Exploring nursing students’ experiences of normal vaginal delivery simulation using immersive virtual reality (IVR): a qualitative research

Abstract

Background

This study qualitatively explored the feasibility and effectiveness of immersive virtual reality (IVR) simulation as an educational tool to overcome the limitations experienced by nursing students during clinical practice in maternity settings. Many nursing students face restrictions in their practical experiences due to cultural and gender-related barriers in clinical settings, and traditional simulation methods often lack sufficient realism, thus diminishing their educational effectiveness. This study aimed to comprehend nursing students’ perceptions and emotional responses regarding their experiences with IVR natural childbirth simulations.

Methods

We conducted focus group interviews with 30 third-year nursing students and analyzed their IVR simulation experiences using thematic analysis, a qualitative method involving systematic coding and identification of emerging themes.

Results

Three main categories emerged from the thematic analysis as follows: (1) advantages of IVR simulations (four sub-categories: proactive participation, integration of theory and practice, enhanced communication and problem-solving, and learner-centered repetition); (2) unique aspects of IVR learning experiences (two sub-categories: realism and immersion and comprehensive visualization); and (3) areas for improvement in IVR practice (three sub-categories: diverse scenarios, comprehensive evaluations, and enhanced realism through detailed controls). However, the students suggested improvements such as incorporating more diverse scenarios and variables, providing comprehensive evaluation reports for each stage, and enhancing realism through detailed controls.

Conclusions

This study suggests that IVR simulation has significant potential as an innovative educational tool to effectively overcome clinical limitations and enhance nursing students’ readiness for clinical practice.

Background

Clinical practice in maternity wards is an essential component of maternal nursing education, which allows nursing students to gain direct observational and practical experience. However, numerous nursing students encounter difficulties in observing or actively participating in childbirth care during clinical practice. Several factors contribute to this challenge. In Eastern cultures, such as Korea, where Confucianism is prevalent, or in Islamic countries, cultural and religious perspectives frequently lead mothers or guardians to refuse nursing students’ participation or observation, citing privacy concerns. In particular, male nursing students often face strict prohibitions against providing basic nursing care to mothers [1–3]. Furthermore, even when nursing students are allowed access to delivery rooms for clinical practice, it remains practically difficult for them to witness childbirth directly due to the inherent unpredictability of onset and progression [4]. Given that the exact timing of childbirth cannot be predicted accurately, students may frequently miss the opportunity unless they remain continuously available, which is unrealistic in typical clinical practice settings. Consequently, these limitations hinder students’ acquisition of essential clinical knowledge and nursing skills, potentially negatively affecting their future confidence and professional competence.

To overcome these limitations, various educators have sought alternative solutions, primarily through simulation-based education, which refers to the use of structured scenarios and controlled environments to replicate clinical situations for educational purposes [5]. Traditional simulations typically involve role-playing activities, standardized patients, or simple scenario enactments without advanced technological support [6]. Mannequin-based simulations utilize patient simulators to mimic human physiological responses, enabling students to practice clinical procedures [7]. However, mannequin-based simulations and online programs often lack realism, leaving students with the feeling that such activities resemble theoretical rather than practical experiences [8, 9]. Immersive virtual reality (IVR) simulations have emerged as an innovative and safe educational method that enables students to experience childbirth [10]. Compared to traditional simulation methods, IVR has been recognized as more effective in various nursing education contexts, including intravenous catheter insertion [11], extracorporeal membrane oxygenation nursing [12], and nasogastric tube insertion [13] and clinical reasoning and critical thinking development specifically among nursing students [14]. Additionally, VR simulation has demonstrated effectiveness in improving emergency response and patient assessment skills across diverse healthcare learners, including nursing professionals [15, 16]. IVR significantly improves nursing students’ knowledge, confidence, self-efficacy, performance, and technical competence [17–20]. Moreover, IVR allows the unrestricted participation of all students regardless of gender.

The application of IVR simulations offers numerous advantages to educators. Specifically, it has been recognized as an effective instructional method capable of motivating learners and increasing their active participation [21]. A key advantage is the flexibility that provides instructors with the ability to design customized scenarios. When used in maternity nursing simulations, educators can develop diverse childbirth scenarios that allow students to anticipate and experience unexpected clinical situations [22, 23]. Through this process, students are presented with valuable opportunities to actively engage in clinical problems and independently seek effective solutions, highlighting the substantial educational benefits of simulation-based learning.

Therefore, this study aims to understand nursing students’ perceptions and emotional responses regarding their experiences with IVR simulations of natural childbirth. Given the significant clinical training limitations nursing students encounter, particularly in maternity care settings due to cultural and practical barriers, clearly understanding their perceptions and emotional responses to IVR can guide educators in effectively integrating virtual simulations into curricula. Although previous studies have shown general benefits of IVR in nursing education, there remains limited qualitative exploration specifically targeting maternity nursing, and little is known about how IVR influences emotional engagement and professional confidence in childbirth scenarios. By qualitatively analyzing students’ experiences and reflections, this study contributes to the body of knowledge by providing deeper insights into how immersive simulations impact nursing students’ emotional preparedness, clinical confidence, and overall readiness for real-world maternity care. Ultimately, our findings can inform evidence-based strategies for enhancing nursing education through IVR technology, potentially addressing critical gaps in clinical training. This study aimed to investigate nursing students’ experiences with a normal vaginal delivery simulation using IVR. The research question was: “What are nursing students’ experiences with IVR simulation for normal vaginal delivery?”

Methods

Research design

This study employed a qualitative research design utilizing thematic analysis of data gathered through focus group interviews to explore third-year nursing students’ experiences with IVR simulations of normal childbirth.

Thematic analysis was specifically chosen because it aligns well with our research aim—to gain deep insights into students’ perceptions, emotional responses, and subjective experiences with IVR childbirth simulations. This method is particularly suitable for exploring and capturing complex human experiences, as it systematically identifies, analyzes, and interprets meaningful patterns or themes emerging from qualitative data [24, 25].

A key benefit of thematic analysis is its flexibility and ability to produce detailed, nuanced insights into participants’ lived experiences, which quantitative methods often cannot adequately capture. However, thematic analysis also has limitations, including the potential for researcher bias and subjectivity during coding and interpretation.

To address these limitations and enhance trustworthiness, we implemented several strategies. First, two researchers independently analyzed the data and regularly discussed emerging themes to ensure consistency and reduce bias through investigator triangulation. Second, we maintained rigorous documentation throughout the data analysis process, clearly defining and revising themes iteratively.

Additionally, we explicitly acknowledged our positionality as researchers with professional backgrounds in nursing education, which could influence our interpretations. To mitigate this potential bias, we actively engaged in reflexivity throughout the research process, critically reflecting on our personal experiences, professional assumptions, and potential biases. These reflections were documented and regularly discussed within the research team to ensure transparency and rigor in our analysis.

Participants

Participants were third-year male and female university nursing students. Third-year students were specifically chosen because they experience clinical practice in maternity nursing and IVR-based simulation education for the first time in our curriculum; fourth-year students were excluded due to prior experiences, making them unsuitable for the study’s objectives. From an initial pool of 58 students who had completed at least one semester of theoretical maternal nursing education and had participated in both traditional delivery room clinical practice and IVR simulation sessions, 30 volunteered to participate (25 females and five males). The average age was approximately 22.27 years.

Data collection

Participant recruitment was initiated one week prior to the study by posting an announcement on the nursing department bulletin board describing the study. Students who expressed interest after completing their maternal nursing clinical rotations individually contacted the research assistant listed on the recruitment notice to schedule the interviews. Before starting the interviews, detailed explanations were provided regarding the purpose of the study, recording of sessions, data storage duration, and the voluntary nature of participation, including the right to withdraw consent at any time. Written informed consent was obtained from all the participants. Participants were selected specifically from students who had completed maternal nursing coursework in the second semester of 2022, including both traditional clinical practice and IVR simulation sessions. Data were collected between November 1, 2023, and July 30, 2024, exclusively through a series of focus group interviews conducted in a designated meeting room on campus. No individual interviews were conducted. Each group comprised three to four students, with a total of eight groups participating. The interviews were conducted once or twice per group until data saturation was achieved.

The focus group discussions followed a semi-structured format using open-ended questions exploring students’ perceptions of IVR simulations. A full list of these questions is provided in Appendix 1.

Each interview lasted between 25 and 63 min per student. Traditional maternal nursing clinical practice was conducted for 1–2 weeks, including 1 week specifically dedicated to delivery room practice. The IVR simulation session lasted approximately 30–40 min and was conducted separately on the second day of delivery room clinical practice on campus. The IVR simulation program, developed by the principal investigator, covered childbirth stages from the first to the fourth stages of labor. For comparison, the traditional simulation program utilized SimMom, a mannequin-based simulation that primarily focused on nursing care during the first stage of labor, lasting approximately 20–30 min. This limitation occurs mainly due to technical constraints of the mannequin simulator, restricting its capability to realistically portray subsequent stages of labor. After completing the IVR simulation sessions, participants were instructed to write self-reflection notes to facilitate the debriefing process. These notes encouraged students to reflect deeply on their simulation activities, decisions made during practice, gained insights, and areas for improvement. This process was designed to help students internalize and better understand their simulation experiences.

Data analysis

This study employed thematic analysis, as outlined by Kiger and Varpio [26], to identify, analyze, and interpret patterns and themes from qualitative data, aiming to capture the key elements and characteristics emerging from nursing students’ experiences. The analysis procedure was conducted in six stages. In stage one (familiarizing oneself with the data), two researchers independently read and reviewed the data repeatedly, noting initial ideas and patterns. With participants’ consent, the interviews were audio-recorded and transcribed verbatim. Researchers individually immersed themselves in the transcripts and self-reflection notes to understand the overall meaning of the participants’ experiences with IVR simulations. In stage two (generating initial codes), the researchers identified interesting aspects within the data and summarized them into concise codes or specific concepts. Meaningful words and sentences were extracted from the transcripts, coded, and organized by merging related ideas. In stage three (searching for themes), the codes and concepts were grouped to determine whether they could be combined into broader themes. A thematic map was created to visualize the relationships among themes. In stage four (reviewing themes), the researchers reviewed the identified themes to confirm their consistency with the original data and ensure their relevance and meaningfulness. In stage five (defining and naming themes), themes were clearly defined by clarifying their scope, content, and significance and by ensuring interrelationships among themes. The themes were named concisely to represent the data accurately. Finally, in stage six (producing the report), the final stage involved describing the interrelationships between themes and interpreting the results in a meaningful way to reflect the participants’ experiences.

Rigor of the study

To ensure trustworthiness, this study adhered to the four criteria for rigor suggested by Lincoln and Guba [27]: credibility, applicability, consistency, and neutrality. Credibility refers to the extent to which the research findings accurately reflect reality. To ensure credibility, participants capable of adequately expressing the phenomena under investigation were selected. The researchers maintained objectivity and neutrality, fully respecting and striving to understand the participants’ perspectives. The researchers repeatedly reviewed the collected data and held regular meetings to collaboratively discuss and confirm the findings. Applicability refers to the extent to which the findings can be applied to other contexts or groups. To enhance applicability, the researchers provided the participants with detailed explanations of the study and conducted the surveys. Additionally, the results were shared with students who did not participate in the study during the maternal nursing clinical study group meetings to verify their shared understanding and resonance. Consistency involves the reproducibility of the study results in repeated investigations. To ensure consistency, the researchers conducted collaborative discussions throughout the data collection and analysis procedures, striving to achieve consensus and methodological coherence. Neutrality refers to the absence of researcher bias or preconceptions regarding the research process and findings. Before beginning the study, researchers discussed and documented their assumptions, biases, and preconceptions. These reflections were utilized throughout the study as reflexive materials. In addition, the use of traditional thematic analysis techniques facilitated an objective and unbiased interpretation of the collected data, thereby supporting neutrality.

Ethical considerations

To protect the participants ethically, clear information regarding the research objectives, procedures, and methods was posted on the campus bulletin board before initiating the study. The students were explicitly informed that choosing not to participate would not result in any disadvantages. Those interested in participating were instructed to contact the research assistant individually after completing the clinical practice of maternal nursing. Consequently, only nursing students who fully understood the nature of the study and provided voluntary consent were selected as participants. Before data collection, the participants were thoroughly informed about the potential risks, benefits, estimated time commitments, and possibilities of audio recording and subsequent publication. Participants were explicitly informed that their participation involved focus group discussions, and they were instructed not to disclose group discussions or other participants’ identities outside the interview context, ensuring confidentiality among participants. Focus group discussions were conducted in a secure, private meeting room on campus to guarantee participants’ comfort and privacy. Each participant was assigned a unique identification code to ensure confidentiality. All audio-recorded interview data were securely stored on a USB device and personally maintained by the principal investigator in a locked cabinet with double-lock security to prevent unauthorized access. Participants received written assurance that the collected interview data would be used exclusively for academic purposes and would be permanently destroyed upon study completion. Ethical approval for this study was obtained from the Institutional Review Board (IRB) of the authors’ affiliated institutions before commencement (WKIRB-202310-SB-074), and the study was conducted in accordance with the Declaration of Helsinki.

Results

From the interviews conducted with the nursing students who participated in the IVR-based maternity nursing simulations, three main categories and nine subcategories emerged.

Revealed advantages of engaging with VR in maternity nursing practicum

Interviewed nursing students evaluated VR simulations positively, highlighting their various advantages over traditional clinical practices or online-based simulations. Students described how VR allowed them to participate directly and proactively in patient care, enabling the practical integration of theoretical knowledge learned in the classroom, thereby significantly enhancing their clinical competencies. Additionally, they reported improvements in communication and problem-solving skills, as the VR simulation allowed repeated practice of critical clinical situations, thus preparing them effectively for real-world emergencies.

Possibility of direct and proactive participation

Nursing students expressed frustration with traditional clinical practice, noting that clinical rotations often limit them to passive observation. Particularly in specialized environments, such as maternity units, students’ direct involvement in patient care is constrained. However, they appreciated that the virtual environment allowed active, hands-on interventions such as calculating the APGAR scores of newborns and directly administering medications to mothers, both during and after childbirth.

I could directly calculate the newborn’s APGAR scores, provide newborn care after delivery, and perform postpartum interventions for mothers myself. I felt this was much better. (Participant 10)

In real clinical settings, as nursing students, we would only observe from a distance due to patient privacy. But in IVR simulation, we could closely observe anything we wanted and proactively perform nursing care, which was excellent. (Participant 15)

Integration of theoretical knowledge and practical skills in maternity care

Students reported that the VR simulation provided valuable opportunities to practically apply the theoretical concepts learned during lectures, thereby significantly enhancing their clinical skills. Another notable advantage is the continuity of the nursing care provided within the VR environment. In traditional clinical practice, students are limited to eight-hour shifts, which often results in fragmented experiences. In contrast, VR allowed continuous, uninterrupted engagement with one patient, facilitating clearer clinical judgment regarding nursing priorities and systematic practice of the nursing process from beginning to end.

In clinical practice, after finishing my shift, I can’t continue caring for the patient chosen for case study. So, continuity of nursing care is lacking. But in VR simulation, I could provide continuous, comprehensive care for one patient from start to finish. This ensured better judgment of nursing priorities and allowed me to systematically apply procedures learned in class, thus improving my clinical competence. (Participant 28)

Applying theoretical knowledge from classes during VR simulation clarified my understanding of both theory and practice. This experience will help me effectively apply this knowledge during actual maternity nursing clinical practice. (Participant 2)

Improvement of communication and problem-solving abilities

The participants reported that encountering unexpected clinical problems presented through quizzes within VR scenarios significantly enhanced their problem-solving abilities. As they identified and resolved simulated patient issues, they felt that their capacity to solve problems improved independently. Additionally, engaging in simulated communication with patients and other healthcare providers enhanced their communication skills, which they anticipated would greatly assist them in future nursing practice.

During the VR session, we encountered unexpected quizzes highlighting clinical problems. Solving these quizzes helped me develop my problem-solving abilities, as I learned exactly what kind of nursing care was required in specific situations.(Participant 4)

In real clinical practice, I will need to communicate with delivery-room nurses and other related healthcare providers. This experience will be very beneficial because I can recall my VR simulation experience, making communication with patients and other medical staff more effective.(Participant 8)

Possibility of learner-centered repetitive learning

Participants noted that a significant advantage of the VR simulation was the opportunity for repeated practice. They appreciated the ability to repeatedly practice specific critical or complex scenarios at their own pace according to their individual learning needs and preferences. Although emergency situations initially cause anxiety, repeated practice increases familiarity, competence, and confidence.

With real patients, in emergency situations, we would just observe nurses or doctors performing interventions. But in VR, I could actively practice interventions repeatedly, revisiting challenging parts as many times as necessary. This repetition was really helpful. (Participant 7)

When a postpartum hemorrhage occurred, and the mother’s blood pressure dropped dramatically, I initially panicked. However, repeatedly practicing interventions such as uterine massage, reporting to the doctor, and administering oxytocin made the experience unforgettable. Now, I feel prepared and know what to do as a future nurse. (Participant 12)

Unique aspects of VR learning experience

The participants identified the distinct advantages of virtual reality simulation over traditional simulation methods or clinical rotations. They emphasized enhanced realism, improved immersion, and increased learning efficiency through repetitive practice. Specifically, they valued experiencing the entire labor process comprehensively and visually, including the three-dimensional visualization of fetal movements during childbirth.

Enhanced realism and immersive learning experience

Participants reported that VR provided significantly greater realism than traditional mannequin-based simulations or Internet-based programs such as vSim. Unlike Internet-based simulations, in which actions are limited to clicking buttons on a computer screen and imagining subsequent steps, VR allows students to actively immerse themselves in clinical scenarios and interact realistically with virtual patients and medical staff.

In VR simulation, I felt as though I was genuinely part of the situation, which was excellent. On the other hand, vSim, being computer-based, sometimes lacked realism. (Participant 1)

In vSim, we just imagine scenarios and click buttons, which reduces realism. Traditional simulation with mannequins also lacks realism because the patient is merely a doll. However, the moment I put on the VR headset, it was like entering another world. I really felt as though I had become a nurse in a real hospital. (Participant 23)

Comprehensive experience of the entire labor process

The IVR simulation specifically focused on nursing care during normal childbirth. The participants indicated that the ability to observe the seven stages of labor in a three-dimensional virtual reality environment was uniquely advantageous compared to other available programs. Students appreciated the distinctive capability of IVR to visually represent fetal movements and the childbirth process dynamically in real-time, greatly facilitating their understanding of theoretical concepts. Additionally, participants noted that visualizing anatomical structures such as maternal pelvic bones, spinal structures, fetal positions within the pelvis, placental location, and the uterus in 3D significantly enhanced their anatomical comprehension.

In reality, the mother’s internal abdomen isn’t visible, but IVR makes it transparent, allowing detailed observation of fetal movements through all seven stages of labor, which I found particularly unique. (Participant 19)

Being able to visually follow the natural childbirth process was beneficial. Concepts like fetal positioning and pelvic bones taught in class became clearer and easier to understand when experienced firsthand in IVR. (Participant 24).

Aspects needing improvement in IVR practice

Although the participants recognized the multiple strengths and unique advantages of the IVR simulation, several areas were identified as requiring improvement. Specifically, the students suggested including diverse scenarios and additional variables to expand their options and engagement. They also expressed concerns about skipping minor procedural details during the simulation and emphasized the need for comprehensive evaluation feedback following each simulation session.

Need for providing diverse situations and variables

Participants expressed dissatisfaction with the current IVR simulation being limited to only one normal childbirth scenario. They emphasized the need for diverse scenarios involving different patient conditions and complications. The students suggested that incorporating additional algorithms and unexpected variables would further enhance their interest and concentration, ultimately improving their clinical decision-making and nursing competencies in complex situations.

If more variables and scenarios were included, allowing me to think independently about the necessary interventions in varied situations, it would greatly enhance my learning experience. Improvements in this area would be very beneficial. (Participant 10).

I wish additional scenarios were available, similar to vSim, where situations vary based on choices. Experiencing and solving complex scenarios would further improve my nursing competencies. (Participant 14)

Enhancement of realism through detailed control

Participants indicated that although this IVR program was considerably more realistic than online simulations, there were still technical limitations. They noted that certain detailed nursing actions were either simplified or entirely skipped, thereby diminishing the overall sense of realism and immersion. For example, precise nursing procedures requiring aseptic techniques, such as syringe preparation or accurate medication measurements, are difficult to execute realistically within the current system. Additionally, because the entire interaction relied on controllers held in both hands, the participants could not experience the tactile sensation or realistic weight of the objects.

The procedures were somewhat simplified—just touching the item triggered automatic steps, omitting detailed intermediate processes. It felt like it required only physical action rather than actual thinking. (Participant 18)

If we could feel sensations like the injection, I think the immersion would significantly improve. The lack of tactile realism was disappointing. (Participant 27)

Provision of results for comprehensive evaluation of the entire process

The participants expressed a strong desire to receive comprehensive evaluation feedback after completing each IVR simulation, noting that this aspect was currently missing. The simulation program used in this study did not include an integrated assessment system capable of automatically highlighting participants’ errors or providing immediate explanations. Instead, the evaluation depended on manual recordings made by the evaluators during the session. The students suggested implementing an automated evaluation system similar to that used in vSim, which would provide detailed feedback on mistakes, correct answers to quiz questions, and explanatory information upon completion.

While immediate feedback on my mistakes during VR practice was useful, having a comprehensive summary at the end would be more beneficial. For instance, after completing a pediatric vSim session, all my errors are clearly displayed. A similar summarizing feature in VR would significantly improve my learning. (Participant 7)

After completing the scenario, I wanted clear indications of what I did well or poorly. Currently, it ends abruptly without feedback, which was disappointing. (Participant 1)

Discussion

This study’s findings highlight that IVR simulation offers significant supplementary advantages to traditional clinical training and online simulation methods. However, this study does not fully replicate certain tactile sensations critical to clinical practice, such as performing a fundal massage. Nursing students were able to actively and proactively engage in patient care within the IVR environment, making IVR a valuable alternative capable of overcoming the many limitations encountered in clinical settings. In particular, IVR simulations provide an equitable educational approach that is accessible to all students regardless of sex, making it notably beneficial for male nursing students who frequently experience sex inequality due to cultural biases in female-dominated clinical environments [28, 29]. Furthermore, IVR simulations alleviate psychological stress and positively transform the learning experiences of students who face barriers due to cultural influences, such as in Eastern or Islamic cultures, where female patients often refuse participation from male students [4, 28].

Unlike traditional clinical practice, in which nursing students primarily engage in observational roles, IVR allows students to actively perform critical procedures in maternal and neonatal care and to independently formulate nursing care plans. Experiences such as independently calculating APGAR scores and administering medications to mothers facilitated the direct application of classroom knowledge to realistic clinical scenarios, thereby significantly enhancing students’ clinical competencies [30] and self-confidence [31]. These findings align with previous studies [10, 18] that reported IVR’s effectiveness in bridging theoretical and practical knowledge, thereby promoting the development of realistic nursing problem-solving skills. Thus, IVR simulation effectively compensates for limited clinical experience, providing students with learner-centered, active, and practical learning opportunities. Recent studies have demonstrated that IVR significantly enhances nursing students’ clinical competencies, critical thinking skills, and confidence by allowing repeated, self-directed practice in realistic clinical scenarios, effectively supplementing limited clinical exposure [23].

An important finding of this study is that IVR simulation effectively integrates theoretical knowledge with clinical skills, particularly by ensuring clinical continuity. In traditional clinical settings, students experience fragmented patient care due to limited duty hours. Conversely, IVR allows for continuous care experiences [32], enabling students to manage the complete care process for a single patient throughout the labor and postpartum stages. Such experiences significantly aided students in setting clear nursing priorities and systematically implementing the nursing process. These findings support previous research indicating that IVR simulation enhances students’ abilities in clinical judgment and prioritization of nursing care [33, 34]. Our results suggest that IVR is an effective educational strategy for strengthening nursing students’ clinical competencies.

The IVR simulation also positively influenced the improvement of learners’ problem-solving and communication skills. In this study, the students recognized improvements in their problem-solving abilities as they independently identified and resolved various nursing issues and spontaneous quizzes presented within the IVR environment. These findings align with those of previous studies [35, 36], which demonstrated that IVR-based simulations effectively enhance learners’ self-efficacy and confidence by providing opportunities for active and autonomous problem-solving experiences. Moreover, the virtual reality environment provides students with realistic opportunities to engage in active communication with patients and other healthcare providers, thereby enhancing their clinical communication competencies. This finding is consistent with that of Schuelke et al. [33], who reported that IVR simulation environments strengthen students’ clinical judgment skills and enhance the patient-centered communication abilities necessary for clinical practice. Compared to traditional online simulation programs, which typically provide standardized scenarios and limited interactions, IVR distinctly allows educators to create and repeatedly expose students to complex and critical clinical situations, effectively improving their ability to manage these scenarios [37–39]. Thus, IVR simulation is not merely a tool for mastering clinical skills but can also be considered a new strategic approach for comprehensively enhancing nursing students’ clinical reasoning and practical decision-making skills by realistically reflecting the uncertainties and complexities of real-world clinical environments.

The findings of this study not only confirm the effectiveness of the IVR simulation program but also identify three key areas requiring future improvements. First, the participants expressed disappointment that the current IVR simulation scenario was limited to a single clinical case (normal vaginal delivery), which did not adequately provide diverse clinical experiences. This limitation has also been highlighted in previous research, which reported significant improvements in learners’ clinical reasoning and problem-solving abilities when diverse and complex scenarios were included [40, 41]. Doğan et al., (2024) emphasized that scenario diversity and the inclusion of unpredictable variables are crucial factors in enhancing learner engagement and immersion [42]. Therefore, future IVR simulation programs should incorporate diverse clinical situations and complex nursing scenarios to maximize their educational effectiveness.

Second, participants highlighted concerns about the lack of realism in detailed and precise nursing interventions within the IVR environment. In particular, owing to technological limitations, detailed actions such as syringe preparation or medication administration were either simplified or omitted, and the absence of tactile sensations and realistic weights diminished the students’ immersive experiences. These concerns align with the findings reported by Fang et al. [43], who noted that the educational effectiveness of IVR could decrease when the technology does not adequately replicate real clinical environments. Similarly, Lin et al. [44] reported that higher technical realism significantly enhances students’ clinical judgment and confidence, thus emphasizing the importance of developing more sophisticated simulation technologies. Consequently, the results of this study indicate that advanced technological improvements, such as incorporating haptic feedback or precise motion-tracking technologies, are essential for overcoming the current limitations and enhancing the realism of IVR simulations.

Finally, participants expressed dissatisfaction with the absence of comprehensive evaluation and feedback following the IVR simulation exercises. This study clearly revealed students’ strong desire for detailed visual feedback on their performance, including mistakes and areas for improvement, which is consistent with previous literature. Chan et al. [36] emphasized that immediate and specific feedback is crucial to promote self-reflection and improve clinical decision-making among learners. Similarly, Slamon et al. [45] suggested that an effective IVR-based simulation requires a systematic approach for comprehensive evaluation and post-simulation feedback. Therefore, future IVR simulation programs should incorporate automated, detailed evaluation and feedback systems to enable students to accurately assess and continuously improve their clinical performance.

Implications for practice and education

This study provides significant implications for nursing education, particularly within maternity nursing contexts, as follows:

1. Enhanced Clinical Readiness.

   • IVR simulations offer substantial benefits by providing realistic, learner-centered, and risk-free clinical experiences, effectively preparing nursing students for real-world clinical situations and enhancing their clinical competencies and confidence. Consequently, nursing educators should actively integrate IVR into maternity nursing curricula to bridge the gap between theory and practice.

2. Supplementing Limited Clinical Opportunities.

   • IVR addresses common challenges faced in clinical settings, including limited clinical placement availability, privacy concerns, and gender-related restrictions. Nursing programs can strategically use IVR to supplement traditional clinical placements, ensuring consistent and equitable learning opportunities for all students.

3. Curriculum Development and Innovation:

   • The flexibility and realism of IVR technology enable educators to develop diverse and complex childbirth scenarios, improving students’ problem-solving abilities, critical thinking, and clinical judgment. Therefore, nursing faculties should consider ongoing collaboration with technological developers to continuously update and diversify simulation scenarios.

4. Policy and Educational Standards:

   • The findings underscore the importance of integrating IVR into nursing education standards and guidelines, emphasizing evidence-based education. Nursing regulatory bodies and educational institutions should consider these findings when revising educational policies and curricula standards.

5. Future Research Directions:

   • The study identifies specific areas for further improvement of IVR simulations, including enhancing tactile realism, providing diverse clinical scenarios, and incorporating comprehensive assessment feedback. Future studies should explore advanced technologies (e.g., haptic feedback) and evaluate their effectiveness in nursing education outcomes.

Conclusion

This study confirmed that nursing students who participated in IVR simulations of normal vaginal delivery experienced improvements in their clinical skills, confidence, communication abilities, and problem-solving competencies. IVR effectively addresses the limitations associated with traditional clinical practice and online simulation programs, such as reduced realism and restricted student participation. IVR provides an innovative and inclusive educational method that mitigates cultural and sex-related barriers, allowing equitable access to clinical education for all nursing students. Consequently, IVR technology should be actively utilized as a critical educational tool to overcome the constraints in traditional clinical settings, greatly contributing to the development of realistic nursing skills and enhanced clinical judgment among students.

However, this study had several limitations. First, as the study was conducted with nursing students from a single university, the generalizability of the results may be limited. Second, the participants were predominantly female, potentially limiting the representativeness of the experiences of male nursing students. Thirdly, the IVR simulation program involved only a single clinical scenario, thus restricting the assessment of its applicability across diverse clinical situations. Finally, technical limitations in realistically depicting detailed nursing procedures and the absence of an integrated evaluation and feedback system restrict the precise assessment and improvement of student performance.

Appendix 1. Focus group interview guide

• Opening questions.

  1. Can you describe your experiences during clinical practice in the delivery room?
  2. When did you participate in the immersive virtual reality (IVR) childbirth simulation?

• Main questions.

  1. What did you find most beneficial during your immersive virtual reality (IVR) childbirth simulation experience?
  2. What challenges or discomforts did you experience during the immersive virtual reality (IVR) childbirth simulation?
  3. What improvements do you think are necessary to make the immersive virtual reality (IVR) childbirth simulation more effective in the future?
  4. Compared to traditional clinical practice in the actual delivery room, were there any unique experiences or learning outcomes you gained specifically through immersive virtual reality (IVR)? If yes, please explain why.
  5. How do you think the immersive virtual reality (IVR) childbirth simulation influenced your confidence or competencies as a future nurse?
  6. What are your thoughts about continuing to include immersive virtual reality (IVR) childbirth simulation as a regular part of maternity nursing clinical practice education?

Author contributions

SJ- Conceptualization, Methodology, Investigation, Data Curation, Writing- Original draft, Funding Acquisition SL – Methodology, Writing-Review & Editing, Supervision.

Funding

This work was supported by the National Research Foundation of Korea(NRF) grant funded by the Korea government(MSIT)(IRIS RS-2022-NR070028).

Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board (IRB) of Wonkwang University and conducted in accordance with the Declaration of Helsinki, with the approval number WKIRB-202310-SB-074. The researcher personally explained the purpose, procedures, potential benefits, risks, and voluntary nature of the study to all participants. Written informed consent was obtained from all participants prior to data collection. Participants were also informed about anonymity, confidentiality, and their right to withdraw from the study at any time without any disadvantage. Data collection was then conducted with patients who agreed to participate in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.