilities to use the technologies effectively (2,3), not just for the function of their job, but also to adapt their communication styles to accommodate the new technology channels (4).

Though there have been several studies about how to effectively complete telehealth visits (1,5,6), little has looked at how to modify the use of the video conferencing software to affect patients’ perceptions of a nurse practitioner. Instead, extant research primarily focuses on logistical and procedural issues, such as how to best prepare for telehealth visits by reviewing relevant medical records beforehand, strategies for protecting patient privacy in a digital environment, and methods for assessing the quality of interactions between patients and providers to ensure effective and satisfactory care (1,5,6). The present study examines a best practice for using video conferencing technology based on where a nurse practitioner’s gaze falls during telehealth visits through the guidance of a communication theory, expectancy violation theory. We present this article in accordance with the CONSORT reporting checklist (available at https://ht.amegroups.com/article/view/10.21037/ht-24-8/rc).

Gaze and telehealth

Since the COVID-19 outbreak, the topic of gaze during telehealth has received some attention in research. Recently, Bavngaard et al. (7) found that patients will look away from the screen during telehealth consults when they need to think deeply about the answer to a provider’s question, and thus providers should not interpret the lack of gaze as distraction. Drawing on experiences delivering telehealth for ophthalmology during the COVID-19 pandemic, a team of providers suggests that patients should ensure their camera is positioned at eye level for telehealth visits, as this positioning makes the view of their face as similar as possible to an in-person visit, thereby facilitating more natural communication and observation opportunities (8). In a synthesis of literature, Gustin (9) recommends that providers should also look directly into an eye-level camera during telehealth visits (rather than offscreen or to a camera not at eye-level) because when patients notice providers looking in a direction other than straightforward, they may perceive that the provider is disengaged.

The guidance of Gustin (9) is echoed by scholarship in communication. Christen and Kelly (10) found that when students were trained to position their webcam at eye level and to look directly into their webcam during an interview, this resulted in better interview assessment by potential employers. Rocker et al. (11) suggested that the observations of Christen and Kelly (10) regarding interview assessment with eye-level webcam positioning and direct camera gaze may be explained in the concept of augmented gaze. In the world of virtual gaming, simulated eye contact by avatars (i.e., augmented gaze) has resulted in heightened engagement and overall better assessment of avatars as communicators (12). As such, Rocker et al. (11) posited that looking into a webcam set at eye level is the closest communicators can come to augmented gaze, or simulated eye contact, during teleconferencing, making the mediated communication experience feel as much as possible like face-to-face.

This study examines how a nurse practitioner’s use of gaze during telehealth visits influences people in two ways. First, this study investigates whether a nurse practitioner who speaks while looking directly at the webcam will be perceived as more credible than looking at the screen. Second, the study investigates whether a nurse practitioner who looks directly at the webcam will have patients with higher attitudes toward telehealth.

Credibility

Credibility is the degree to which a communicator is perceived to be trustworthy, competent, and caring (13,14). Trustworthiness is the extent to which the information conveyed by the communicator is perceived to be accurate. Competence is the extent to which the communicator is perceived to be capable. Caring is the extent to which the audience believes that the communicator cares about their wellbeing.

Although there is a plethora of research on clinical credibility (15), there is little work on credibility of nurses or nurse practitioners as a multidimensional communication construct. The work that does exist looks at the dimensions independently. For example, patients are more satisfied with the care they receive when they perceive that their nurse cares about their wellbeing (16). Studies of nursing competence have primarily focused on best practices (17) and nursing education (18). There seems to be more focus on trust rather than trustworthiness of a nurse. For example, Recio-Saucedo et al.’s (19) review of research on patient trust in nurses found that trust is developed from communication and establishing relationships with patients. Patient trust in nurses is important because trust is necessary to elicit disclosure that allows nurses to fully understand patient needs (20). However, there seems to be less focus on trustworthiness. Although trust and trustworthiness have been used as interchangeable terms in some research, trust is different than trustworthiness: trust is a perception of a message receiver, but trustworthiness is a characteristic of the message sender (21).

Thus, while it is recognized that individually, trustworthiness, caring, and competence play an important role in nursing, there is little research on how nurses or nurse practitioners establish credibility across dimensions, and no research has examined these dimensions of credibility in telenursing. To address this research gap, the study examines the dimensions of credibility that consist of trustworthiness, caring, and competence (13) in a telenursing context. Expectancy violation theory helps explain why gaze may be important during telehealth for some patients.

Expectancy violation theory

Expectancy violation theory explains that changes in attitudes occur when a person’s experiences become misaligned with their expectation (22). Expectations are formed by past experiences related to the new experience, and cognitive dissonance increases as the change in attitudes occurs because expectations are not met for better or worse (23). In the case of telehealth visits, prior experiences with telehealth, video conferencing outside of the telehealth context, and healthcare professionals can all form expectations of how the telehealth visit “should” go. Ho (24) defines attitudes as “the outcome of an individual’s overall evaluation” of a construct. As such, when expectations of a telehealth visit are out of alignment with what a patient anticipated, expectancy violation theory predicts that this will change general attitudes toward such experiences as well as specific attitudes such as the perceived credibility of the provider.

Expectancy violation theory further explains that these mismatches between expectation and experience can be thought of as expectancy violation (22). When there is a positive expectancy violation (i.e., the experience with the construct was better than what was expected), then attitudes become more positive. When there is a negative expectancy violation (i.e., the experience with the construct was worse than what was expected), then attitudes become more negative. Notably, expectancy violation can occur through lived experiences or an observation of the experience, such as watching a video of the experience (25). In short, expectancy violation theory explains that individuals who already have prior telehealth experiences would already have certain expectations for how communication will be different during telehealth than in-person visits, while individuals without prior experience are more likely to experience expectancy violation.

Given the importance of understanding how to foster perceptions of trustworthiness, competence, and caring in nurse-patient relationships, this study examines how a nurse practitioner’s gaze may affect people’s perceptions and experiences. Expectancy violation theory predicts that prior experiences will influence how attitudes toward telehealth or a nurse practitioner may change. Although the use of a confederate actor in experiments can guarantee that no participant will have prior experience with the “nurse practitioner” from a study, participants may have had prior telehealth experiences that affect their expectations of telehealth experiences. This must be accounted for when assessing the influence of gaze on the telehealth experience. Therefore, the following research questions (RQs) are proposed:

RQ1: how do prior experiences with telehealth and a nurse practitioner’s gaze affect perceptions of the nurse practitioner’s credibility (i.e., trustworthiness, caring, and competence)?

RQ2: how do prior experiences with telehealth and a nurse practitioner’s gaze affect attitudes toward telehealth?

Methods

Design and materials

The present study conducted an online experiment employing a two-group (camera gaze vs. other gaze) comparison between-subjects design. To examine the proposed RQs, two videos were developed which provided introductory information of telehealth services from a student health center. First, a script (Appendix 1) was created, and videos were filmed with a university-branded background with a professional camera for high-quality videos. For clarity, the difference between the two group conditions are as follows:

• Camera gaze: in this condition, participants viewed a version of the video in which the webcam was positioned at eye level and the nurse practitioner looked directly at the webcam while speaking.
• Other gaze: in this condition, participants viewed a version of the video in which the webcam was positioned at eye level, but the nurse practitioner looked at the center of her screen while speaking.

The center of the screen was chosen for the other gaze condition because this is where the patient’s face would appear during a telehealth visit, making it a natural focal point. Besides the gaze direction, everything remained the same across the conditions. The videos were approximately 1 minute in length.

An actor (female, White, 38 years old) who is not associated with the university where data collection occurred played the part of the nurse practitioner. The actor memorized the script that would occur at the beginning of a telehealth visit to the student health center. The script was proposed by the researchers after reviewing the information about telehealth services provided on the student health center website. The script was then reviewed by three nurses who provide telehealth care regarding the soundness and believability of the script. The script content was tweaked until all nurses verified it was a believable, natural-sounding script for them to use at the beginning of a telehealth visit.

Procedure

Participants were recruited from undergraduate communication courses, primarily general education, at a large, urban, public university in the U.S. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Institutional Review Board of the University of Central Florida (STUDY00005805). Informed consent was taken from all individual participants. Informed consent was provided in written form, and participants gave consent by proceeding into the study after the information was reviewed.

Upon the approval by a university’s institutional review board, a recruitment message was distributed to undergraduate courses. Interested individuals were invited to click on a study link, which was included in the recruitment message. At the beginning of the study, participants were asked to read and acknowledge the informed consent.

The study consisted of two sections. The first section included a telehealth video. In this section, participants were told that they would watch a clip of a nurse practitioner speaking at the beginning of a telehealth visit at the student health center of their university; then, they were randomly assigned to watch one of the two videos through the Qualtrics random assignment function. After watching the video, participants completed the measures as described in the “Measures” section.

Data cleaning and sample

Initially, a total of 306 individuals responded to the study. Data cleaning was performed to remove respondents who failed an attention check (n=12), had prior telehealth experience with the student health center (n=19), and those who participated more than once (n=17). After the data cleaning, the sample included a total of 258 individuals. There were more females (n=141) than males (n=117), with no participants identifying with a third gender option. The ages were between 18 and 45 years with the average age of 21.82 years [standard deviation (SD) =3.30 years], and the median and the mode of 21 years. A majority of the participants identified as White/Caucasian (n=120), followed by Hispanic or Latino/a/x (n=69), Black/African American (n=50), Asian (n=9), and other racial and ethnic groups (n=10). Regarding class standing, the majority was junior (n=121), followed by senior (n=96), sophomore (n=32), and first year (n=6). Three participants did not identify their class standing. Categorical demographics are summarized in Table 1.

Participants were randomly assigned to one of the two conditions. The following are cell sizes: telehealth experiences in the other gaze condition (n=41), telehealth experiences in the camera gaze condition (n=51), no telehealth experience in the other gaze condition (n=92), and no telehealth experience in the camera gaze condition (n=74).

Measures

The questionnaire contained three subsections. First, as an attention check, participants were asked to identify the color of the nurse practitioner’s scrubs. Second, participants completed assessments of the nurse practitioner’s credibility and attitudes toward telehealth. Third, closed-ended items were presented to capture whether a participant had ever used telehealth services (yes/no), whether the participant had used telehealth services at the health center of the university where data was collected (yes/no), and demographic information.

The three dimensions of credibility were measured with McCroskey and Teven’s (13) assessment. Each submeasure contained six items with 7-point semantic differential response ranges. Reliability scores for the measures were as follows: competence α=0.91, caring α=0.83, and trustworthiness α=0.93.

Attitudes toward telehealth services (α=0.96) were measured with McCroskey and Richmond’s (26) generalized attitude assessment. The assessment is designed so that participants can respond to the items thinking of any referent. In this instance, participants were responding to think of “telehealth”. Responses were obtained on a 7-point semantic differential scale.

Statistical analysis

All authors, one of whom is a psychometrician, analyzed the data independently and came together post-analyses to ensure results were identical as a way a verifying analyses. To test proposed RQs, a series of analysis of variance (ANOVA) tests were performed. Each ANOVA was complemented with a Bonferroni correction which is applied to adjust the significance threshold to account for multiple comparisons, reducing the likelihood of type I errors. This reduces the familywise error rate.

Results

For the perceived competence of a nurse practitioner, neither the main effect of gaze F(1, 254) =0.64, P=0.42, ηp² =0.003, nor telehealth experiences, F(1, 254) =3.76, P=0.054, ηp² =0.015, was found. The interaction effect was not statistically significant either, F(1, 254) =2.66, P=0.10, ηp² =0.01. Through a close examination, a noticeable pattern was observed in the other gaze condition. A Bonferroni correction to the analysis indicated that participants with previous telehealth experiences (mean =6.29, SD =0.78) rated the nurse practitioner to be more competent than participants with no previous telehealth experiences (mean =5.84, SD =1.04), F(1, 254) =6.17, P=0.01, ηp² =0.024. The variance in group means can be seen Figure 1, and output for all analyses is summarized in Table 2.

Figure 1 Competence interaction effect.

Next, another ANOVA was performed on the perceived caring of a nurse practitioner. The results did not find any statistically significant main effect of gaze, F(1, 254) =0.32, P=0.57, ηp² =0.001, nor previous telehealth experiences, F(1, 254) =1.16, P=0.28, ηp² =0.005. There was no interaction effect, F(1, 254) =0.95, P=0.33, ηp² =0.004.

Another ANOVA was conducted on the perceived trustworthiness of the nurse practitioner. There was no statistically significant main effect of gaze, F(1, 254) =1.20, P=0.27, ηp² =0.005. However, the results found a statistically significant effect of telehealth experiences, F(1, 254) =5.19, P=0.02, ηp² =0.02. Specifically, participants with previous telehealth experiences (mean =5.93, SD =1.05) evaluated the nurse practitioner to be more trustworthy than did participants with no previous telehealth experiences (mean =5.63, SD =1.02). Further examination through a Bonferroni correction revealed that this difference is particularly evident in the other gaze condition. Participants with previous telehealth experiences (mean =6.10, SD =0.94) rated the nurse practitioner to be more trustworthy than participants with no previous telehealth experiences (mean =5.63, SD =0.99), F(1, 254) =6.05, P=0.01, ηp² =0.023. See Figure 2 for a visualization of the difference in group means. There was no interaction effect, F(1, 254) =1.58, P=0.21, ηp² =0.006.

Figure 2 Trust interaction effect.

The last ANOVA was conducted regarding attitudes toward telehealth services. There was no main effect of gaze, F(1, 254) =0.48, P=0.49, ηp² =0.002. However, the results found a statistically significant effect of telehealth experiences, F(1, 254) =6.66, P=0.01, ηp² =0.026. Participants with previous telehealth experiences (mean =6.00, SD =1.09) perceived telehealth services more favorably than did participants with no previous telehealth experiences (mean =5.63, SD =1.17). Especially, Bonferroni correction revealed that in the other gaze condition, F(1, 254) =6.91, P=0.009, ηp² =0.026, participants with previous telehealth experiences (mean =6.16, SD =0.99) perceived telehealth service more positively than did participants with no previous telehealth experiences (mean =5.59, SD =1.11). See Figure 3 for a visualization of the difference in group means.

Figure 3 AttiTele interaction effect. AttiTele, attitude towards telehealth.

Discussion

The purpose of this study was to determine the importance of nurse practitioners’ gaze during telehealth visits. While telehealth is not new to nursing care, there are few studies that investigate the nuances of how nurse practitioners can adapt their communication through video conferencing technology to provide better care. The overall results of this study indicate that gazing directly into the webcam during telehealth should be a best practice.

One of the core findings of the study suggests that gazing directly into the webcam is particularly important among patients who are new to telehealth services. The study finds that participants who had prior experiences using telehealth felt the nurse practitioner was more trustworthy than those who did not; yet the difference is most manifested in the condition in which the nurse practitioner did not look at the webcam. Post-hoc analyses also revealed this pattern for perceived competence as well. Further, participants who had no prior telehealth experiences had less favorable attitudes toward telehealth than those with prior experience; yet this difference was most present when the nurse practitioner did not look at the webcam. This means that for those who had no prior telehealth experiences, their perceived trustworthiness and competence of a nurse practitioner, as well as their attitude towards telehealth, were negatively affected by the nurse practitioner’s failure to gaze directly at the webcam.

One of the primary explanations for such findings is related to expectancy violation (22). If someone had only in-person healthcare experiences, their expectations for the telehealth provider will be solely based on their previous in-person experiences. That is, these patients might be expecting a diverse range of communication cues from their healthcare provider as their previous interactions are solely based on face-to-face interactions that provide considerable cues (verbal, nonverbal). However, when these patients see their provider in a mediated context, their expectations might be violated as mediated interactions limit many of the nonverbal cues, including lack of strong eye contact. As such, although a healthcare professional may provide competent care, this may not satisfy patients who expect more direct nonverbal cues during healthcare visits. As the data imply, after the first visit, patients may adjust their expectations.

The study also found that, in general, those with prior telehealth experiences perceived the nurse practitioner to be more trustworthy and competent and had more favorable attitudes toward telehealth than those without prior telehealth experiences. This is particularly noteworthy, because it means that the nurse practitioner’s failure to look at the webcam was not detrimental to patients’ perceived trustworthiness or competence of a nurse practitioner and attitudes towards telehealth for those who had prior experiences. Those who had prior experience with telehealth perceived the nurse practitioner to be competent and trustworthy regardless of gaze condition. This indicates that there is a very different expectancy violation happening for those who have prior telehealth experience and those who do not. Gaze simply matters less when other expectations of telehealth are familiar. Just as Bavngaard et al. (7) found that patients’ lack of gaze did not mean lack of engagement, it is possible that patients may learn that weak eye contact does not mean that the healthcare provider is not performing their job well in the mediated context. In fact, this perspective is in line with social information processing theory (27), which argues that technology-mediated communication can be as effective as face-to-face communication over time. As such, it is possible that patients who have prior experiences of telehealth visits may have established how they may effectively communicate with a provider in a mediated context. To test this conjecture, this study calls for follow-up research.

While it is important to discuss the statistically significant findings of a study, it is also important to note those that are not statistically significant. This study found that neither independent variable (i.e., gaze or prior experience) influenced participant’s perceptions of how much the nurse practitioner cared. This means that other variables unaccounted for in this study must explain how much a patient perceives a telehealth nurse practitioner care. To better understand the possible factors that may directly influence the way patients perceive caring of their telehealth nurse practitioner, the study again calls for follow-up research.

Overall, the study contributes to expanding the body of literature on telehealth from a communication perspective. While research on clinical credibility is well established (15), relatively little has examined credibility of a provider as a multidimensional communication construct. Also, the study’s approach to understanding “trustworthiness” of a nurse practitioner rather than “trust”, provides better understanding of how patients describe a nurse practitioner (sender of a message), rather than the mental state of a patient (receiver of a message). This approach ultimately contributes to distinguishing trustworthiness from trust, which are related but different constructs (21).

Implications for practice

The practical finding of this study is that, for first time telehealth patients, gaze matters. For first time users, the amount of trustworthiness and competence they perceive in their nurse practitioner and their attitudes toward telehealth will be damaged by a nurse practitioners’ failure to look at the webcam. As gazing into the webcam can positively influence telehealth experiences for first-time users, it should be incorporated into telehealth training and can be used as an overall best practice, but must be used as a best practice for new telehealth patients. This means that, consistent with the call of Gustin (9), training nurse practitioners to gaze directly into their webcam when speaking should be part of telehealth training. If they cannot gaze directly into their webcam due to reviewing records on screen, then they need to inform the patients why they appear to be looking away so as not to lower their trustiness and competence as well as patients’ attitudes toward telehealth.

Limitations and future research directions

This study acknowledges a few limitations that should be addressed in future research. First, the findings might be limited to the age group of college students who participated in this study. Although college-age individuals make up a substantial portion of the population, the limited range of age and potential similarity in health literacy and technology efficacy may have played a role in the pattern of the findings. Considering that the use of telehealth services may continue to grow and be a primary service to all age groups, future research should strive to replicate this finding using other age groups.

Second, the stimulus video was rather short compared to a full appointment. During the actual telehealth visits, it is more likely that patients spend several minutes with their provider. Although their first minute of interaction with the provider will establish first impressions, it is possible that patients’ perceptions may change as they communicate for a considerable amount of time during the visit. In this regard, future researchers are encouraged to employ a stimulus that may be similar to the actual visit in length.

Third, the induction material was limited to an actor playing the role of a nurse practitioner. While it is likely that gazing directly into the camera is a good practice for all providers during telehealth as posited by Gustin (9), this data can only speak to nursing. Researchers who have access to other healthcare professionals who can review the script for authenticity should consider replicating this study.

Fourth, there are many additional credibility factors that future research may wish to explore when considering the impact of gaze on telehealth. In particular, the title of the confederate as “nurse practitioner” rather than “nurse” may have given credibility and forgiveness for lack of augmented gaze that a provider with less credentials may have received. Likewise, a provider with a label of “doctor” may receive other forgiveness or be held to other expectations. The effect of rank should be explored in future research. Likewise, the role of provider experiences also should be considered. It would be useful to see if providing information upfront about providers’ years of experiences may alter expectations of the telehealth experience for patients. Future research is needed to explore these avenues.

Finally, the results of the ANOVAs found evidence of a nurse practitioner’s gaze affecting participants only through post-hoc analyses. While ANOVA is more prone to type II statistical error, post-hoc analyses are more prone to type I statistical error. Replication work of this study is needed to see if the finding is an artifact of this sample resulting in type 1 error or a generalizable claim.

Conclusions

The results of this study indicate that prior experiences with telehealth predict whether gaze will affect patients’ perceptions of a nurse practitioner and attitudes toward telehealth services. For recurring telehealth patients, gaze may not have a direct impact on their attitudes or perceived trustworthiness or competence of the nurse practitioner. However, for first-time telehealth patients whose expectations are established through prior in-person experience, seeing this communication skill in their nurse practitioner matters. As such, gaze is an important communication skill for telehealth nurse practitioners to practice.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://ht.amegroups.com/article/view/10.21037/ht-24-8/rc

Data Sharing Statement: Available at https://ht.amegroups.com/article/view/10.21037/ht-24-8/dss

Peer Review File: Available at https://ht.amegroups.com/article/view/10.21037/ht-24-8/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ht.amegroups.com/article/view/10.21037/ht-24-8/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Institutional Review Board of the University of Central Florida (STUDY00005805). Informed consent was taken from all individual participants. Informed consent was provided in written form, and participants gave consent by proceeding into the study after the information was reviewed.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Rutledge CM, Gustin T. Preparing nurses for roles in telehealth: now is the time! Online J Issues Nurs 2021; [Crossref]
2. Koivunen M, Saranto K. Nursing professionals' experiences of the facilitators and barriers to the use of telehealth applications: a systematic review of qualitative studies. Scand J Caring Sci 2018;32:24-44. [PubMed]
3. van Houwelingen CT, Moerman AH, Ettema RG, et al. Competencies required for nursing telehealth activities: A Delphi-study. Nurse Educ Today 2016;39:50-62. [PubMed]
4. Barbosa IA, Silva MJPD. Nursing care by telehealth: what is the influence of distance on communication? Rev Bras Enferm 2017;70:928-34. [PubMed]
5. Balestra M. Telehealth and legal implications for nurse practitioners. J Nurse Pract 2018;14:33-9.
6. Tyson RL, Brammer S, McIntosh D. Telehealth in Psychiatric Nursing Education: Lessons From the Field. J Am Psychiatr Nurses Assoc 2019;25:266-71. [Crossref] [PubMed]
7. Bavngaard MV, Lüchau EC, Hvidt EA, et al. Exploring patient participation during video consultations: A qualitative study. Digit Health 2023;9:20552076231180682. [Crossref] [PubMed]
8. Bowe T, Hunter DG, Mantagos IS, et al. Virtual Visits in Ophthalmology: Timely Advice for Implementation During the COVID-19 Public Health Crisis. Telemed J E Health 2020;26:1113-7. [Crossref] [PubMed]
9. Gustin T. Telemedicine etiquette. In: Atanda A Jr, Lovejoy JF III. editors. Telemedicine in Orthopedic Surgery and Sports Medicine: Development and Implementation in Practice. Cham: Springer International Publishing; 2020:65-80.
10. Christen S, Kelly S. Preparing students for online interviews. Bus Educ Forum 2018;73:4-6.
11. Rocker KT, Bell C, Kelly S. Online interviews. In: Kelly S. editor. Computer-mediated communication for business: Theory to practice. Newcastle upon Tyne: Cambridge Scholars Publishing; 2019:111-9.
12. Bailenson JN, Beall AC, Loomis J, et al. Transformed social interaction, augmented gaze, and social influence in immersive virtual environments. Hum Commun Res 2005;31:511-37. [Crossref]
13. McCroskey JC, Teven JJ. Goodwill: A reexamination of the construct and its measurement. Commun Monogr 1999;66:90-103. [Crossref]
14. Teven JJ, Katt J. Instructor credibility. In: Witt P. editor. Communication and learning. Berlin, Boston: De Gruyter Mouton; 2016.
15. Cardwell R, McKenna L, Davis J, et al. How is clinical credibility defined in nursing? A concept mapping study. J Clin Nurs 2021;30:2441-52. [Crossref] [PubMed]
16. King BM, Linette D, Donohue-Smith M, et al. Relationship Between Perceived Nurse Caring and Patient Satisfaction in Patients in a Psychiatric Acute Care Setting. J Psychosoc Nurs Ment Health Serv 2019;57:29-38. [Crossref] [PubMed]
17. Gillespie BM, Polit DF, Chaboyer W. The influence of personal characteristics on perioperative nurses' perceived competence: implications for workforce planning. Aust J Adv Nurs 2013;30:14-25. [Crossref]
18. Roh YS, Issenberg SB, Chung HS, et al. A survey of nurses' perceived competence and educational needs in performing resuscitation. J Contin Educ Nurs 2013;44:230-6. [Crossref] [PubMed]
19. Recio-Saucedo A, Dall'Ora C, Maruotti A, et al. What impact does nursing care left undone have on patient outcomes? Review of the literature. J Clin Nurs 2018;27:2248-59. [Crossref] [PubMed]
20. Rørtveit K, Hansen BS, Leiknes I, et al. Patients' experiences of trust in the patient-nurse relationship-a systematic review of qualitative studies. Open J Nurs 2015;5:195-209. [Crossref]
21. Weidmüller L. Human, hybrid, or machine?: Exploring the trustworthiness of voice-based assistants. Hum-Mach Commun 2022;4:85-110. [Crossref]
22. Burgoon J. Nonverbal violations expectations. In: Wiemann JM, Harrison RR. editors. Nonverbal interactions. Sage; 1983:53-69.
23. Harmon-Jones E, Mills J. An introduction to cognitive dissonance theory and an overview of current perspectives on the theory. In: Harmon-Jones E. editor. Cognitive dissonance: Reexamining a pivotal theory in psychology. 2nd ed. Washington: American Psychological Association; 2019:3-24.
24. Ho CH. Continuance intention of e-learning platform: Toward an integrated model. Int J Electron Bus Manag 2010;8:206-15.
25. Claure H, Khojasteh N, Tennent H, et al. Using expectancy violations theory to understand robot touch interpretation. In: Companion of the 2020 ACM/IEEE International Conference on Human-Robot Interaction. 2020:163-5.
26. McCroskey JC, Richmond VP. Bipolar scales. In: Emmert P, Barker LL. editors. Measurement of communication behavior. London: Longman Publishing Group; 1989;154-67.
27. Walther JB. Computer-mediated communication: Impersonal, interpersonal, and hyperpersonal interaction. Commun Res 1996;23:3-43. [Crossref]