An innovative immersive learning program for healthcare communication training

Abstract

Objective

This study aims to develop and evaluate an Immersive Learning (IL) to enhance healthcare communication skills training.

Methods

The IL consisted of a digital tool using a branching scenario model for six clinical themes with feedback provided to students at each critical point. A pre-post-trial design was conducted comparing the IL program against traditional role-playing exercises at Brussels University. Third year physiotherapy students were randomly assigned to an experimental IL group or a control group. Outcomes measures included students' self-perceived communication skills, satisfaction with the IL as well as its usability. Statistical analyses included Wilcoxon tests for skill progression.

Results

The IL group showed significantly improved self-perceived communication skills compared to the control group (p ≤0.001). Students considered IL program to be highly usable (satisfaction = 82) and strongly recommended its use (NP score = 63.83).

Conclusion

The IL program enhanced students' self-perceived communication skills, offering a supportive, engaging, and safe learning environment. IL is a valuable complement to traditional methods in healthcare education.

Innovation

This study introduces an innovative IL tool that provides personalized, interactive, and scenario-based learning, fostering autonomy and skill development in a low-pressure environment.

Graphical abstract

Highlights

• •Immersive Learning (IL) Enhances Communication Skills: The integration of IL, significantly improves students' self-perceived communication skills.
• •Psychologically Safe Learning Environment: IL creates a environment where students can repeatedly practice without fear of judgment, encouraging confidence and autonomy.
• •High Usability and Satisfaction: The IL program received positive feedback from students, with high scores on both the System Usability Scale and the Net Promoter Score.

1. Introduction

Mastery of communication skills is particularly critical for healthcare providers, especially when navigating challenging clinical encounters [1]. High-quality communication depends on specific theoretical and practical knowledge, which requires targeted learning. Health care students are first expected to acquire conditional and procedural knowledge that are encapsulated before applying skills in simulated or real contexts of practice. Indeed, an important first step for learning a social skill is the acquisition of conceptional, conditional and procedural knowledge, which is then encapsulated to the application of skills [2]. Communication skills are thought to be controlled by psychological mechanisms incorporating cognitive schemata or scripts for action that help construct interpretations of situations [3]. In 1990, George Miller, a foundational figure in modern medical education, developed a pyramidal model of professional competencies. This model categorizes learning outcomes into several levels: at the base lies theoretical knowledge, followed by demonstration of practical skills (knows hows), performance (does), and at the top, the integration of these elements in real-life contexts (action) [4]. Kurtz et al. [5] described various teaching methods based on Miller's model to help health care students and professionals develop appropriate communication skills, fostering the acquisition of specific competencies. These methods emphasize experiential learning to move learners beyond knowledge. In class-room settings, they include small group discussions, video observations, and role plays (with or without simulated patients). Within this context, simulation-based training has been highlighted as an essential approach for developing communication skills, as it allows students to engage in realistic scenarios within a controlled environment, thereby promoting experiential learning [6]. Additionally, the use of virtual patients has been recognized as an effective way to enhance interprofessional communication and prepare students for real-world encounters [7]. These methods align with the third level of Miller's pyramid (how to), where showing how to apply learned skills is settings mimicking real practice is key. Simulation offers learners a safe environment to practice their skills while replicating clinical reality, with feedback enabling them to refine their actions over time. Through realistic, interactive scenarios, simulation fosters skill exploration, feedback-driven improvement, and increases learner confidence in real-world applications [8].

Simultaneously, in recent years, the growing number of healthcare students has made it more challenging to implement individualized practical teaching, as described by Kurtz et al. [5] and Miller [4]. For this reason, and spurred by the COVID-19 pandemic, e-learning has expanded significantly in the medical field, introducing new perspectives in educational methodologies. E-learning typically relies on digital resources, such as videos, quizzes, online courses, or forums, enabling learners to access content asynchronously, flexibly, and independently [9]. However, interactions are often limited to content review, module completion, or exchanges with instructors via online platforms, which restricts these methods primarily to the lower levels of Miller's pyramid. Immersive learning (IL), an advanced form of e-learning, appears more suitable for acquiring clinical skills as it places learners in realistic virtual environments [10], effectively extending traditional simulation. Immersive learning refers to an educational approach that utilizes advanced technologies, including virtual reality (VR), augmented reality (AR), and interactive simulations, to create an engaging and immersive learning environment. [11]. What distinguishes IL from traditional simulation-based methods is its flexibility: students can engage with immersive content at their own pace, fostering autonomy and supporting personalized learning [12]. This method allows students to repeatedly practice clinical scenarios in a low-stakes setting, where they can make mistakes and learn from them without the pressures of real-time patient care, thereby creating a psychologically safe learning environment [13].

Accumulating evidence suggests that IL is an effective approach in medical education, particularly in fostering the acquisition of technical skills in medicine [14], nursing but also in physiotherapy [15]. Recent evidence indicates that, alongside the emergence of patient-centered care and pedagogical strategies aimed at strengthening relational competencies, IL has been also evaluated as a means of enhancing empathy and communication skills among students, particularly in medicine and physiotherapy [16,17]. Other studies highlight IL's positive effects on student satisfaction and motivation [12,13] as well as their self-confidence, especially in managing complex patient interactions [[18], [19], [20]].

In summary, IL represents a significant innovation in healthcare education by fostering an interactive, flexible, and safe learning environment that enables students to engage closely with clinical realities. It promotes autonomy and self-regulated learning while helping students develop essential communication skills, such as empathy, along with confidence-key attributes for successful healthcare professionals.

However, despite these immersive methods' efforts to closely approximate reality, we are unware of health care communication related IL replicating scenarios in which learners must make real-time decisions at critical communication junctures, with outcomes that vary based on the timing of their responses. This narrative structure, in fact, enhances learner engagement and enables critical reflection on the consequences of their choices, as occurs in branching scenarios who is an interactive pedagogical approach in which learners are required to make decisions at critical junctures within a simulation or immersive environment. Each decision leads to distinct outcomes and generates immediate feedback, thereby shaping a personalized and adaptive learning pathway [21]. While branching scenarios in an immersive learning context have been implemented for technical decision-making, they have not yet been applied to communication-based situations [22].

In light of the absence of such educational programs in the field of professional communication training in healthcare, this study aims to: (1) present the methodological process that led to the development of a six-scenario immersive learning program using a branching scenario model focused on professional healthcare communication; and (2) report the initial validation results of the program.

2. Methods

2.1. IL development

To develop the interactive branching scenarios, we first established a multidisciplinary steering committee composed of a professor of health psychology specializing in professional healthcare communication (project lead), a pedagogue, an educational technologist, healthcare professionals with expertise in the selected themes (physicians, nurses, and physiotherapists), two healthcare students, and an expert patient.

Six themes related to professional healthcare communication were selected: initiating the consultation, motivational interviewing, managing angry patients, delivering bad news, referring a patient to a psychologist, and managing hope and uncertainty in the context of advanced illness. All students were exposed to these six scenarios.

Each scenario included between three and five branching points, where learners were required to make communication-related decisions at key moments. Storytelling was a central element of the instructional design, providing realistic clinical narratives—based on actual clinical experiences—in which students could become immersed. The branching structure allowed learners to experience how different communication choices influenced the progression of the scenario and the quality of the therapeutic relationship. As described by Bateman [23], branching scenarios can be designed in various formats, including linear (a), rubber band (b), parallel (c), threaded (d), and nodded (e) configurations (Fig. 1). We choose the format b and c for our project.

Fig. 1.

Narration designs, linear (a), rubber band (b), parallel (c), threaded (d) and nodded (e) adapted from Bateman [19].

All narrative pathways were scripted and filmed with professional actors. The interactive content was then assembled using the H5P platform (H5P: Interactive content made easy), (Fig. 2). When a suboptimal choice was made, the learner could continue the scenario but was required to adjust their communication strategy in order to restore the therapeutic alliance with the patient. To determine whether a given response was optimal or suboptimal, each scenario was analyzed using established theoretical frameworks in healthcare communication, selected according to the theme addressed. These included the Calgary-Cambridge guide, the principles of motivational interviewing, the SPIKES protocol for breaking bad news, among others [[24], [25], [26], [27]]. The categorization of the branching options presented to students was initially proposed by the program initiator (JF), then reviewed and refined through consensus by the steering committee. The feedback provided to students was explicitly grounded in these theoretical models and aimed to support critical reflection rooted in evidence-based healthcare communication practices (Fig. 3).

Fig. 2.

Example of video-based interaction.

Fig. 3.

example of feed-back (translated in English, initial version in French).

2.2. Study design and setting

To validate the digital immersive learning (IL) program designed to enhance healthcare communication skills, we conducted a two-arm pre-post study in which the six IL scenarios were directly compared to a traditional role-playing intervention. The role-playing group engaged in structured peer-to-peer interactions as well as human simulations with standardized patients. Validation was based on a comparative analysis of students' self-perceived communication skills, measured through questionnaires administered before and after the intervention in both groups. This comparative design served as the basis for evaluating the pedagogical relevance and functional validity of the IL program among third-year physical therapy students. We enrolled all eligible individuals who provided consent to participate in the study. Although no formal sample size was calculated, the objective was to enroll as many participants as possible within the study time frame. Indeed, participation in the communication program was mandatory for the students, as it constituted a required component of their academic credits. However, participation in the study was voluntary, and students were informed that they could decline to participate by choosing not to complete the questionnaires. Participants who decided to take part provided informed consent.

2.3. Setting and participants

This study was conducted at the Faculty of Human Movement Sciences of the Université Libre de Bruxelles, which includes a four-year physical therapy curriculum. All third-year students who attended the communication program were invited to participate in the study. The communication program is designed for all third-year students with the aim of preparing them for clinical placements in their fourth year. This is a one-year program consisting of 18 h of theoretical content delivered in lecture format and 10 h of practical exercises. To conduct our study, at the beginning of the year, students were allocated to either the immersive learning (IL) or control group (CT) using computer-generated simple randomization. Assignments were communicated individually by email. This method was deemed appropriate given the study's exploratory design and limited sample size.

Students in the experimental group (IL) followed a learning pathway that began with theoretical instruction, continued with immersive learning resources (6 scenarios, approximately 6H), and concluded with practical exercises, 4 h of role-playing and 2 h of actor-based simulation. Students in the control group (CT) also completed the full pathway but in a different sequence, with immersive learning resources provided last, following the 4 h of role-playing and the 2 h of actors-based simulation. This design allows for a distinct evaluation and comparison of the effects of the two practical approaches. At the end of the study both groups were given access to the full program. The IL group then completed 4 h of role-playing and 2 h simulation, while the CT group used the immersive learning (IL) program, ensuring that all students received the same type of training in their curriculum.

2.4. Evaluation

2.4.1. Outcome measures

To evaluate the impact of the IL on students using three dimensions:

• •Self-perceived communication skills (SPCS): The communication skills were formulated based on the Calgary-Cambridge Guide [24]. Each item was rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating better self-perceived communication skills. The 16 items covered various aspects of communication skills, including « using open-ended questions appropriately », « rephrasing what has been expressed by the patient », etc.… (Table 1). The self-assessment questionnaire was administered electronically, and participants were instructed to rate their own communication skills based on their self-perceptions.
• •Satisfaction Dimension: This was evaluated using the Net Promoter Score (NPS) [28]. The NPS is a score which can be used to measure student satisfaction regarding a learning program [29]. It includes a single question posed to the users of the program: “How likely are you to recommend this program to a health care student needing to improve their communication skills?” The respondent rates this probability on a scale from 0 (not at all likely) to 10 (highly likely). Based on their score, the respondent is categorized into one of three groups: Promoters (score of 9 or 10), Passives (score of 7 or 8), Detractors (score of 0 to 6). To calculate the NPS score, the first step is to convert the number of responses in each category into a percentage. Passives are included in the total number of respondents. Then, the percentage of detractors is subtracted from the percentage of promoters. This yields a result between −100 (if all your students are detractors) and + 100 (maximum number of student promoters).

• •Usability Dimension: Usability was assessed using the System Usability Scale (SUS). It includes ten items Likert scale (0 to 5) that give a global view of usability using subjective assessments [30]. The System Usability Scale (SUS) score is calculated by assigning a rating from 0 to 4 for odd-numbered questions (subtracting 1) and from 0 to 4 for even-numbered questions (subtracting the rating from 5), then multiplying the total score by 2.5 to obtain a final score ranging from 0 to 100. The SUS score ranges from 0 to 100 but does not represent a percentage. It's a standardized calculation method.

Table 1.

Participants' self-perceived skills in communicating with their patients before and after IL intervention for Il group compared to Control Group (role play) (5-item Likert scale: 1 = not at all, 5 = totally).

Communication item	IL T1	IL T2	IL Δ	IL p-value	CT T1	CT T2	CT Δ	CT p-value
Asking open questions when appropriate	3.66	4.08	0.42	<0.001**	3.79	3.59	−0.2	0.088
Asking closed questions when appropriate	3.63	3.94	0.31	0.013**	3.59	3.95	0.36	0.003**
Using open or closed questions judiciously	3.32	3.83	0.51	<0.001**	3.46	3.81	0.35	0.005**
Actively listening to the patient	3.98	4.47	0.49	<0.001**	4.34	4.28	−0.06	0.627
Tactfully interrupting the patient if necessary	3.09	3.6	0.51	<0.001**	3.53	3.32	−0.21	0.207
Identifying verbal cues to respond	3.43	4.05	0.62	<0.001**	3.53	3.61	0.08	0.485
Using appropriate vocabulary	3.52	3.97	0.45	<0.001**	3.89	3.79	−0.1	0.341
Being attentive and fully dedicated	4.11	4.49	0.38	<0.001**	4.4	4.36	−0.04	0.598
Identifying when to use reflective listening	3.21	4.22	1.01	<0.001**	3.12	4.02	0.9	<0.001**
Showing empathy	3.95	4.16	0.21	0.008**	4.0	4.0	0.0	0.855
Progressing from one section to another	3.57	4.29	0.72	<0.001**	3.91	4.0	0.09	0.511
Attending to non-verbal communication	3.69	4.29	0.6	<0.001**	3.89	3.91	0.02	0.255
Periodically summarizing patient's statements	3.39	4.38	0.99	<0.001**	3.81	3.91	0.1	0.417
Rephrasing for mutual understanding	3.53	4.4	0.87	<0.001**	3.91	3.93	0.02	0.886
Asking questions to check understanding	3.63	4.09	0.46	<0.001**	3.81	3.85	0.04	0.743
Involving the patient in care planning	3.73	4.23	0.5	<0.001**	4.12	4.28	0.16	0.073

2.4.2. Collection of measures

Both groups (IL and CT) completed the self-assessment questionnaire at four time points: before the experiment (T0), after the theoretical course (T1), and following the immersive learning and role-playing sessions (T2 or T3, depending on the group) (Fig. 4; Fig. 5).

Fig. 4.

study design for group IL.

Fig. 5.

study design for CT group.

2.4.3. Analyses

We excluded partial responders, participants who completed only one of the questionnaires, to ensure that the analysis was based on a consistent sample of participants who provided complete data. The data collected from the questionnaires were retrieved through the Virtual University platform (Moodle), then converted into tables in Excel, making them suitable for analysis in JASP software [31]. We used Wilocoxon test to analyze potential differences between the intervention and control group for each measure. To evaluate the statistical power of our results a posteriori with respect to our study population, we conducted a post-hoc power analysis. For this analysis, the global SPCS score was considered as the primary outcome. The p-value of each item was converted into a Z-statistic (Z = Φ⁻¹(1 − p/2)), which was then used to compute Rosenthal's r (r = Z / √N). Rosenthal's r was subsequently transformed into Cohen's d (d = 2r / √(1 − r²)). The magnitude of the effect size at the global level was estimated as the median of |d| (= 0.56).

3. Result

A total of 180 students were eligible to participate in this study but only 114 completed all questionnaires: 68 participants in the experimental group (IL) and 46 in the control group students (CT). The comparison of the two groups at the initial test (T0) (appendix B) showed no significant difference between them on any of the 16 items assessed in the questionnaire. After IL program, the intervention group improved significantly their self-perceived skills after all in communication items (Table 1) while the control group perceived improvement only in 3 items: asking closed questions when appropriate using open or closed questions judiciously, and identifying the moments when I should use reflective listening.

To consider the initial level of communication skills, we evaluated the gains and losses between the results of the group after completing the theoretical course and after the interventions (IL vs CT). The results obtained were significant in 10 items. The gains of the experimental group were greater than those of the control group for ten items after the use of Immersive Learning. The magnitude of the effect size at the global level, estimated as the median of |d|, was 0.56. The post-hoc power analysis indicated that the power to detect this effect size on the global SPCS score was 0.82. This calculation was based on a two-sample test (noncentral t, two-sided α = 0.05) and the actual sample sizes of the intervention group (n IL = 68) and the control group (n CT = 46). These results suggest that our study had adequate statistical power to detect a moderate effect size at the global level. Item-level results are presented in Table 2. Differences of gains essentially focused on active listening and structuring skills, attention paid to the patient, patient involvement as well as to verbal non-verbal cues.

Table 2.

Study of gains and losses between groups (between the post-theoretical course assessment and the practical curses (digital IL or control CT).

Communication items	Experimental Group (IL) n = 68			Control Group (CT) n = 46			ρ-value
I feel skilled to:	Mean T1	Mean T2	Gain/ Loss %	Mean T1	Mean T2	Gain/loss %
Asking open questions when it is appropriate	3.66	4.08	25.33	3.79	3.59	15.00	0.15
Asking closed questions when it is appropriate	3.63	3.94	19.48	3.59	3/95	19.93	0.95
Using open or closed questions judiciously	3.32	3.83	25.89	3.46	3.81	25.95	0.99
Actively listening to my patient	3.98	4.47	38.33	4.34	4.28	12.21	0.003**
Tactfully interrupting my patient if necessary	3.09	3.60	26.83	3.53	3.32	0.65	<0.001**
Identifying verbal cues from my patient to respond	3.43	4.05	33.19	3.53	3.61	12.38	0.006**
Using appropriate vocabulary for the situation	3.52	3.97	26.20	3.89	3.79	2.31	<0.001**
Being attentive and fully dedicated to the consultation	4.11	4.49	32.16	4.40	4.36	6.84	0.001**
Identifying when I should use reflective listening	3.21	4.22	51.48	3.12	4.02	42.79	0.273
Showing empathy	3.95	4.16	22.14	4.00	4.00	9.80	0.097
To progress from one section to another in the patient interview.	3.57	4.29	36.88	3.91	4.00	9.18	<0.001**
Being attentive to the patient's non-verbal communication	3.69	4.29	38.52	3.89	3.91	13.50	0.002**
Periodically summarizing what the patient says	3.39	4.38	52.46	3.81	3.91	19.18	<0.001**
Rephrasing what the patient says to ensure mutual understanding (both mine and the patient's)	3.53	4.40	50.59	3.91	3.93	16.56	<0.001**
Asking questions to check the patient's understanding	3.63	4.09	27.72	3.81	3.85	12.62	0.053
Involving the patient in the care planning?	3.73	4.23	32.58	4.12	4.28	16.19	0.039**

The final assessment (T3), conducted when both groups (n = 114) had completed both the immersive learning (IL) and role-play sessions, showed that the progress of the two groups was comparable, with no significant differences remaining between them (See Table 3).

Table 3.

Study of gains and losses between groups (between the pre-theoretical course assessment and the final self-evaluation).

Communication items	Experimental Group (IL) n = 68			Control Group (CT) n = 46			ρ-value
I feel skilled to:	Mean T0	Mean T3	Gain/ Loss%	Mean T0	Mean T3	Gain/loss %
Asking open questions when it is appropriate	3.75	4.10	22.1	3.98	4.21	25.9	0.635
Asking closed questions when it is appropriate	3.70	4.01	22.1	3.90	4.19	25.8	0.639
Using open or closed questions judiciously	3.66	3.94	21	3.78	4.04	22.5	0.847
Actively listening to my patient	4.52	4.52	16.5	4.67	4.51	85	0.336
Tactfully interrupting my patient if necessary	3.45	3.72	19.7	3.39	3.61	16	0.629
Identifying verbal cues from my patient to respond	3.68	3.86	17.9	3.80	4.00	21	0.712
Using appropriate vocabulary for the situation	3.69	3.91	21.1	3.92	3.97	10.6	0.220
Being attentive and fully dedicated to the consultation	4.44	4.45	18.4	4.51	4.46	10.5	0.335
Identifying when I should use reflective listening	3.39	3.77	26.3	3.27	3.87	33.3	0.440
Showing empathy	4.35	4.27	22.1	4.16	4.08	25.8	0.639
To progress from one section to another in the patient interview.	4.07	4.05	21	4.20	4.17	22.5	0.847
Being attentive to the patient's non-verbal communication	3.93	4.10	16.5	3.98	4.10	8.5	0.336
Periodically summarizing what the patient says	3.75	4.19	19.7	3.57	4.25	16	0.629
Rephrasing what the patient says to ensure mutual understanding (both mine and the patient's)	3.93	4.30	17.9	4.02	4.27	21	0.712
Asking questions to check the patient's understanding	3.77	4.07	20.1	3.84	4.14	10.6	0.220
Involving the patient in the care planning?	4.01	4.29	18.4	4.10	4.38	10.5	0.335

The Net Promoter Score, which indicates the extent to which students recommend the IL program to other students, stands at 63.83, which exceeds the generally accepted threshold of 50 for considering the tool as one that is recommended to other users.

Regarding the System Usability Scale, which aims to determine the level of satisfaction of users of a service or system, all the participants scored high: a score of 82 which translates to a level of usability between good and excellent.

4. Discussion and conclusion

4.1. Discussion

The objective of this study was to present the methodological steps that led to the development of an IL program based on storytelling, utilizing a branching scenario model focused on professional communication and validate its relevance within the curriculum for third-year students in physiotherapy. Using a randomized controlled trial, we assessed the effect of IL on students' self-perceived improvement in communication skills. Additionally, we evaluated students' satisfaction with IL and its usability.

Our findings demonstrate that IL program significantly enhances communication skills across all evaluated items in our participant group. In contrast, a traditional training approach (composed of peer-to-peer role-playing exercises and actor-based simulations) led to improvements in students' perceived skills in only three items. A gain and loss analysis further supports these findings, showing that progress was significantly higher in 10 out of 16 items within the IL group from the beginning (T0) to the end of either the immersive or control program. This underscores the value of incorporating IL into healthcare communication skills training, aligning with previous studies [32].

The comparison between IL and traditional approaches reveals that IL offers a distinct advantage in perceived skills likely due to the repeated practice opportunities it provides. Unlike traditional methods, where the number of practice attempts is often limited, IL allows students to engage in unlimited, self-paced practice sessions. Many students, in different studies reported using this flexibility to practice repeatedly [6,7], an option not available in structured traditional methods.

In conventional role-play settings, not all students may have the opportunity to play the role of the clinician, according to potential time constraints. IL, however, ensures that each student remains actively involved in the learning experience as clinician. Bullard et al. [33] demonstrated that direct experience in simulated scenarios is highly beneficial for developing clinical skills, emphasizing the importance of active student engagement. In large groups, as is common in health curricula, few students may be able to engage in consistent practice, making real-world simulation exercises essential for healthcare training. Kaplonyi et al. [8] found that simulated patients provide learners with the opportunity to practice with real individuals, receive feedback on their performance, and reflect on their practice. While this feedback is crucial for identifying areas for improvement, a digital simulation in the form of IL offers an innovative preparatory step before hands-on practice with simulated patients.

Our study confirms that after both groups completed the full curriculum (IL followed by role-play), no significant differences remained between them, suggesting that both methods foster comparable development in communication skills. Johnsen et al. [34] confirms that the aim is not to establish one method as universally superior, but to clarify how different approaches may complement each other. They stress the importance of exploring contextual conditions under which each method adds educational value. In our study, the finding implies that IL and role-playing exercises complement one another, allowing students to develop diverse skill sets. This alignment is logical, as IL scenarios are pre-programmed, limiting the user's ability to deviate from set pathways or interrupt the simulated patient. The tool therefore provides a structured yet limited level of autonomy, making it particularly relevant for students during pre-clinical years who have not yet encountered real-world scenarios due to the absence of practical internships.

Nevertheless, several limitations of immersive approaches in medical education, particularly in physiotherapy education, have been reported in the literature. Reviews of digitally enhanced curricula highlight that, while these tools support knowledge acquisition, they may provide fewer opportunities for authentic interpersonal interaction and can sometimes lead students to perceive reduced self-efficacy in relational contexts [35]. Other systematic reviews emphasize methodological constraints such as small sample sizes, heterogeneity in intervention design and duration, and the difficulty of demonstrating consistent benefits beyond theoretical knowledge [36,35]. Moreover, the technical requirements of VR/AR tools and the challenge of creating realistic patient scenarios may limit ecological validity and raise concerns about generalizability [37]. Our findings should thus be interpreted within this broader context, reinforcing the idea that IL represents a promising but complementary approach to traditional communication training methods.

Regarding the usability of IL program, our results indicate high levels of student satisfaction. Participants strongly recommended IL to other healthcare students as a valuable resource for improving communication skills. This kind of approach with branching scenarios offers, indeed, an authentic interactive experience where students make real-time decisions, promoting critical reflection and mastery of communication skills [22]. This method allows students to explore multiple narrative paths and understand the consequences of their choices by simulating clinical reality.

4.2. Limitation

This study has several limitations that should be acknowledged. First, the assessment of communication skills relied on self-perception data, which may be subject to social desirability bias and does not necessarily reflect objective performance. Although self-reported measures are commonly used in educational research, future studies should incorporate external evaluations, such as expert ratings or standardized patient assessments, to strengthen the validity of findings.

Second, the study was conducted within a single institution with third-year physiotherapy students, which may limit the generalizability of results to other educational contexts, health professions, or academic levels. Replication in diverse settings and with interprofessional cohorts would help to establish the broader applicability of IL in communication training.

Finally, this validation study was limited to short-term outcomes, and no follow-up was conducted to assess retention of communication skills over time. Longitudinal research is needed to determine whether the benefits of IL are sustained in clinical practice.

4.3. Innovation

This method provides students opportunities to explore multiple narrative paths and understand the consequences of their choices by simulating clinical reality. We have demonstrated that the psychologically safe environment in link with IL allows students to make mistakes without judgment, significantly boosting their self-perception in their communication abilities compared to traditional role-playing methods. Finally, the flexibility of digital learning, through platforms like H5P, enables autonomous and personalized learning.

The innovation of this pedagogical tool lies in several aspects, from its initial design to its implementation. Notably, this immersive tool was developed collaboratively with an expert patient who contributed to the creation of branching scenarios. The goal of involving the patient was to incorporate not only theoretical models and practitioner perspectives but also to address patient expectations in terms of communication. While many expert patients now participate in the development of educational tools, their involvement is far less common in digital platforms [39]. Additionally, students were also involved in the tool's creation to ensure their input was considered regarding the tool's realism, engagement, and graphical interface.

Regarding the program itself, our pedagogical device facilitates immersive experiences by combining augmented reality (AR), along with branching scenarios in the context of teaching communication skills in healthcare. This approach enables students to explore multiple narrative paths and understand the consequences of their choices by simulating clinical reality. Moreover, all responses provided by the students are immediately corrected based on theoretical models of professional communication in healthcare. Therefore, students can rely on theoretical reminders each time to understand why a given response is suboptimal. At the end of the program, students receive a descriptive feedback on all the suboptimal responses they produced, along with recommendations on the theoretical areas they should review to better apply the concepts in practical situations.

5. Conclusion

Our findings highlight the creation and effectiveness of IL program in enhancing these skills among students in physical therapy curricula. The IL approach not only significantly increased the sense of capability across various communication competencies but also provided a more engaging and supportive learning environment compared to traditional role-playing exercises. Students found the IL tool to be both user-friendly and worthy of recommendation to their peers. In addition, IL programs may have practical implications for curriculum design by serving as a preparatory step before live simulations with standardized patients or peer role-play. By strengthening both theoretical knowledge and practical application at the lower levels of Miller's pyramid [4], immersive approaches allow students to enter subsequent face-to-face simulations with greater confidence and foundational competence. This preparation may enable learners to focus more effectively on higher-order relational skills during role-play, thereby enhancing the overall efficiency and impact of communication training within healthcare curricula.

These results support the assertion that IL environments can bridge gaps in communication training, offering students the opportunity to practice essential skills in a safe and controlled setting. As healthcare continues to evolve, integrating innovative pedagogical approaches like IL will be crucial for developing competence and confidence among healthcare providers. Future research should explore long-term outcomes and the integration of IL across various healthcare disciplines to fully understand its impact on professional practice.

CRediT authorship contribution statement

Jennifer Foucart: Writing – original draft, Supervision, Methodology, Data curation, Conceptualization. Maxime Etenaille: Software, Resources. Noelle Junod-Perron: Writing – review & editing.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the author(s) used Chat GPT 4.0 to check English grammar and style or translate some part of the text. After using this tool, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Appendix A (System Usability Scale: French version)

Appendix B

	Experimental Group (IL) n = 68	Control Group (CT) n = 46	p-value
	Mean	Mean
Asking open questions when it is appropriate	3.75	3.98	0.136
Asking closed questions when it is appropriate	3.70	3.90	0.200
Using open or closed questions judiciously	3.66	3.78	0.455
Actively listening to my patient	4.52	4.67	0.203
Tactfully interrupting my patient if necessary	3.45	3.39	0.754
Identifying verbal cues from my patient to respond	3.68	3.80	0.479
Using appropriate vocabulary for the situation	3.69	3.92	0.211
Being attentive and fully dedicated to the consultation	4.44	4.51	0.534
Identifying when I should use reflective listening	3.39	3.27	0.523
Showing empathy	4.35	4.16	0.254
To progress from one section to another in the patient interview.	4.07	4.20	0.354
Being attentive to the patient's non-verbal communication	3.93	3.98	0.788
Periodically summarizing what the patient says	3.75	3.57	0.297
Rephrasing what the patient says to ensure mutual understanding (both mine and the patient's)	3.93	4.02	0.553
Asking questions to check the patient's understanding	3.77	3.84	0.707
Involving the patient in the care planning?	4.01	4.10	0.583