The effect of wearable simulated birth model on students’ empathy and privacy protection levels: a randomised controlled trial

Abstract

Background

Simulation-based education is widely used to enhance clinical competence and communication skills in health professions. However, limited evidence exists on combined educational models that integrate simulation with structured counseling to strengthen empathy and privacy protection among midwifery students.

Methods

This randomized controlled trial examined the effects of a two-component educational intervention—wearable birth simulation followed by seven weeks of structured counseling—on students’ empathic tendency and privacy protection competencies. A total of 105 final-year midwifery students were randomly assigned to three groups: normal birth simulation (n = 35), breech birth simulation (n = 35), and control (n = 35). Data were collected at four time points using the Empathic Tendency Scale and the Privacy Protection in Obstetrics and Gynecology Scale. Mixed-model analyses were applied.

Results

Students in the breech birth simulation group demonstrated significantly higher empathy scores compared with the control group (p = 0.025). Across all groups, empathy and privacy awareness increased significantly over time (p < 0.001). However, the intervention did not produce significant improvements in the frequency of applying privacy-protective behaviors (p > 0.05).

Conclusions

The combined intervention—simulation followed by structured counseling—enhanced students’ empathy and awareness regarding privacy protection, although behavioral change did not occur to the same extent. Integrating multi-component educational strategies into midwifery curricula may strengthen both emotional and cognitive dimensions of respectful maternity care.

Trial registration

ClinicalTrials.gov, NCT05864859. Registered on 05 May 2023.

Introduction

Simulation training is widely recognized as a valuable and effective learning tool that fosters experiential learning through active participation, iterative practice, and the transfer of theory into real-life applications, resulting in enhanced competency. It has been shown to produce positive educational outcomes [1–3]. Simulation not only complements practice-based learning but also supports the development of essential skills required for clinical practice [4]. Evidence indicates that simulation improves knowledge, attitudes, and skills, contributes to patient safety, positive health outcomes, and satisfaction [3], and enhances professional abilities such as collaboration, motivation, communication, and teamwork [5].

Various simulation methods are applied in health professions education, including standardized patients, mannequin-based training, role-playing, games, and virtual reality [6]. Wearable simulation technologies, in particular, provide opportunities for learners to gain deeper insights into patient experiences [7]. Research suggests that wearable models offer learning outcomes comparable to high-fidelity simulators in terms of communication, clinical judgment, and patient safety [8]. Approaches that allow students to “step into the patient’s shoes” appear especially effective for developing empathy and patient-centered perspectives [6]. For example, role-playing interventions have been shown to strengthen students’ ability to understand patients’ viewpoints compared with standardized patient methods [9]. Recent evidence highlights the growing importance of innovative educational strategies and the role of nurses’ cognitive and emotional capacities in improving clinical outcomes. High-fidelity simulation has been shown to significantly enhance students’ self-satisfaction and self-confidence, supporting its value as an effective teaching approach in nursing education [10]. Moreover, emotional intelligence has been identified as a key predictor of clinical decision-making among nurses, particularly in high-acuity environments such as neonatal intensive care units [11]. These recent findings underscore the need to integrate advanced training methods and cognitive-emotional competencies to strengthen clinical performance and patient safety. Accordingly, further experimental studies are recommended to examine the influence of such approaches on empathy development [6].

Role-playing and wearable simulations are particularly relevant for preparing future nurses and health professionals to provide respectful care. By simulating the experiences of pregnancy and childbirth, wearable birth models offer immersive learning opportunities that foster empathy and awareness of privacy—two essential components of maternal and newborn care. Despite their potential, only a limited number of studies have explored the impact of wearable simulation on learners in midwifery and nursing education [12]. Therefore, the present study was designed to evaluate the effects of a wearable simulated maternity model on students’ empathy and privacy protection. To our knowledge, this is among the first randomized controlled trials to simultaneously investigate the influence of simulation on both empathy and privacy competencies in health professions education.

Wearable simulation was implemented using two types of birth scenarios—normal birth and breech birth—to reflect differing levels of clinical complexity and emotional demand. Breech birth is internationally recognized as a higher-risk and less frequently encountered intrapartum situation, requiring more advanced decision-making, heightened situational awareness, and intensified communication with both the birthing woman and the healthcare team [13]. Research on experiential learning indicates that learners demonstrate stronger emotional engagement, deeper reflection, and greater activation of empathic processes when exposed to scenarios perceived as complex, uncertain, or clinically challenging [6, 14]. Similarly, emotionally charged or high-stakes obstetric scenarios have been shown to enhance perspective-taking, self-regulation, and empathic responsiveness more than routine clinical encounters [14, 15]. Therefore, incorporating a breech birth simulation allowed us to examine whether exposure to a more demanding and emotionally intense scenario would foster greater empathy and awareness of respectful care compared with a standard normal birth simulation. This theoretical rationale informed our decision to include two experimental groups in the present study.

Hypotheses

1. Experiencing normal birth with a wearable simulated maternity model increases students’ empathy levels.

2. Experiencing normal birth with a wearable simulated maternity model increases students’ awareness of privacy.

3. Experiencing normal birth with a wearable simulated maternity model increases the frequency of applying privacy-protective behaviors among students.

4. Experiencing breech birth with a wearable simulated maternity model increases students’ empathy levels.

5. Experiencing breech birth with a wearable simulated maternity model increases students’ awareness of privacy.

6. Experiencing breech birth with a wearable simulated maternity model increases the frequency of applying privacy-protective behaviors among students.

Methods

Design

This study was conducted using a randomized controlled experimental design. The study was registered with Clinical Trials (protocol number NCT05864859, dated 05/09/2023).

Population and sample

The sample size was calculated using G*Power 3.1.9.7 based on effect sizes from a previous two-group study by Karakoç (2019), with α = 0.05 and 80% power, yielding a required sample of 35 participants per group for a between-group comparison at the primary post-intervention assessment. At the time of planning, no suitable three-arm repeated-measures datasets were available to estimate the within-subject correlation structure or to conduct a power analysis for detecting group × time interaction effects. Therefore, the study was primarily powered to detect medium-sized between-group differences at the main endpoint rather than the more complex interaction effects across four time points. As a result, while repeated measurements may increase statistical efficiency, the sample size may still be insufficient to detect small interaction effects in a mixed-model framework. The inclusion criteria required participants to be final-year midwifery students, nulliparous, and willing to participate in the study. Students who did not have proficiency in reading, listening, writing, speaking, or understanding Turkish, or who were repeating the course, were excluded. Students who did not attend at least one session were also removed from the study.

The participant flow diagram was updated to provide full transparency regarding enrollment, allocation, follow-up, and analysis. Of the 114 students assessed for eligibility, nine were excluded for not meeting the inclusion criteria. A total of 105 students were randomized equally into the normal birth, breech birth, and control groups (n = 35 per group). During follow-up, two participants in the control group and one participant in the breech birth group did not complete all stages of data collection due to absence from scheduled sessions. No participants crossed over between groups, and no additional withdrawals occurred after allocation. All remaining participants who completed the intervention and follow-up assessments were included in the final analysis (normal birth: n = 35; breech birth: n = 34; control group: n = 33, Fig. 1).

Fig. 1.

The CONSORT flow diagram of the research

Randomization and blinding

Simple randomization was performed using an electronic random sequence generator (Research Randomizer). The random sequence was generated independently by an academic staff member who was not involved in participant recruitment, data collection, or intervention delivery. Allocation concealment was ensured through the use of sequentially numbered, opaque, sealed envelopes (SNOSE) prepared by the same independent academic. Each envelope contained the group assignment and was opened only after students completed baseline measurements. The researcher responsible for delivering the simulation and counseling interventions had no access to the allocation list prior to assignment.

Although blinding of the intervention provider was not feasible due to the nature of the simulations, the statistician remained fully blinded, and group labels were coded as A, B, and C until all analyses were completed. To reduce performance bias, intervention groups were scheduled on different days, and students were asked not to discuss the intervention content with peers.

Data collection tools

Data were collected using the Demographic Information Form, the Empathic Tendency Scale, and the the Privacy Protection Scale in Obstetrics and Gynecology.

Demographic Information Form: It evaluates factors such as age, type of high school graduated from, willingness to choose the field of study, and level of fear towards childbirth.

Empathic tendency scale

This scale was developed by Dökmen (1988) to measure individuals’ potential for empathy in their daily lives [16]. The scale consists of 20 items rated on a 5-point Likert scale. Items 3, 6, 7, 8, 11, 12, 13, and 15 are reverse scored. The lowest possible score is 20, and the highest possible total score is 100. A higher total score indicates a higher empathic tendency. The Cronbach’s alpha reliability coefficient of the scale was found to be 0.82. In this study, Cronbach’s alpha coefficients obtained at different times ranged between 0.634 and 0.790.

Privacy protection scale in obstetrics and gynecology

Developed by Karakoç and Özerdoğan (2019) to assess the level of protection of individual privacy by healthcare professionals in the field of obstetrics and gynecology, this scale is a valid and reliable measurement tool [17]. The scale consists of two sections: awareness level and frequency of applying privacy-protective behaviors. It also has two sub-dimensions: physical-social privacy (items 1–15) and psychological-informational privacy (items 16–30), totaling 30 items. There are no items that require reverse scoring when calculating the total scale score. The Cronbach’s alpha reliability coefficient was found to be 0.95 for the awareness level section, 0.96 for the frequency of applying privacy-protective behaviors section, 0.90 and 0.92 for the physical-social privacy sub-dimension, and 0.93 and 0.94 for the psychological-informational privacy sub-dimension. In this study, Cronbach’s alpha coefficients for the sections and sub-dimensions of the scale ranged between 0.825 and 0.973.

Scenarios

To enhance the educational relevance of the intervention, two simulation scenarios—normal birth and breech birth—were selected to reflect both routine and more complex clinical situations encountered in midwifery practice. Normal birth represents a standard physiological process, whereas breech birth was included to expose students to a higher-complexity scenario that requires greater attention to communication, teamwork, and emotional regulation. Because increased clinical complexity may inherently influence students’ emotional responses, both scenarios were carefully standardized to ensure comparability. Each scenario followed the same structure (pre-briefing, simulation, debriefing), had identical duration, and was developed in accordance with the Standards of Best Practice for Simulation [18]. Six faculty experts (Midwifery: 4, Nursing: 2) evaluated both scenarios using the Clinical Scenario Evaluation Form [19], and revisions ensured that the cognitive, affective, and communication demands were appropriate for final-year students and aligned across both simulation types. This approach allowed the study to examine the impact of scenario type while maintaining consistent instructional design and difficulty level.

Subsequently, the content validity ratio (CVR) for each item and the content validity index (CVI) for all items were calculated. In the study, the CVR values for the scenarios were calculated as min = 0.80, max = 1.00, and the CVI was found to be 0.99. Given that the obtained content validity ratio is greater than 0.80, it was determined that the content of the scenarios is valid in terms of coverage. All feedback from the experts was incorporated, and the scenario content was finalized before the pilot application.

The clinical scenarios were conducted in groups of two (1 midwife, 1 pregnant woman) and consisted of three sessions: pre-briefing (10 min), simulation (10 min), and debriefing (20 min). The midwife role was performed by the researcher.

Pre-briefing

The student was informed about the scenario. The purpose of the simulation and the learning objectives were shared, orientation to the environment was provided, equipment was introduced, and questions were answered. The clinical scenarios were introduced to the students for the first time during the pre-briefing session.

Simulation

Two participants (1 midwife, 1 pregnant woman) performed the roles according to the clinical scenario. The student playing the role of the pregnant woman wore a Wearable Pregnancy Simulator. During the simulation, participants could interact with facilitators if they had any questions.

The duration of each simulation was limited to a maximum of eight minutes to ensure that all participants experienced the scenarios under standardized conditions while avoiding cognitive overload associated with longer high-intensity simulations. This time frame aligns with recommendations from the Standards of Best Practice for Simulation, in which the brief simulated encounter serves primarily as a catalyst for deeper reflection during the 20-minute structured debriefing session, considered the core component of experiential learning. Therefore, although the simulation itself was brief, the educational depth of the intervention was achieved through the combined effect of the simulation, guided reflection, and the structured debriefing process that followed.

Debriefing session

The debriefing session used the 4Es technique (events, emotions, empathy, explanations) to promote reflective thinking.

Counseling intervention

The counseling component was delivered over seven weeks, with one 60-minute session per week. Sessions were conducted in group, consistent with the university’s standard counseling class sizes. All counseling sessions were facilitated by a PhD-level midwifery faculty member who had formal training in counseling techniques, and possessed substantial experience in simulation-based education and structured debriefing processes. To minimize the risk of bias, the facilitator responsible for delivering both the simulation and counseling components had no role in generating the randomization sequence or implementing group allocation.

The counseling sessions focused on four core areas: effective communication with the healthcare team, professional and sensitive communication with pregnant women, managing one’s own empathy and emotional responses, and supporting students’ academic progress. Each session was conducted in an interactive format, encouraging students to analyze situations encountered during clinical practice, reflect on communication dynamics, and internalize empathy-based and humanistic care principles. The counseling program was implemented with identical content and sequence for all participants to ensure standardization and consistency across the intervention.

Intervention

In the relevant institution, senior midwifery students receive one hour of theoretical and 32 h of clinical practice education as part of their curriculum. Clinical practices are carried out in the maternity wards of city hospitals. As part of the study, in the skills laboratory, the first intervention group performed a normal birth simulation, and the second intervention group performed a breech birth simulation using a wearable simulated maternity model.

The wearable birth simulator can be worn by the instructor or student and includes a newborn simulator, placenta, cord and blood concentration. After wearing the simulator, vaginal examination, fetal heart sound listening, fetal delivery, placenta delivery, urinary catheterization procedures can be performed.

After completing the simulation, both intervention groups received seven weeks of counseling sessions, one hour per week, focusing on communication with the team, communication with the pregnant woman, managing empathy, and academic progress. No intervention other than routine curriculum was performed on the control group of the study, and research data were collected at the same intervals as the intervention group.

Data collection

Data collection for this randomized controlled trial was conducted between October and December 2023, corresponding to the spring academic semester of the relevant university. All simulation activities, counseling sessions, and follow-up measurements were carried out within this semester’s scheduled institutional curriculum. The simulation sessions for both intervention groups were completed within the first two weeks of the data collection period. Immediately before any intervention, baseline data (T1) were collected from all participants. The second measurement (T2) was obtained immediately after the simulation session. The third measurement (T3) was collected at the beginning of the counseling period, approximately one week after the simulation. The final measurement (T4) was gathered at the end of the seven-week counseling program, approximately seven weeks after the simulation, allowing evaluation of both immediate and short-term retention of intervention effects.

The subsequent seven-week counseling program was delivered once per week, with each session lasting approximately 60 min. The counseling sessions did not overlap with students’ examinations or major curricular activities; sessions were scheduled outside clinical practice hours to minimize potential confounding effects related to academic workload or simultaneous educational interventions. The seven-week counseling process for the intervention groups was delivered after completion of the simulation sessions and followed the same standardized sequence for both experimental groups. The control group did not receive any additional training beyond the routine curriculum during this period. To reduce potential contamination, groups were assigned to separate laboratory days, and counseling sessions were held in different scheduled time slots. The study team also verified that no concurrent institutional workshops, seminars, or skill-based training that could influence empathy or privacy-related competencies took place during the intervention period.

Pilot study

Before initiating full data collection, a pilot test of the simulation scenarios was performed with six senior students who were not included in the main sample. This pilot study aimed to evaluate the clarity, flow, realism, and time management of the scenarios and to ensure feasibility of laboratory implementation. Feedback obtained from the pilot participants and expert reviewers was used to refine scenario instructions, timing, and debriefing prompts. No modifications were required for the data collection tools, and therefore pilot data were excluded from the main analysis.

Data analysis

Data analysis was conducted using IBM SPSS V23 and R software. The normality of distribution was assessed using the Shapiro–Wilk test, and appropriate mixed-model analyses were applied as described above. In addition, a detailed missing data assessment was performed prior to inferential analyses. Missing data occurred only during the follow-up measurement stages due to the absence of three participants who did not attend at least one scheduled data collection session. Consequently, missingness was limited to the time-dependent variables of the Empathic Tendency Scale and the Privacy Protection Scale, with 1 to 3 missing values per variable, and no item-level missing responses were observed. To evaluate the mechanism of missingness, Little’s MCAR test was conducted and yielded a non-significant result (p = 1.000), indicating that the missing data were missing completely at random (MCAR) and unrelated to participant characteristics or study outcomes. Because the missingness resulted from attendance-related factors rather than systematic dropout, the Expectation–Maximization (EM) algorithm was applied for imputation in order to preserve statistical power and avoid listwise deletion. All analyses were subsequently repeated using the imputed dataset.

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the KTO Karatay University Faculty of Medicine Non-Drug and Medical Device Research Ethics (Approval No: 2022/003, Date: November 21, 2022). Written informed consent was obtained from all participants before participation. All participants were informed about the purpose, procedures, risks, and benefits of the study prior to data collection. Participation was entirely voluntary, and students were assured that they could withdraw from the study at any time without any academic or personal consequences. Written informed consent was obtained from all participants before the commencement of the study.

Results

Demographic characteristics of the groups

The demographic characteristics of the intervention and control groups are presented in Table 1, and it was determined that the groups were similar.

Table 1.

Comparison of demographic characteristics according to groups

	Normal birth	Breech birth	Control Group	Total	Test	p
Age	21.83±0.92	21.86±1.03	21.66±1.11	21.78±1.02	1.022	0.600***
	22.00 (20.00 - 23.00)	22.00 (20.00 - 24.00)	21.00 (20.00–24.00.00.00)	22.00 (20.00–24.00.00.00)
Education
Science High School	4 (11.4)	4 (11.4)	4 (11.4)	12 (11.4)	0.942	0.958**
Anatolian High School	28 (80)	26 (74.3)	28 (80)	82 (78.1)
Health Vocational High School	3 (8.6)	5 (14.3)	3 (8.6)	11 (10.5)
To prefer the department willingly
Yes	24 (68.6)	26 (74.3)	23 (65.7)	73 (69.5)	0.629	0.730*
No	11 (31.4)	9 (25.7)	12 (34.3)	32 (30.5)

*Ki-square test

**Fisher-Freeman-Halton test

***Kruskal Wallis test, frequency (percentage), mean±s. deviation, median (minimum - maximum)

Empathic tendency levels of the groups

Regardless of time, the mean empathic tendency scores differed between the groups (p = 0.025). A difference was found between the breech birth group and the control group.

Regardless of group, the mean empathic tendency scores differed over time (p = 0.011). A difference was observed between the post-simulation and pre- and post-counseling follow-ups. There was no significant difference in mean empathic tendency scores based on the interaction of group and time (Table 2, p = 0.061).

Table 2.

Comparison of empathic tendency score by group and time

Time	Normal birth	Breech birth	Control Group	Total		Df1	Df2	F	P	KEK
Pre-test	69.14 ± 8.40	70.00 ± 7.66	69.71 ± 6.56	69.62 ± 7.51ab	Group	2.000	408.000	3.732	0.025	0.018
Intervention After	73.34 ± 7.97	74.91 ± 10.58	68.06 ± 4.56	72.10 ± 8.53a	Time	3.000	408.000	3.762	0.011	0.027
Counselling before	69.23 ± 7.38	69.60 ± 4.81	69.11 ± 5.05	69.31 ± 5.81b	Group x Time	6.000	408.000	2.028	0.061	0.029
Counselling After	69.43 ± 7.37	70.23 ± 5.16	68.80 ± 5.70	69.49 ± 6.12b
Total	70.29 ± 7.91ab	71.19 ± 7.66a	68.92 ± 5.49b	70.13 ± 7.15

F Generalised Mixed ANOVA test statistic, df1 numerator degrees of freedom, df2 denominator degrees of freedom, mean ± s. deviation, PEC Partial eta squared, a-b No difference between groups/times with the same letter

Fear levels related to childbirth experience of the groups

Regardless of time, the trimmed mean scores for fear of childbirth did not differ between groups (p = 0.163). Regardless of group, the trimmed mean scores for fear of childbirth differed over time (p < 0.001). A difference was observed between the post-simulation follow-up and other follow-ups. There was no significant difference in trimmed mean scores for fear of childbirth based on the interaction of group and time (Table 3 Group x Time, p = 0.387).

Table 3.

Comparison of the level of fear towards the experience of giving birth by group and time

Time	Normal birth	Breech birth	Control Group	Total		Df1	Df2	F	P	KEK
Pre-test	5.64 ± 0.48	5.45 ± 0.45	6.24 ± 0.39	5.79 ± 0.26b	Group	2.000	62.264	1.868	0.163	0.057
Intervention After	4.70 ± 0.46	4.55 ± 0.42	5.24 ± 0.39	4.82 ± 0.25a	Time	3.000	72.997	530.721	< 0.001	0.956
Counselling before	5.61 ± 0.52	5.75 ± 0.40	6.30 ± 0.41	5.89 ± 0.25b	Group x Time	6.000	59.506	1.076	0.387	0.098
Counselling After	6.03 ± 0.54	6.13 ± 0.33	7.18 ± 0.33	6.49 ± 0.24b
Total	5.49 ± 0.25	5.51 ± 0.20	6.24 ± 0.19	5.74 ± 0.13

F Robust Mixed ANOVA test statistic, df1 numerator degrees of freedom, df2 denominator degrees of freedom, pruned mean ± s. error, PEC Partial eta squared, a-b No difference between times with the same letter

Awareness level of protecting privacy in the groups

Regardless of time, the trimmed mean awareness scores did not differ between groups (p = 0.455). Regardless of group, the trimmed mean awareness scores differed over time (p < 0.001). A difference was observed between the post-simulation and pre-counseling follow-ups. There was no significant difference in trimmed mean awareness scores based on the interaction of group and time (Table 4, p = 0.263).

Table 4.

Comparison of awareness level and frequency of practice by group and time

	Normal birth	Breech birth	Control Group	Total		Df1	Df2	F	P	KEK
Level of awareness about privacy
Pre-test	90.35 ± 1.70	87.65 ± 1.31	88.36 ± 1.29	88.94 ± 0.80ab	Group	2.000	63.674	0.797	0.455	0.024
Intervention After	93.74 ± 1.46	92.70 ± 1.52	87.98 ± 1.74	91.76 ± 0.91a	Time	3.000	77.832	8.056	< 0.001	0.237
Counselling before	88.46 ± 2.30	87.12 ± 2.12	88.06 ± 1.53	88.32 ± 0.98ab	Group x Time	6.000	63.600	1.317	0.263	0.110
Counselling After	86.49 ± 1.98	84.07 ± 2.23	85.68 ± 2.09	85.68 ± 1.15b
Total	90.11 ± 0.89	88.29 ± 0.83	87.78 ± 0.79	88.73 ± 0.48
Frequency of practices to protect privacy
Pre-test	91.24 ± 1.73	88.64 ± 1.60	88.79 ± 1.49	89.82 ± 0.89	Group	2.000	63.900	2.132	0.127	0.063
Intervention After	91.26 ± 1.94	88.33 ± 1.70	87.20 ± 1.57	89.22 ± 0.98	Time	3.000	76.234	1.175	0.325	0.044
Counselling before	90.56 ± 1.84	85.96 ± 2.29	87.58 ± 1.79	88.39 ± 1.04	Group x Time	6.000	63.014	0.473	0.826	0.043
Counselling After	90.56 ± 1.91	85.30 ± 1.86	86.69 ± 2.05	87.68 ± 1.13
Total	91.27 ± 0.88	87.39 ± 0.86	87.72 ± 0.85	88.80 ± 0.51

F Robust Mixed ANOVA test statistic, df1 numerator degrees of freedom, df2 denominator degrees of freedom, pruned mean ± s. error, PEC Partial eta squared, a-b No difference between times with the same letter

Frequency of applying privacy-protective behaviors in the groups

Regardless of time, the trimmed mean frequency of practice scores did not differ between groups (p = 0.127). Regardless of group, the trimmed mean frequency of practice scores did not differ over time (p = 0.325). There was no significant difference in trimmed mean frequency of practice scores based on the interaction of group and time (Table 4, p = 0.826).

Discussion

Empathic tendency levels of the groups

The finding that empathy levels improved, particularly in the breech birth simulation group, underscores the potential of simulation to support the development of emotional competencies in health professions education. While the midwife–mother relationship is uniquely close [20], empathy is recognized globally as a core professional value in midwifery and nursing practice. Prior studies indicate that simulation, especially when combined with structured debriefing, can enhance learners’ ability to understand patients’ perspectives and apply these insights in clinical settings [15, 21]. Our results align with these findings, suggesting that simulation-based educational strategies may contribute to improved empathy among students.

Fear levels related to childbirth experiences of the groups

Regardless of group, fear of childbirth decreased after the simulation practice. Previous research has shown that direct involvement in birth processes does not necessarily influence fear levels, but students with pre-existing anxiety or a preference for cesarean birth may experience higher levels of fear [22]. Simulation-based childbirth education has been associated with reduced fear and improved birth-related outcomes in the literature. Consistent with this evidence, the present results support the integration of simulation activities into midwifery curricula, particularly for students who experience childbirth-related anxiety.

Awareness levels regarding the protection of privacy in the groups

Awareness of privacy protection increased across all groups after the simulation. Respectful maternity care is emphasized internationally as a key curricular component, encouraging students to identify inappropriate practices and discuss positive examples in supportive learning environments [23]. Few studies have examined students’ privacy awareness directly, but existing research highlights the importance of awareness in safeguarding privacy during childbirth [24]. In our study, although awareness increased, this change did not correspond with improved behavioral practice. This discrepancy between awareness and behavior has been reported previously and is often discussed in relation to broader contextual factors such as role modeling, physical constraints, and institutional norms. It is important to clarify, however, that our study did not collect observational or environmental data, and therefore such explanations remain theoretical considerations drawn from prior literature, not conclusions supported by our data.

Frequency of applying privacy-protective behaviors in the groups

No significant group or time differences were found in the frequency of applying privacy-protective behaviors. A study examining healthcare professionals’ knowledge and attitudes towards patient privacy indicated that while most healthcare professionals are sensitive to this issue, education plays a critical role in reinforcing and transforming this knowledge into positive attitudes and behaviors [25]. Similarly, as observed in this study, despite an awareness of privacy, the actual practices for protecting privacy remain limited [26, 27]. Similar patterns were observed in our study. However, because we did not measure environmental conditions, clinical routines, or organizational factors, we cannot attribute the lack of behavioral change to structural or contextual barriers. Such factors represent plausible explanations suggested in the literature, but they should be interpreted as hypotheses rather than evidence-based conclusions. Future research incorporating observational methods is needed to explore these possibilities empirically.

Global implications

This study adds to the growing body of research suggesting that wearable simulation may enhance both technical and emotional competencies in health professions education. Although conducted within a single institutional and cultural setting, the findings reflect broader challenges documented internationally—particularly the difficulty of translating knowledge and awareness into sustained behavioral change. The results support the use of wearable simulation as a pedagogical tool to promote empathy and respectful care.

Strengths and limitations

This study is among the first randomized controlled trials to examine the effects of wearable birth simulation on both empathy and privacy awareness in health professions education. The use of validated instruments, along with blinded data analysis and structured debriefing, strengthened methodological rigor and supported both emotional and technical learning.

Several limitations should be acknowledged. First, the sample consisted of a single cohort of midwifery students from one university, which may limit generalizability; replication across diverse educational settings is recommended. Second, the study did not assess long-term outcomes, leaving the sustainability of the effects uncertain. Third, although privacy awareness increased, behavioral change remained limited, and—because no observational or environmental data were collected—any explanation involving structural or contextual factors remains speculative. Finally, Empathic Tendency Scale ranged between 0.634 and 0.790 across time points, this level of reliability is considered acceptable for affective constructs such as empathy, which often demonstrate greater variability and context-dependence in repeated measurements. Prior methodological literature indicates that alpha values between 0.60 and 0.70 can be regarded as acceptable in studies examining psychological or attitudinal constructs, particularly in exploratory designs [28]. Therefore, while the scale’s internal consistency may have limited sensitivity to detect very small changes over time, it does not undermine the overall interpretability or publication merit of the study. Thus, findings related to empathy should be interpreted with caution, and future studies may consider additional or more stable measures of empathic competence.

Conclusion

Wearable birth simulation improved students’ empathy and privacy awareness and reduced fear of childbirth. These gains, however, did not extend to consistent behavioral changes in privacy-protective practices. The study highlights the educational value of wearable simulation for promoting emotional and cognitive dimensions of respectful maternity care. While it is possible that contextual factors influence behavioral outcomes, our study did not measure these elements; therefore, no causal inferences can be drawn. Integrating simulation with broader educational and institutional strategies may support students in applying privacy-protective behaviors more consistently, but further research is needed to test this assumption directly.

Authors’ contributions

H.K and H.Ö. led the study’s conceptualization, methodology, study design, data analysis, resource management, and manuscript drafting. They also supervised the project and managed its administration. All authors ensured the study’s rigor and quality.

Funding

This research was supported by the TÜBİTAK 2218 Domestic Postdoctoral Research Fellowship Programme (Project No: 122C089). The funder had no role in the design of the study, data collection, analysis, interpretation, or writing of the manuscript.

Data availability

Study data are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the KTO Karatay University Faculty of Medicine Non-Drug and Medical Device Research Ethics (Approval No: 2022/003, Date: November 21, 2022). Written informed consent was obtained from all participants before participation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.