Development and Evaluation of Synchronous Haptic Feedback Simulation in Dual-Perspective Virtual Reality for Labour Care: A Situated Learning-Based Randomised Controlled Trial

Development and Evaluation of Synchronous Haptic Feedback Simulation in Dual-Perspective Virtual Reality for Labour Care: A Situated Learning-Based Randomised Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Evaluation of Synchronous Haptic Feedback Simulation in Dual-Perspective Virtual Reality for Labour Care: A Situated Learning-Based Randomised Controlled Trial Pao-Ju Chen, Wei-Kai Liou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6220812/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Labour care involving clinical decision-making and pain management is challenging for nursing students. Existing virtual teaching methods, such as spherical video-based virtual reality (SVVR), predominantly rely on visual and auditory stimuli, thus they provide no haptic feedback or interactivity. This study aimed to develop and evaluate a virtual reality synchronous haptic feedback system (VR-SHFS) to improve nursing students’ skills, knowledge, and empathy development regarding labour care. A randomised controlled trial was conducted with nursing students randomly assigned to experimental (VR-SHFS, n = 40) and control (SVVR, n = 40) groups. The experimental group engaged in haptic feedback and dual-perspective learning, whereas the control group learnt through 360° panoramic videos. Learning outcomes were assessed at the baseline (T0), immediately (T1) and two months (T2) after the intervention. Learning satisfaction was evaluated using the system usability scale (SUS) and a focus group. The data analysis revealed that the VR-SHFS group demonstrated significantly improved labour care skills and empathy at T1 and T2, as well as knowledge application at T2 compared to the SVVR group. From the students’ perspective, VR-SHFS can enhance clinical realism through haptic feedback and interactive learning, facilitating skill transfer, although there is a need for additional instructions and more time to become familiar with the system. VR learning approaches that integrate haptic feedback and dual perspectives effectively improve nursing students’ learning outcomes in labour care and outperform those based on SVVR. Improved VR technology and its interactive mechanism may further enhance learning outcomes and broaden clinical application. Virtual reality Synchronous haptic feedback Dual-Perspective Labour care Empathy Nursing students Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1 Introduction Maternity nursing education emphasises people-centred care and simulation-based learning to equip students with clinical skills, professional knowledge, and empathy, ensuring they can effectively assist women during labour and childbirth and thus promote the health of mothers and infants (Aktas and Pasinlioglu 2020 ; Temple et al. 2024 ). However, limited clinical placements, insufficient resources, and a lack of timely feedback make it difficult for students to adequately practice nursing skills. In addition, constraints within the clinical environment lead to a lack of hands-on experience, restricting skill development and clinical decision-making (AlMekkawi and El Khalil 2022 ; Bradford et al. 2021 ; Moller et al. 2021 ). Traditional teaching relies heavily on lectures and demonstrations with students often taking a passive observational role with no active participation and hands-on opportunities (Jenkins Barnard et al. 2024 ; Moraes et al. 2024 ). Although simulation-based training facilitates knowledge acquisition, it fails to fully replicate the real-time needs and authentic interactions that characterise maternal care (Villegas et al. 2021 ). Virtual reality (VR) provides an immersive training environment where learners can safely practise skills through avatars and make mistakes without pressure (Foronda et al. 2014 ; Melo et al. 2020 ) but most VR-based teaching approaches rely on static images or one-way information delivery, turning learners into passive observers with limited interaction and real-time feedback (Shadiev et al. 2022 ). For example, spherical video-based virtual reality (SVVR) simulates clinical scenarios but does not allow learners to engage in hands-on practice (Ulrich et al. 2021 ). Additionally, traditional VR-based teaching depends on visual and auditory inputs and does not enable bodily perception or role-based experience which may limit learners’ understanding of clinical contexts and application of their clinical skills (Cho and Kim 2024 ; Choi et al. 2022 ; Plotzky et al. 2021 ). By contrast, VR systems equipped with motion tracking and haptic feedback can enhance immersion and learner engagement (Eidenberger 2018 ) because stimulating both cutaneous and kinaesthetic receptors provides a more realistic tactile feedback experience (Wang et al. 2019 ). Moreover, integrating visual, auditory, and haptic feedback in a VR environment facilitates sensory integration and motor coordination, improving the effectiveness of healthcare skills training (Melo et al. 2020 ). Haptic feedback technology can improve the precision of learners’ procedural skills such as urinary catheterisation (Butt et al. 2018 ) and venipuncture (Jung et al. 2012 ). Thus, high-interactivity VR technology can address the limitations of traditional VR-based teaching, offering a more effective learning approach. The first-person perspective (FPP) allows learners to engage with others’ life experiences, thus helping them understand complex and nuanced concepts, such as empathy (Ma et al. 2021 ; Young et al. 2022 ), emotional management, and care-related stress (Dubovi and Itzhaki 2023 ). Chen and Liou ( 2023 ) found that when learners used the FPP to experience a pregnant woman’s situation, they gained a deeper understanding of her needs, thereby fostering their empathy. It is essential for obstetric nurses to accurately perceive labour pain and emotional changes in pregnant women to provide appropriate care (Ouma et al. 2024 ; Srisopa et al. 2021 ). Therefore, we designed a ‘dual-perspective learning mode’ whereby students experienced the physiological and psychological stresses of labour from the mother’s perspective before shifting to the nurse’s perspective to acquire clinical care skills in line with the situated learning theory (SLT) which asserts that learning occurs dynamically through social interaction and practical application (Lave and Wenger 1991 ). Accordingly, knowledge is not acquired through one-way transmission but is gradually internalised in real-world contexts via community interaction, observation, participation, and practice (a process known as ‘contextual learning’). Additionally, the theory highlights ‘legitimate peripheral participation’ whereby learners are involved through observation and simple participation before progressively integrating into the professional community and eventually becoming conversant members. It also emphasises that knowledge is co-constructed through social interaction and practice so learning in a realistic clinical environment may better equip students to acquire and apply nursing skills (Chen et al. 2017 ; Wighus and Bjørk 2018 ). A virtual reality synchronous haptic feedback system (VR-SHFS) was developed that simulated clinical procedures and improved the application of clinical skills using haptic feedback to reinforce learners’ VR experiences and motion tracking to allow interaction with virtual characters and physical assistive devices ( e.g. , birth balls and hospital beds). Grounded in the SLT, the VR-SHFS was used to design a VR teaching plan that used the dual-perspective learning mode to improve learners’ immersion and interactive experiences, thereby facilitating skills training and empathy development. 1.1 Objectives To compare the efficacy of the VR-SHFS and SVVR in improving nursing students’ skills, knowledge application, and empathy regarding labour care. To explore the influence of the FPP experiences of labouring women on nursing students’ empathy development and evaluate their learning outcomes in the dual-perspective learning mode. To analyse the usability of and learning satisfaction with the VR-SHFS and SVVR, and elucidate what benefits synchronous haptic feedback VR technology can bring to nursing education. 2 Materials and Methods 2.1 Study design This randomised controlled trial (RCT) integrated a pre-test and two post-tests. A focus group was conducted to collect qualitative data to comprehensively assess the effects of the VR learning system on students’ knowledge, empathy, and nursing skills regarding labour care. 2.2 Settings and participant allocation A total of 83 nursing students who had completed fundamental courses in nursing and engaged in simulation-based learning were recruited from a technical university in Taiwan. Stratified and block randomisation was performed to ensure that participants of both sexes and groups were equally distributed (Polit and Beck 2021 ), with eight male students and 75 female students randomly assigned to the experimental (n = 42) and control (n = 41) groups. Three participants withdrew from the study due to VR-induced dizziness, leaving a final sample of 80 (40 in each group) (Fig. 1 ). 2.3 Educational programmes 2.3.1 Experimental group: virtual reality synchronous haptic feedback system (VR-SHFS) The VR-SHFS used the VIVI 3.0 tracker for precise tracking of physical objects (e.g., birth balls, pregnant women, and hospital beds) and constructed a 1:1 scale virtual environment to enable complete alignment between virtual and real-world objects in terms of position and size. This system allowed the participants to touch corresponding physical objects whilst navigating the virtual space, achieving high realism and immersion by producing a haptic illusion effect similar to the rubber hand illusion (Botvinick and Cohen 1998 ; Ehrsson et al. 2004 ). Moreover, the system was equipped with the VIVE Ultimate Tracker (a self-tracking device) and VIVE 3.0 Tracker (a motion tracker) attached to the upper arms, calves, hands, and the centre of the torso to accurately capture body movements and achieve synchronisation between virtual and real-world actions. The learning environment comprised a physical hospital bed (91.44 cm × 203 cm), a birth ball (65 cm in diameter), and a pregnant female mannequin modelled on the 1:1 scale using 3ds Max with texture mapping, mesh optimisation, rendering, and dynamic lighting applied to improve visual authenticity. The environment was developed in Unity 6, with software/hardware integration completed through SteamVR SDK, and inverse kinematics were used to synchronise the movements of virtual characters with those of the participants whilst supporting their interaction with physical objects (e.g., hospital beds and birth balls). This enhanced both visual and haptic feedback, enriching the immersive learning experience. The participants wore the HTC VIVE PRO 2 HMD with a per-eye resolution of 2448 × 2448 pixels (4896 × 2448 pixels combined), 120° field of view, and refresh rate of 90/120 Hz providing a high-resolution visual experience for detailed representation and immersion (Fig. 2 ). A VR-SHFS-based teaching plan that created an immersive learning experience from the perspectives of labouring women and nurses was implemented to improve the participants’ nursing skills and empathy regarding labour care. The learning process consisted of two stages, with the first involving a 15-minute session in which the participants experienced the patient’s physiological and psychological changes during labour whilst learning non-pharmacological pain relief techniques (Fig. 3 ). This stage aligns with the ‘contextual learning’ aspect of the SLT by creating immersive experiences for the participants to deepen their understanding of maternal needs and fostering their connections with clinical scenarios. To facilitate knowledge internalisation, the participants had a 10-minute break to reflect on their experiences and reduce their fatigue. In the second stage, the participants switched to the nurse’s perspective and engaged in a 15-minute session in which they interacted with a virtual pregnant woman, developed labour care and communication skills, and applied the lessons gained from the first stage to improve their empathy and perform clinical tasks (Fig. 4 ). This process aligns with the ‘legitimate peripheral participation’ aspect of the SLT, whereby learners progress from passive observers to active participants, internalising professional knowledge through hands-on practice. The VR-SHFS provided real-time assessment scenarios, encouraging immediate reflection and behaviour modification in the ‘practice-feedback-adjustment’ manner. On completion, the participants were awarded an achievement certificate in line with the ‘situated interaction and social recognition’ aspect of the SLT to enhance their learning motivation and practical application. Synchronous haptic feedback and motion tracking to simulate the operation of birth balls and massage aids ensured that the participants could utilise the relevant skills (Table 1 ). The interactive process within the VR-SHFS is provided in the following link: https://youtu.be/k8k-0xnQiEw 2.3.2 Control group: spherical video-based virtual reality (SVVR) The SVVR system utilises 360° panoramic video technology to create learning environments. The footage was captured using a Ricoh Theta Z1 360° camera and edited using Power Director 2025 before being embedded into the Unity VR application. The control group viewed the learning content using a Samsung S21 smartphone paired with a mobile VR head-mounted display (HMD), exploring the menu through gaze selection and a handheld controller, selecting learning modules of their choice and accessing the corresponding 360° VR videos. The SVVR system used a fixed viewpoint with no interactive functions, creating clinical scenarios in the form of panoramic videos to provide a visual learning experience that improved the participants’ understanding of obstetrical nursing procedures and the contexts where they are performed (Fig. 5 ). The control group followed the same SLT-based learning process as the experimental group but the SVVR delivered content through immersive viewing in which the participants learned about labour care through passive observation and did not engage in real-time interaction or hands-on practice (Table 1 ). Table 1 Comparison of educational programmes between VR-SHFS and SVVR Item VR-SHFS (Experimental group) SVVR (Control group) Learning mode Dual-perspective model: mother-to-nurse perspective switch with interactive engagement Dual-perspective video: mother-to-nurse perspective switch with no interaction System technology Haptic feedback, real-time assessment, synchronised visual-audio feedback, motion tracking, 1:1 simulation 360° panoramic video with visual-audio immersion, lacking haptic feedback Learning content Hands-on labour care skills: massage, birth ball, acupressure, breathing guidance Passive observation of labour care techniques via a 360° video Interactivity High: Free operation with real-time feedback Low: Passive viewing, no engagement Immersion High: Synchronised haptic, visual, and auditory feedback integrated with motion tracking Moderate: Visual-audio immersion, no haptic feedback Real-time assessment Integrated assessment for real-time feedback Self-guided reflection Learning duration 35 min (15 min maternal + 15 min nurse + 5 min assessment) 30 min (15 min maternal + 15 min nurse) 2.4 Health monitoring for virtual reality To ensure the participants’ health and comfort during the VR learning process, each session was limited to 15 minutes, followed by a 10-minute break to reduce potential visual fatigue and discomfort caused by prolonged HMD use. The participants were evaluated for any prior experiences of dizziness, blurred vision, or nausea and were closely monitored during the learning process. The process was immediately paused and they were allowed to rest if any discomfort arose. Additionally, the participants were asked to perform eye relaxation exercises or take a short walk to alleviate fatigue during the break (Choi et al. 2022 ). A 5-minute orientation session was provided to familiarise the participants with the VR environment before the learning process began. This included instructions on wearing the HMD properly, operating the controller, and navigating the user interface, as well as information about potential discomfort and guidance on coping with it (Güngör et al. 2024 ). 2.5 Data collection and procedure This study was conducted in August 2023 following ethics approval for human research (No. NCCU-REC-202306-E068). The researchers developed the VR-SHFS and SVVR systems and all participants provided written informed consent. The data were collected on the participants’ knowledge, empathy, and nursing skills at three time points in a controlled environment to ensure data accuracy and consistency: (1) T0 baseline, (2) T1 immediately after the intervention when the empathy level was measured following the session focused on the labouring woman’s perspective, and knowledge and nursing skills were evaluated following the session focused on the nurse’s perspective; and (3) T2 two months after the intervention when learning retention and system usability were measured. Focus groups were conducted after T2 to explore the participants’ learning experiences and elicit suggestions for system improvement. The study flow diagram is shown in Fig. 1 . 2.6 Instruments 2.6.1 Demographic characteristics questionnaire Since VR may induce motion sickness (Chang et al. 2020 ), a questionnaire was administered to assess the participant’s health status and medical history of conditions such as vertigo, epilepsy, visual or auditory impairments, and panic disorder to ensure that all participants met the physical requirements necessary to engage in VR-based learning activities. 2.6.2 Jefferson Scale of Empathy - Healthcare Providers, Chinese version (JSE-HP) The Chinese version of the Jefferson Scale of Empathy-Health Professionals (JSE-HP) (Cheng et al. 2011 ) translated from the original American English version, adapted for cultural relevance, and validated was used in this study. The JSE-HP consisted of 20 items measured on a 7-point Likert scale (1 = ‘strongly disagree’ and 7 = ‘strongly agree’), with a total score ranging from 20 to 140 and higher scores indicating greater empathy. The scale comprised three dimensions: perspective taking (10 questions), compassionate care (8 questions), and standing in the patient’s shoes (2 questions) explaining 52.40% of the total variance. Cronbach’s α was 0.89 for perspective taking, 0.84 for compassionate care, and 0.73 for standing in the patient’s shoes, with an overall reliability of 0.90 and a split-half reliability of 0.93. The scale had a Cronbach’s α of 0.88–0.90, confirming its suitability for assessing empathy development. 2.6.3 Labour care knowledge scale (LCKS) A labour care knowledge scale (LCKS) was developed to assess the participants’ knowledge of non-pharmacological pain relief methods and techniques (Ouma et al. 2024 ; Srisopa et al. 2021 ). It consisted of 10 multiple-choice questions designed based on clinical scenarios, with each correct response awarded one point, resulting in a total score of 10. Different versions of the LCKS were administered at the three measurement points to reduce familiarity bias whilst ensuring content and difficulty consistency across all versions. The content validity was assessed by two labour ward nurses, one obstetrician, and two academic professors and the content validity index was 1.0, indicating significantly high content validity. 2.6.4 Nursing skills assessment The objective structured clinical examination (OSCE) was used to assess the participants’ labour care skills. It involved physical evaluation and the execution and guidance of non-pharmacological pain relief techniques in a standardised simulated clinical setting. The participants were asked to complete all designated tasks within 15 minutes, and their performance with respect to care skills, care guidance, and nurse-patient communication ability was evaluated by two experienced nurse educators using a standardised proforma. The examiners had to reach a consensus score to ensure the consistency and objectivity of the assessment. The total score was 52 with a pass mark of 32 (Angoff 1971 ). 2.6.5 System usability scale (SUS) The system usability scale (SUS) (Brooke 1996 ) was employed to evaluate the usability and user satisfaction of the VR-SHFS and SVVR learning systems and consisted of 10 items measured on a 5-point Likert scale. The odd-numbered items (1, 3, 5, 7, and 9) are positively worded and are scored minus 1 by the respondent, whereas the even-numbered items (2, 4, 6, 8, and 10) are negatively worded and are scored 5 minus. The total SUS score was obtained by summing all item scores and multiplying by 2.5, resulting in a range of 0 to 100 with higher scores indicating better system usability (Bangor et al. 2008 ). 2.6.6 Focus group Focus groups were conducted after T2 to explore the participants’ experiences with the dual-perspective learning mode, in particular, their understanding and application of the perspectives of the labouring woman and nurse, overall impressions about the learning systems, and suggestions for improvement. The semi-structured design involved the following questions: (1) From the labouring woman’s perspective, what emotions or needs did you perceive? (2) From the nurse’s perspective, did you apply any insight gained from the labouring woman’s perspective? Please describe your application of such insight in specifics. (3) During simulated clinical communication, which features of the system were most helpful to you? What aspects of the system need to be improved? 2.7 Statistical analysis The data were analysed using IBM SPSS 25.0, with generalised estimating equations (GEE) used to examine the effects of time points, group allocation, and their interaction on the participants’ knowledge, empathy, and nursing skills (Liang and Zeger 1986 ). An independent samples t-test was conducted to compare the usability of the VR-SHFS and SVVR systems and a p < .05 was considered significant. Thematic analysis was conducted to identify the main themes from the focus groups (Creswell 2003 ; Houghton et al. 2013 ) which were audio-recorded and transcribed before being coded separately by two qualitative research experts. Peer review was conducted to ensure the consistency and reliability of the qualitative analysis. 3 Results 3.1 Demographics and health characteristics In total, 80 nursing students were recruited and randomly assigned to the experimental ( n = 40) and control ( n = 40) groups. There was no significant difference in the mean age between groups with a similar sex distribution (90% female and 10% male) and no participants had a relevant medical history (Table 2 ). Table 2 Demographic and health profile of participants Variable Experimental ( n =40) Control ( n =40) t p -value Age (years) 21.45 ± 0.59 21.28 ± 0.45 1.478 .143 Gender Female, n (%) 36 (90.0) 36 (90.0) Male, n (%) 4 (10.0) 4 (10.0) Medical history None reported None reported Note: t values are provided for continuous variables (age). The gender distribution is identical between the groups (90% female, 10% male), and no statistical test was performed for gender. The medical history includes dizziness, epilepsy, visual impairments, hearing impairments, cognitive impairments, and panic disorder. No cases were reported in either group. 3.2 Assessment of empathy As shown in Tables 3 and 4 , there was no significant difference between groups in their empathy score at baseline (T0) but the experimental group’s score increased immediately after the intervention (T1) and remained higher than the control group two months after the intervention (T2). The GEE analysis showed significant time/group interactions at T1 (β = 8.97, p = .014) and T2 (β = 10.47, p = .003), indicating that the increase in empathy was noticeably greater in the experimental group than in the control group. 3.3 Knowledge of labour care At baseline (T0), there were no significant differences in the group’s labour care knowledge but the experimental group’s score increased immediately after the intervention (T1), further increasing two months after the intervention (T2) and was significantly higher than the control group (Tables 3 and 4 ). However, the GEE model analysis showed significant time/group interactions at T2 (β = 1.60, p < .001) but not at T1 (β = 0.25, p = .435), suggesting that the experimental group demonstrated superior knowledge retention than the control group. 3.4 Nursing skills performance There were no significant differences in the group’s nursing skills at baseline (T0), with the experimental group’s score significantly increasing immediately after the intervention (T1) and remaining considerably higher than the control group two months after the intervention (T2) (Tables 3 and 4 ). The GEE analysis showed significant time/group interactions between time and group at T1 (β = 8.57, p < .001) and T2 (β = 13.65, p < .001), indicating that the experimental group’s nursing skills markedly improved over time. 3.5 Usability of the VR learning systems The overall usability score of the VR-SHFS was significantly higher ( p = .026) than the SVVR system (Table 5 ). Of all positively worded items, the VR-SHFS attained higher scores in ‘I would frequently use this system’ (4.95 vs. 3.77, p < .001), ‘The system’s functions are well integrated’ (4.92 vs. 3.22, p < .001), and ‘I feel confident using the system’ (4.90 vs. 4.05, p < .001), scoring lower score in ‘The system's functions are inconsistent’ (1.30 vs. 2.75, p < .001), indicating better functionality consistency. However, the VR-SHFS scored higher in items related to the operational burden, suggesting a higher learning barrier whereas the SVVR was easier to use, attaining significantly higher scores in ‘The system is easy to use’ (4.45 vs. 4.05, p = .014) and ‘Most people would quickly learn to use it’ (4.65 vs. 4.20, p = .009). Table 3 Descriptive statistics for knowledge, empathy and skills Variable Sub-Dimension Group T0 (Mean ± SD) T1 (Mean ± SD) T2 (Mean ± SD) Knowledge Experimental 6.82 ± 1.12 8.62 ± 0.92 8.87 ± 1.06 Control 6.92 ± 1.30 8.47 ± 0.98 7.37 ± 1.25 Empathy Experimental 100.23 ± 10.35 118.85 ± 10.81 119.10 ± 11.19 Control 102.02 ± 15.25 111.67 ± 10.32 110.42 ± 10.56 Perspective taking Experimental 59.01 ± 7.19 65.07 ± 5.19 64.87 ± 5.40 Control 60.50 ± 6.51 62.42 ± 6.92 61.27 ± 4.84 Compassionate care Experimental 34.67 ± 6.50 44.35 ± 6.84 44.57 ± 7.07 Control 34.82 ± 8.72 40.97 ± 5.94 41.01 ± 5.78 Standing in the patient's shoes Experimental 6.55 ± 1.52 9.42 ± 1.79 9.65 ± 1.81 Control 6.70 ± 2.08 8.27 ± 1.95 8.15 ± 1.83 Skills Experimental 23.95 ± 8.04 46.15 ± 5.36 45.87 ± 5.64 Control 24.25 ± 9.95 37.87 ± 7.96 32.52 ± 7.86 Note: T0 = Baseline; T1 = Immediately after the intervention; T2 = Two months after the intervention. Experimental group n = 40; Control group n = 40. Table 4 Generalised estimating equation analysis of time effects on knowledge, empathy and skills across groups Variable Estimated parameter (β) Standard error (SE) 95% CI Wald χ2 p- value Lower Upper Knowledge Intercept 6.92 0.20 6.52 7.32 1149.07 <.001 Group a − 0.10 0.27 − 0.63 0.43 0.14 .711 T1 b 1.55 0.24 1.07 2.03 40.08 <.001 T2 b 0.45 0.28 − 0.11 1.01 2.49 .114 Group × T1 0.25 0.32 − 0.38 0.88 0.61 .435 Group × T2 1.60 0.38 0.84 2.37 17.22 <.001 Empathy Intercept 102.02 2.38 97.35 106.69 1834.41 < .001 Group a − 1.80 2.87 − 7.44 3.84 0.39 .532 T1 b 9.65 2.87 4.01 15.28 11.26 .001 T2 b 8.40 2.60 3.30 13.50 10.42 .001 Group × T1 8.97 3.64 1.84 16.11 6.08 .014 Group × T2 10.47 3.47 3.66 17.28 9.09 .003 Skills Intercept 24.25 1.55 21.20 27.29 243.41 < .001 Group a − 0.30 1.99 − 4.22 3.62 0.02 .881 T1 b 13.62 0.81 12.04 15.21 285.77 < .001 T2 b 8.27 0.79 6.71 9.84 107.41 < .001 Group × T1 8.57 1.02 6.57 10.58 70.54 < .001 Group × T2 13.65 1.07 11.55 15.75 161.78 < .001 Note: T0 = Baseline; T1 = Immediately after the intervention; T2 = Two months after the intervention. a Reference group: control group. b Reference point: pre-test (T0). Table 5 Comparison of usability scores between VR-SHFS and SVVR systems Usability item VR-SHFS (Mean ± SD) SVVR (Mean ± SD) t p -value 1. I think I would frequently use this system. 4.95 ± 0.32 3.77 ± 1.07 6.638 < .001 2. I found the system unnecessarily complex. 2.40 ± 0.62 1.97 ± 0.77 − 2.703 .008 3. I thought the system was easy to use. 4.05 ± 0.61 4.45 ± 0.81 − 2.504 .014 4. I think I would need technical support to use this system. 4.47 ± 0.68 3.20 ± 0.69 − 8.350 < .001 5. I found the various functions of this system well-integrated. 4.92 ± 0.66 3.22 ± 0.86 11.916 < .001 6. I think the various functions of this system are inconsistent. 1.30 ± 0.52 2.75 ± 0.98 8.275 < .001 7. Most people would learn to use this system quickly. 4.20 ± 0.88 4.65 ± 0.58 − 2.695 .009 8. I found the system very cumbersome to use. 2.45 ± 0.87 1.97 ± 0.77 − 2.580 .012 9. I felt very confident using this system. 4.90 ± 0.57 4.05 ± 0.89 5.482 < .001 10. I needed to learn a lot of things before I could start using this system. 2.75 ± 0.80 1.82 ± 0.74 − 5.488 < .001 Total score 74.06 ± 4.96 71.06 ± 6.69 2.277 .026 Note: Odd-numbered items (1, 3, 5, 7, 9) are scored as "score minus 1", and even-numbered items (2, 4, 6, 8, 10) as "5 minus the score". The total score is then multiplied by 2.5, resulting in a range of 0 to 100. 3.6 Qualitative analysis of learning experiences Five main themes emerged from the focus groups as follows: (1) Improved empathy The high level of immersion and interactivity offered by the VR-SHFS allowed the participants to better understand the anxiety and discomfort experienced by labouring women, ultimately enhancing their empathy: ‘When experiencing the labouring woman’s perspective, I could feel her helplessness and anxiety, especially when she was alone in the labour room’ (P03, VR-SHFS). ‘Through VR, I started thinking about how to change my tone when talking with the labouring woman to reduce her tension’ (P11, VR-SHFS). By contrast, SVVR presented the learning content through 360° videos and lacked interactivity: ‘It felt like watching a video—I couldn’t truly experience what the labouring woman was feeling’ (P49, SVVR). (2) Improved communication skills The real-time interactivity offered by the VR-SHFS enabled the participants to improve their nurse-patient communication skills: ‘When I switched to an encouraging approach, such as “Try taking a deep breath, it will help you relax”, the labouring woman responded more positively’ (P07, VR-SHFS). Although SVVR lacked interactivity, it allowed the participants to observe how the nurse communicated with the labouring woman: ‘Although I couldn’t engage in actual conversation, I could see how the nurse reassured an anxious labouring woman, which was helpful for clinical practice’ (P52, SVVR). (3) Improved technical competence The haptic feedback and motion tracking technology offered by the VR-SHFS enabled the participants to practise labour care skills: ‘VR allowed me to actually use the birth ball and change the labouring woman’s posture based on system feedback to relieve her discomfort’ (P25, VR-SHFS). By contrast, SVVR relied primarily on observation and the participants could not perform the tasks: ‘The video demonstrated nursing techniques, but I couldn’t practise them myself, and this was a limitation’ (P60, SVVR). (4) Improved learning motivation The real-time assessment and certificates awarded by the VR-SHFS improved the participants’ learning motivation and sense of accomplishment: ‘Receiving a certificate after completing the training gave me a sense of achievement and made the learning experience feel more valuable’ (P37, VR-SHFS). Some participants felt the videos in SVVR enhanced their learning interest: ‘The 360-degree videos helped me understand pain relief techniques and gave me a clearer sense of obstetrical nursing’ (P68, SVVR). (5) Discomfort and system issues Some participants reported that prolonged use of VR equipment caused discomfort such as dizziness and eye fatigue: ‘I felt a bit dizzy after wearing it for too long, and my eyes got really tired looking at the VR screen for an extended time’ (P05, VR-SHFS). Others stated that the VR-SHFS occasionally experienced delays or tracking inaccuracies which made it difficult to use: ‘Sometimes the hand tracking wasn’t accurate, and the virtual display didn’t match actual movements’ (P21, VR-SHFS). 4 Discussion The effects of the VR-SHFS and SVVR systems on nursing students’ acquisition of labour care skills, knowledge application, and empathy development were assessed, indicating that the VR-SHFS offering high immersion, synchronous haptic feedback, and real-time interaction significantly enhanced the students’ learning outcomes. This aligns with Eidenberger ( 2018 ) who found that multi-sensory synchronisation strengthens VR immersion, with haptic synchronisation exerting the strongest effects. Furthermore, Wang et al. ( 2019 ) argued that simultaneous stimulation of cutaneous and kinaesthetic receptors improves haptic feedback realism, allowing learners to acquire skills more precisely. The motion tracking and haptic feedback offered by the VR-SHFS enabled students to experience physiological limitations from the labouring woman’s perspective and adjust their nursing behaviour in real-time, reinforcing the ‘experience-reflection-application’ learning process (Choshi 2024 ; Gibbs and Priest 2010 ). Whilst SVVR provided an immersive visual and auditory experience, it had limited efficacy in skill and empathy development because of a lack of interactivity (Chang et al. 2020 ; Young et al. 2022 ). This was consistent with the findings of Basri et al. ( 2024 ) who reported that SVVR has limited effects on social skills training for autistic adolescents and recommended the addition of interactive elements. SVVR participants learn primarily through passive observation, making it difficult to emotionally connect with the labouring woman (Donnelly et al. 2020 ; Jiang et al. 2024 ). Whilst 360° videos can deliver knowledge, their lack of interactivity makes it difficult to encourage emotional connection and they must be combined with interactive elements to encourage deep learning (Ulrich et al. 2021 ). The present study contributed to the existing literature by showing that VR-based learning should integrate interactive mechanisms and haptic feedback to improve clinical competence. The dual-perspective learning mode in the VR-SHFS effectively enhanced nursing students’ empathy and aligns with the SLT which argues that learning should occur in actual clinical settings, where participation facilitates the internalisation of knowledge and skills (Lave and Wenger 1991 ). The VR-SHFS provides an FPP to experience the physiological and psychological stresses of the labouring woman before switching to the nurse’s perspective to engage in clinical care and interaction, thereby improving the participant’s understanding of maternal needs and empathy development. Moreover, VR-based role-playing exercises implemented from the nurse’s perspective can enhance emotional connection and the performance of clinical tasks (Dubovi and Itzhaki 2023 ; Ma et al. 2021 ) but FPP alone does not ensure empathy development. The VR-SHFS compared favourably with SVVR because its combination of real-time interaction, immersive haptic feedback, and dynamic perspective switching allowed the students to not only ‘see’ the needs of the labouring woman but also ‘feel’ them and apply what they had learnt. Similarly, Salminen et al. ( 2022 ) and Young et al. ( 2022 ) reported that multi-modal technologies which deliver haptic, auditory, and physiological feedback can enhance the effects of VR on emotional interaction, thereby developing learners’ empathy. The VR-SHFS participants maintained strong learning outcomes even two months after the intervention, particularly labour pain management techniques. This sustained effect may be attributed to VR-SHFS's integration of synchronous haptic feedback and motion tracking technology, enabling learners to practise maternal positioning adjustments, birthing ball exercises, massage for pain relief, and guided breathing techniques within a virtual environment. This interactive approach facilitates the internalisation and application of acquired skills, enhancing procedural accuracy and clinical competency. This finding aligns with those of Butt et al. ( 2018 ) and Jung et al. ( 2012 ) who showed that VR training with haptic feedback can improve the motivation to acquire nursing skills and competence. Additionally, VR training with haptic feedback can enhance competence in nursing skills, particularly for invasive procedures (Cho and Kim 2024 ; Choi et al. 2022 ; Plotzky et al. 2021 ). However, it is unclear whether the learning outcomes gained through the VR-SHFS can be sustained beyond six months and translated into clinical practice. Although Kim and Park ( 2024 ) maintained that VR training may have long-term effects on clinical skill retention, reinforcement training is required to ensure successful skill transfer to clinical settings. In the case of the SVVR participants, skill application was limited (Chang et al. 2022 ; Jallad and Işık 2024 ) because the VR system primarily delivered 360° videos to teach labour pain relief techniques but provided no hands-on exercises. This study compared the usability and learning satisfaction of the VR-SHFS and SVVR systems with the former being deemed more favourable in terms of system integration and learner confidence. However, due to its greater technical complexity, the VR-SHFS required more time to learn and additional technical support. This is consistent with the findings of Rim and Shin ( 2021 ) and Jallad and Işık ( 2024 ) who reported that whilst haptic feedback enhances skill acquisition, inadequate support may negatively influence the learning experience. Although the VR-SHFS has significant advantages in skill acquisition and empathy development, SVVR remains applicable in certain contexts, for example, as a foundational learning tool for learners with limited technical proficiency or in educational settings with limited resources. SVVR was deemed more favourable regarding usability and adaptability due to its intuitive operation and lower learning difficulty. Likewise, Chang et al. ( 2022 ) reported that simple and intuitive VR designs can reduce learners’ technology-related anxiety, making them particularly suitable for beginners. Therefore, future studies should develop a phased learning model in which SVVR is used to establish fundamental concepts, followed by a VR-SHFS for high-interactivity skills training. The real-time assessment built in the VR-SHFS fosters learning engagement and motivation (Liu et al. 2022 ; Yan 2020 ). The real-time scoring and awarding of certificates enabled the students to track their progress, thereby increasing their willingness to engage in self-directed learning. Indeed, the students perceived real-time feedback as helpful in quickly identifying and addressing mistakes, whilst certificates reinforced their sense of achievement. By contrast, SVVR lacked real-time feedback so the students relied more on video content to engage in learning, hindering personalised learning and the sense of accomplishment (Demircan et al. 2024 ). However, some students reported experiencing physical discomfort when using VR equipment, such as dizziness, eye strain, and the burden of wearing the device (Choi et al. 2022 ). Additionally, some students mentioned occasional system delays and inaccurate hand tracking which affected the smoothness of operation. Mubarrat et al. ( 2024 ) identified motion tracking accuracy and response delay as critical factors affecting the VR experience; this is particularly relevant in healthcare training which requires precise operation (Cho and Kim 2024 ; Vaughan and Gabrys 2020 ). Future studies should improve the comfort of VR equipment, enhance motion tracking and delay control, and integrate adaptive learning mechanisms and physiological sensing technologies to adjust learning difficulty dynamically. 4.1 Research limitations and recommendations This study has several limitations. First, the participants were recruited from one educational institution, resulting in a relatively homogeneous sample, which may affect the generalisability of the findings. Future studies should recruit students from different educational systems and academic levels, or clinical nurses, to assess the applicability and efficacy of VR training across different learner populations. Second, the follow-up period spanned two months post-intervention so future studies should explore the influence of VR training on skill retention and clinical application over an extended follow-up period. Some limitations in the technical aspect of VR equipment should also be discussed. Several participants reported discomfort when wearing VR equipment for an extended time, and they also stated that motion-tracking errors and system latency hindered learning. Enhancing equipment comfort, increasing motion-tracking accuracy, and reducing system latency may improve the learning experience and technical feasibility of VR. Finally, future studies should compare long-term learning outcomes between VR training and clinical simulation training to assess the applicability and sustained influence of VR in the context of nursing education. 5 Conclusion The VR-SHFS demonstrated efficacy in enhancing nursing students’ skills, empathy, and knowledge application whilst maintaining short-term learning outcomes. Further research is needed to explore long-term skill retention, equipment comfort, and technical optimisation to ensure the sustained benefits of the system for clinical training. Moreover, the VR-SHFS integrating synchronous haptic and motion tracking technology can be used in emergency training such as cardiopulmonary resuscitation, airway management, and trauma care to enhance skill precision and the ability to perform clinical tasks, thereby expanding the innovative application and value of VR in nursing education. Declarations Acknowledgements The authors extend their gratitude to the nursing student participants for their time and patience in this study. Author contributions PJC designed all experiments and drafted the main manuscript; WKL contributed VR technology; all authors reviewed and approved the manuscript. Funding National Science and Technology Council, Taiwan, under Project Numbers NSTC 112-2637-H-161-002 and NSTC 113-2637-H-161-001. Data availability Data for scientific purposes can be obtained from the authors on request. Conflict of interest The authors declares that there is no conflict of interest. Ethical approval Before participant recruitment, this study received ethical approval from the National Chengchi University Research Ethics Committee (No. NCCU-REC-202306-E068). References Aktas S, Pasinlioglu T (2020) The effect of empathy training on the empathic communication skills of midwives and the birth satisfaction of mothers giving birth with these midwives: A quasi-experimental study. J Eval Clin Pract 1(1):1–10. https://doi.org/10.1111/jep.13523 AlMekkawi M, El Khalil R (2022) Undergraduate nursing students' readiness to practice: Views of the senior students in the United Arab Emirates. Nurse Educ 47(4):E86–E90. https://doi.org/10.1097/NNE.0000000000001153 Angoff WH (1971) Scales, norms and equivalent scores. In: Thorndike RL (ed) Educational Measurement, 2nd edn. American Council on Education, Washington, DC, pp 508–600 Bangor A, Kortum PT, Miller JT (2008) An empirical evaluation of the System Usability Scale. Int J Hum Comput Interact 24(6):574–594. https://doi.org/10.1080/10447310802205776 Basri MAF, Ismail WSW, Nor NK, Tohit NM, Samad FDA, Ahmad MN et al (2024) Development of a social communication skills intervention using video modeling and spherical video-based virtual reality for high-functioning autism spectrum disorder youth: A preliminary study. IEEE Access 12:77976–77987. https://doi.org/10.1109/ACCESS.2024.3407114 Botvinick M, Cohen J (1998) Rubber hands ‘feel’ touch that eyes see. Nature 391:756. https://doi.org/10.1038/35784 Bradford HM, Farley CL, Escobar M, Heitzler ET, Tringali T, Walker KC (2021) Rapid curricular innovations during COVID-19 clinical suspension: Maintaining student engagement with simulation experiences. J Midwifery Womens Health 66(3):366–371. https://doi.org/10.1111/jmwh.13246 Brooke J (1996) SUS-A quick and dirty usability scale. Usability Eval Ind 189(194):4–7 Butt AL, Kardong-Edgren S, Ellertson A (2018) Using game-based virtual reality with haptics for skill acquisition. Clin Simul Nurs 16:25–32. https://doi.org/10.1016/j.ecns.2017.09.010 Chang CY, Sung HY, Guo JL, Chang BY, Kuo FR (2022) Effects of spherical video-based virtual reality on nursing students’ learning performance in childbirth education training. Interact Learn Environ 30(3):400–416. https://doi.org/10.1080/10494820.2019.1661854 Chang E, Kim HT, Yoo B (2020) Virtual reality sickness: A review of causes and measurements. Int J Hum Comput Interact 36(17):1658–1682. https://doi.org/10.1080/10447318.2020.1778351 Chang SC, Hsu TC, Chen YN, Jong MSY (2020) The effects of spherical video-based virtual reality implementation on students’ natural science learning effectiveness. Interact Learn Environ 28(7):915–929. https://doi.org/10.1080/10494820.2018.1548490 Chen PJ, Liou WK (2023) Constructing an immersive virtual reality obstetric nursing learning system to improve the learning achievement of nursing students' cognition, affection, and skills. J Scholarsh Teach Learn 3(2):79–98. https://doi.org/10.7007/JSoTL.202306_3(2).0004 Chen SH, Chen SC, Lee SC, Chang YL, Yeh KY (2017) Impact of interactive situated and simulated teaching program on novice nursing practitioners' clinical competence, confidence, and stress. Nurse Educ Today 55:11–16. https://doi.org/10.1016/j.nedt.2017.04.025 Cheng JF, Lai YM, Livneh H, Tsai TY (2011) Establishing reliability and validity of the Chinese version of the Jefferson Scale of Empathy (Healthcare Providers Version). J Nurs 58(2):41–48. https://doi.org/10.6224/JN.58.2.41 Cho MK, Kim MY (2024) Enhancing nursing competency through virtual reality simulation among nursing students: A systematic review and meta-analysis. Front Med 11:1351300. https://doi.org/10.3389/fmed.2024.1351300 Choi J, Thompson CE, Choi J, Waddill CB, Choi S (2022) Effectiveness of immersive virtual reality in nursing education: Systematic review. Nurse Educ 47(3):E57–E61. https://doi.org/10.1097/NNE.0000000000001117 Choshi M (2024) Addressing challenges in undergraduate community health nursing clinical: Kolb's Experiential Learning Theory. J Nurs Educ 1–4. https://doi.org/10.3928/01484834-20240513-02 Creswell JW (2003) A framework for design. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, pp 9–11 Demircan B, Kıyak Y, Aştı T (2024) The effect of role play prepared with video support on ethical decision-making and motivation levels of nursing students: A quasi-experimental study. Nurs Ethics 09697330241287866. https://doi.org/10.1177/09697330241287 Donnelly F, McLiesh P, Bessell SA (2020) Using 360 video to enable affective learning in nursing education. J Nurs Educ 59(7):409–412. https://doi.org/10.3928/01484834-20200617-11 Dubovi I, Itzhaki M (2023) Playing the role of a nurse in a virtual reality simulation: A safe environment for emotion management. Nurse Educ 48(1):13–18. https://doi.org/10.1097/NNE.0000000000001269 Ehrsson HH, Spence C, Passingham RE (2004) That's my hand! Activity in premotor cortex reflects feeling of ownership of a limb. Science 305(5685):875–877. https://doi.org/10.1126/science.109701 Eidenberger H (2018) Smell and touch in the Virtual Jumpcube. Multimed Syst 24(6):695–709. https://doi.org/10.1007/s00530-018-0592-y Foronda C, Gattamorta K, Snowden K, Bauman EB (2014) Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study. Nurse Educ Today 34(6):e53–e57. https://doi.org/10.1016/j.nedt.2013.10.007 Gibbs M, Priest H (2010) Exploring the physical health needs of people with learning disabilities: Facilitation student engagement in learning, using Kolb’s experiential learning cycle. Nurse Educ Pract 10(3):115–118. https://doi.org/10.1016/j.nepr.2009.04.005 Güngör S, Yava A, Koyuncu A (2024) Designing and implementing a training program on surgical hand scrubbing, wearing surgical cap and surgical mask, gowning, and gloving using HMD-based virtual reality technologies for nursing students: An exploration of student perceptions. Front Med 11:1364465. https://doi.org/10.3389/fmed.2024.1364465 Houghton C, Casey D, Shaw D, Murphy K (2013) Rigour in qualitative case-study research. Nurse Res 20(4):2–17. https://doi.org/10.7748/nr2013.03.20.4.12.e326 Jallad ST, Işık B (2024) The effectiveness of immersive virtual reality simulation as an innovative learning strategy for acquisition of clinical skills in nursing education: Experimental design. Games Health J. https://doi.org/10.1089/g4h.2023.01 Jenkins Barnard P, Saylor J, Graber J, Trinkaus D (2024) Educational outcomes in undergraduate nursing: A systematic review. J Nurs Educ 63(6):380–386. https://doi.org/10.3928/01484834-20240404-06 Jiang Z, Zhang Y, Chiang FK (2024) Meta-analysis of the effect of 360‐degree videos on students' learning outcomes and non‐cognitive outcomes. Br J Educ Technol 55(6):2423–2456. https://doi.org/10.1111/bjet.13464 Jung EY, Park DK, Lee YH, Jo HS, Lim YS, Park RW (2012) Evaluation of practical exercises using an intravenous simulator incorporating virtual reality and haptics device technologies. Nurse Educ Today 32(4):458–463. https://doi.org/10.1016/j.nedt.2011.05.012 Kim Y, Park HY (2024) Effects of virtual reality training on clinical skill performance in nursing students: A systematic review, meta-analysis and meta‐regression. Int J Nurs Pract 30(6):e13284. https://doi.org/10.1111/ijn.13284 Lave J, Wenger E (1991) Situated learning: Legitimate peripheral participation. Cambridge Univ Liang KY, Zeger SL (1986) Longitudinal data analysis using generalized linear models. Biometrika 73(1):13–22. https://doi.org/10.1093/biomet/73.1.13 Liu Y, Yang Y, Bai X, Chen Y, Mo L (2022) Do immediate external rewards really enhance intrinsic motivation? Front Psychol 13:853879. https://doi.org/10.3389/fpsyg.2022.853879 Ma Z, Huang KT, Yao L (2021) Feasibility of a computer role-playing game to promote empathy in nursing students: The role of immersiveness and perspective. Cyberpsychol Behav Soc Netw 24(11):750–755. https://doi.org/10.1089/cyber.2020.037 Melo M, Gonçalves G, Monteiro P, Coelho H, Vasconcelos-Raposo J, Bessa M (2020) Do multisensory stimuli benefit the virtual reality experience? A systematic review. IEEE Trans Vis Comput Graph 28(2):1428–1442. https://doi.org/10.1109/TVCG.2020.3010088 Moller AB, Welsh J, Gross MM, Petzold M, Ayebare E, Chipeta E et al (2021) Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: A mixed-method study protocol. Reprod Health 18:1–9. https://doi.org/10.1186/s12978-021-01109-8 Moraes EMBD, Carvalho DRDS, Sandars J, Ozahata TM, Patel R, Cecilio-Fernandes D, Santos TM (2024) Unravelling the differences between observation and active participation in simulation-based education. Med Teach 1–6. https://doi.org/10.1080/0142159X.2024.2396381 Mubarrat S, Chowdhury S, Fernandes A (2024) Evaluating visual-spatiotemporal co-registration of a physics-based virtual reality haptic interface. IEEE Access 12:57017–57032. https://doi.org/10.1109/ACCESS.2024.3391186 Ouma EG, Orango O, Were E, Omwodo KA (2024) Labour pain relief practice by maternal health care providers at a tertiary facility in Kenya: An institution-based descriptive survey. PLoS ONE 19(3):e0299211. https://doi.org/10.1371/journal.pone.0299211 Plotzky C, Lindwedel U, Sorber M, Loessl B, König P, Kunze C et al (2021) Virtual reality simulations in nurse education: A systematic mapping review. Nurse Educ Today 101:104868. https://doi.org/10.1016/j.nedt.2021.104868 Polit DF, Beck CT (2021) Nursing research: Generating and assessing evidence for nursing practice, 11th edn. Lippincott Williams & Wilkins Rim D, Shin H (2021) Effective instructional design template for virtual simulations in nursing education. Nurse Educ Today 96:104624. https://doi.org/10.1016/j.nedt.2020.104624 Salminen M, Järvelä S, Ruonala A, Harjunen VJ, Hamari J, Jacucci G, Ravaja N (2022) Evoking physiological synchrony and empathy using social VR with biofeedback. IEEE Trans Affect Comput 13(2):746–755. https://doi.org/10.1109/TAFFC.2019.2958657 Shadiev R, Yang L, Huang YM (2022) A review of research on 360-degree video and its applications to education. J Res Technol Educ 54(5):784–799. https://doi.org/10.1080/15391523.2021.1928572 Srisopa P, Cong X, Russell B, Lucas R (2021) The role of emotion regulation in pain management among women from labor to three months postpartum: An integrative review. Pain Manag Nurs 22(6):783–790. https://doi.org/10.1016/j.pmn.2021.05.011 Temple F, Carlsson Lalloo E, Berg M, Berg U, Munyali Désiré A, Nyakio O et al (2024) Evaluating the implementation of person-centred care and simulation-based learning in a midwifery education programme in the Democratic Republic of Congo: A study protocol. Glob Health Action 17(1):2370097. https://doi.org/10.1080/16549716.2024.2370097 Ulrich F, Helms NH, Frandsen UP, Rafn AV (2021) Learning effectiveness of 360 video: Experiences from a controlled experiment in healthcare education. Interact Learn Environ 29(1):98–111. https://doi.org/10.1080/10494820.2019.1579234 Vaughan N, Gabrys B (2020) Scoring and assessment in medical VR training simulators with dynamic time series classification. Eng Appl Artif Intell 94:103760. https://doi.org/10.1016/j.engappai.2020.103760 Villegas N, Cianelli R, Cerisier K, Fernandez-Pineda M, Jacobson F, Lin HH et al (2021) Development and evaluation of a telehealth-based simulation to improve breastfeeding education and skills among nursing students. Nurse Educ Pract 57:103226. https://doi.org/10.1016/j.nepr.2021.103226 Wang D, Ohnishi K, Xu W (2019) Multimodal haptic display for virtual reality: A survey. IEEE Trans Ind Electron 67(1):610–623. https://doi.org/10.1109/TIE.2019.2920602 Wighus M, Bjørk IT (2018) An educational intervention to enhance clinical skills learning: Experiences of nursing students and teachers. Nurse Educ Pract 29:143–149. https://doi.org/10.1016/j.nepr.2018.01.004 Yan Z (2020) Self-assessment in the process of self-regulated learning and its relationship with academic achievement. Assess Eval High Educ 45(2):224–238. https://doi.org/10.1080/02602938.2019.1629390 Young GW, O’Dwyer N, Smolic A (2022) Exploring virtual reality for quality immersive empathy building experiences. Behav Inf Technol 41(16):3415–3431. https://doi.org/10.1080/0144929X.2021.1993336 Additional Declarations No competing interests reported. Supplementary Files VirtualRealitySynchronousHapticFeedbackSimulationNEW.mp4 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6220812","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":442710772,"identity":"53295825-3870-4789-b0fe-bcc4b5b8a316","order_by":0,"name":"Pao-Ju Chen","email":"","orcid":"","institution":"Asia Eastern University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Pao-Ju","middleName":"","lastName":"Chen","suffix":""},{"id":442710773,"identity":"c33d4ed3-3387-43ab-8d9a-160aec04658d","order_by":1,"name":"Wei-Kai Liou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2RsUrEQBBAJyycTcy1Gw78hoWDQ1D0V0YCl+YKq3A2h1WuuQ9Q7ieE+4EJU8RiuXQSiWDSWKe0UHBjxEKSaGmxr9ndYd/M7gyAxfIfSddEcinPxmZP5Xd4NKBofUHH+jTwr42CABJAtIrbp+Q4pat47tyROfxJ8XJEeoxZTB+4MlWeVirLCOqI4Vxip+LripKbPXuzYq6M8iJVHoBjIuD2KCpFZBmxmBXYKGwUAeIwNsqkRyFU/DZiZ7cN61bJGMT7kHJvksvm+5PFVxUKQDgDiq81kjRNlsXisqno3+aBSjb70HWfy+6OpWuuP0e5DXd1veSxlyVV+RqdHB1sqFP5+c52ae72TtJisVgsv/MBzq1uIEGiWBMAAAAASUVORK5CYII=","orcid":"","institution":"National Taiwan University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Wei-Kai","middleName":"","lastName":"Liou","suffix":""}],"badges":[],"createdAt":"2025-03-13 14:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6220812/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6220812/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80816289,"identity":"317464ec-be41-4c08-a79f-6c69b650a9be","added_by":"auto","created_at":"2025-04-17 11:09:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":315583,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flow diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6220812/v1/ee179b0d1ea6f042de72ce79.png"},{"id":80817560,"identity":"474427d0-22a5-4668-91b0-964b913dd2f7","added_by":"auto","created_at":"2025-04-17 11:33:58","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":218514,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of VR-SHFS motion tracking and interaction mechanism\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6220812/v1/b85550c94b8a7fb55b8dc05c.jpeg"},{"id":80816518,"identity":"f949ec73-3d62-4d26-8c19-f8937a964d82","added_by":"auto","created_at":"2025-04-17 11:17:58","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":294176,"visible":true,"origin":"","legend":"\u003cp\u003eMaternal perspective mode: the virtual avatar's movements are synchronised with the learner's actions (a); In maternal perspective simulation, the learner experiences labour care as provided by the virtual nurse avatar in VR-SHFS (b)\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6220812/v1/7a5309c07b91fee494eb88c6.jpeg"},{"id":80816519,"identity":"e72bc870-0204-4280-be30-db26424abcc2","added_by":"auto","created_at":"2025-04-17 11:17:58","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":264873,"visible":true,"origin":"","legend":"\u003cp\u003eNurse perspective mode: the virtual avatar's movements are synchronised with the learner's actions (a); In nurse perspective simulation, the learner performs labour care on the virtual maternal avatar in VR-SHFS (b)\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6220812/v1/a2bee2e3e5537ba06dba6eea.jpeg"},{"id":80816296,"identity":"01044638-b5c5-4c34-9abd-b46db155e6ed","added_by":"auto","created_at":"2025-04-17 11:09:58","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":382446,"visible":true,"origin":"","legend":"\u003cp\u003eSVVR system utilises 360° panoramic video to simulate both nurse and maternal perspectives for immersive observational learning\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6220812/v1/37043c59404929d7ae52ddd7.jpeg"},{"id":90361617,"identity":"df5de690-83ce-41c7-a7ba-56996d7e14b9","added_by":"auto","created_at":"2025-09-02 01:31:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2667250,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6220812/v1/95a9a3c1-4af7-4e43-8ba4-6936193888db.pdf"},{"id":80816389,"identity":"505f5722-ba66-49c8-aa84-519f6ab01f2a","added_by":"auto","created_at":"2025-04-17 11:10:45","extension":"mp4","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":730761428,"visible":true,"origin":"","legend":"","description":"","filename":"VirtualRealitySynchronousHapticFeedbackSimulationNEW.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6220812/v1/1738729129f824a2662ab939.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Evaluation of Synchronous Haptic Feedback Simulation in Dual-Perspective Virtual Reality for Labour Care: A Situated Learning-Based Randomised Controlled Trial","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eMaternity nursing education emphasises people-centred care and simulation-based learning to equip students with clinical skills, professional knowledge, and empathy, ensuring they can effectively assist women during labour and childbirth and thus promote the health of mothers and infants (Aktas and Pasinlioglu \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Temple et al. \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, limited clinical placements, insufficient resources, and a lack of timely feedback make it difficult for students to adequately practice nursing skills. In addition, constraints within the clinical environment lead to a lack of hands-on experience, restricting skill development and clinical decision-making (AlMekkawi and El Khalil \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Bradford et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Moller et al. \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Traditional teaching relies heavily on lectures and demonstrations with students often taking a passive observational role with no active participation and hands-on opportunities (Jenkins Barnard et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Moraes et al. \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Although simulation-based training facilitates knowledge acquisition, it fails to fully replicate the real-time needs and authentic interactions that characterise maternal care (Villegas et al. \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVirtual reality (VR) provides an immersive training environment where learners can safely practise skills through avatars and make mistakes without pressure (Foronda et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Melo et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) but most VR-based teaching approaches rely on static images or one-way information delivery, turning learners into passive observers with limited interaction and real-time feedback (Shadiev et al. \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). For example, spherical video-based virtual reality (SVVR) simulates clinical scenarios but does not allow learners to engage in hands-on practice (Ulrich et al. \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Additionally, traditional VR-based teaching depends on visual and auditory inputs and does not enable bodily perception or role-based experience which may limit learners\u0026rsquo; understanding of clinical contexts and application of their clinical skills (Cho and Kim \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Choi et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Plotzky et al. \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). By contrast, VR systems equipped with motion tracking and haptic feedback can enhance immersion and learner engagement (Eidenberger \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) because stimulating both cutaneous and kinaesthetic receptors provides a more realistic tactile feedback experience (Wang et al. \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Moreover, integrating visual, auditory, and haptic feedback in a VR environment facilitates sensory integration and motor coordination, improving the effectiveness of healthcare skills training (Melo et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Haptic feedback technology can improve the precision of learners\u0026rsquo; procedural skills such as urinary catheterisation (Butt et al. \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and venipuncture (Jung et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Thus, high-interactivity VR technology can address the limitations of traditional VR-based teaching, offering a more effective learning approach.\u003c/p\u003e \u003cp\u003eThe first-person perspective (FPP) allows learners to engage with others\u0026rsquo; life experiences, thus helping them understand complex and nuanced concepts, such as empathy (Ma et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Young et al. \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), emotional management, and care-related stress (Dubovi and Itzhaki \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Chen and Liou (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found that when learners used the FPP to experience a pregnant woman\u0026rsquo;s situation, they gained a deeper understanding of her needs, thereby fostering their empathy. It is essential for obstetric nurses to accurately perceive labour pain and emotional changes in pregnant women to provide appropriate care (Ouma et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Srisopa et al. \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Therefore, we designed a \u0026lsquo;dual-perspective learning mode\u0026rsquo; whereby students experienced the physiological and psychological stresses of labour from the mother\u0026rsquo;s perspective before shifting to the nurse\u0026rsquo;s perspective to acquire clinical care skills in line with the situated learning theory (SLT) which asserts that learning occurs dynamically through social interaction and practical application (Lave and Wenger \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). Accordingly, knowledge is not acquired through one-way transmission but is gradually internalised in real-world contexts via community interaction, observation, participation, and practice (a process known as \u0026lsquo;contextual learning\u0026rsquo;). Additionally, the theory highlights \u0026lsquo;legitimate peripheral participation\u0026rsquo; whereby learners are involved through observation and simple participation before progressively integrating into the professional community and eventually becoming conversant members. It also emphasises that knowledge is co-constructed through social interaction and practice so learning in a realistic clinical environment may better equip students to acquire and apply nursing skills (Chen et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Wighus and Bj\u0026oslash;rk \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA virtual reality synchronous haptic feedback system (VR-SHFS) was developed that simulated clinical procedures and improved the application of clinical skills using haptic feedback to reinforce learners\u0026rsquo; VR experiences and motion tracking to allow interaction with virtual characters and physical assistive devices (\u003cem\u003ee.g.\u003c/em\u003e, birth balls and hospital beds). Grounded in the SLT, the VR-SHFS was used to design a VR teaching plan that used the dual-perspective learning mode to improve learners\u0026rsquo; immersion and interactive experiences, thereby facilitating skills training and empathy development.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Objectives\u003c/h2\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo compare the efficacy of the VR-SHFS and SVVR in improving nursing students\u0026rsquo; skills, knowledge application, and empathy regarding labour care.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo explore the influence of the FPP experiences of labouring women on nursing students\u0026rsquo; empathy development and evaluate their learning outcomes in the dual-perspective learning mode.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTo analyse the usability of and learning satisfaction with the VR-SHFS and SVVR, and elucidate what benefits synchronous haptic feedback VR technology can bring to nursing education.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"2 Materials and Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThis randomised controlled trial (RCT) integrated a pre-test and two post-tests. A focus group was conducted to collect qualitative data to comprehensively assess the effects of the VR learning system on students\u0026rsquo; knowledge, empathy, and nursing skills regarding labour care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Settings and participant allocation\u003c/h2\u003e \u003cp\u003eA total of 83 nursing students who had completed fundamental courses in nursing and engaged in simulation-based learning were recruited from a technical university in Taiwan. Stratified and block randomisation was performed to ensure that participants of both sexes and groups were equally distributed (Polit and Beck \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), with eight male students and 75 female students randomly assigned to the experimental (n\u0026thinsp;=\u0026thinsp;42) and control (n\u0026thinsp;=\u0026thinsp;41) groups. Three participants withdrew from the study due to VR-induced dizziness, leaving a final sample of 80 (40 in each group) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Educational programmes\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Experimental group: virtual reality synchronous haptic feedback system (VR-SHFS)\u003c/h2\u003e \u003cp\u003eThe VR-SHFS used the VIVI 3.0 tracker for precise tracking of physical objects (e.g., birth balls, pregnant women, and hospital beds) and constructed a 1:1 scale virtual environment to enable complete alignment between virtual and real-world objects in terms of position and size. This system allowed the participants to touch corresponding physical objects whilst navigating the virtual space, achieving high realism and immersion by producing a haptic illusion effect similar to the rubber hand illusion (Botvinick and Cohen \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Ehrsson et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Moreover, the system was equipped with the VIVE Ultimate Tracker (a self-tracking device) and VIVE 3.0 Tracker (a motion tracker) attached to the upper arms, calves, hands, and the centre of the torso to accurately capture body movements and achieve synchronisation between virtual and real-world actions. The learning environment comprised a physical hospital bed (91.44 cm \u0026times; 203 cm), a birth ball (65 cm in diameter), and a pregnant female mannequin modelled on the 1:1 scale using 3ds Max with texture mapping, mesh optimisation, rendering, and dynamic lighting applied to improve visual authenticity. The environment was developed in Unity 6, with software/hardware integration completed through SteamVR SDK, and inverse kinematics were used to synchronise the movements of virtual characters with those of the participants whilst supporting their interaction with physical objects (e.g., hospital beds and birth balls). This enhanced both visual and haptic feedback, enriching the immersive learning experience. The participants wore the HTC VIVE PRO 2 HMD with a per-eye resolution of 2448 \u0026times; 2448 pixels (4896 \u0026times; 2448 pixels combined), 120\u0026deg; field of view, and refresh rate of 90/120 Hz providing a high-resolution visual experience for detailed representation and immersion (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA VR-SHFS-based teaching plan that created an immersive learning experience from the perspectives of labouring women and nurses was implemented to improve the participants\u0026rsquo; nursing skills and empathy regarding labour care. The learning process consisted of two stages, with the first involving a 15-minute session in which the participants experienced the patient\u0026rsquo;s physiological and psychological changes during labour whilst learning non-pharmacological pain relief techniques (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). This stage aligns with the \u0026lsquo;contextual learning\u0026rsquo; aspect of the SLT by creating immersive experiences for the participants to deepen their understanding of maternal needs and fostering their connections with clinical scenarios. To facilitate knowledge internalisation, the participants had a 10-minute break to reflect on their experiences and reduce their fatigue. In the second stage, the participants switched to the nurse\u0026rsquo;s perspective and engaged in a 15-minute session in which they interacted with a virtual pregnant woman, developed labour care and communication skills, and applied the lessons gained from the first stage to improve their empathy and perform clinical tasks (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This process aligns with the \u0026lsquo;legitimate peripheral participation\u0026rsquo; aspect of the SLT, whereby learners progress from passive observers to active participants, internalising professional knowledge through hands-on practice.\u003c/p\u003e \u003cp\u003eThe VR-SHFS provided real-time assessment scenarios, encouraging immediate reflection and behaviour modification in the \u0026lsquo;practice-feedback-adjustment\u0026rsquo; manner. On completion, the participants were awarded an achievement certificate in line with the \u0026lsquo;situated interaction and social recognition\u0026rsquo; aspect of the SLT to enhance their learning motivation and practical application. Synchronous haptic feedback and motion tracking to simulate the operation of birth balls and massage aids ensured that the participants could utilise the relevant skills (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The interactive process within the VR-SHFS is provided in the following link: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://youtu.be/k8k-0xnQiEw\u003c/span\u003e\u003cspan address=\"https://youtu.be/k8k-0xnQiEw\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Control group: spherical video-based virtual reality (SVVR)\u003c/h2\u003e \u003cp\u003eThe SVVR system utilises 360\u0026deg; panoramic video technology to create learning environments. The footage was captured using a Ricoh Theta Z1 360\u0026deg; camera and edited using Power Director 2025 before being embedded into the Unity VR application. The control group viewed the learning content using a Samsung S21 smartphone paired with a mobile VR head-mounted display (HMD), exploring the menu through gaze selection and a handheld controller, selecting learning modules of their choice and accessing the corresponding 360\u0026deg; VR videos. The SVVR system used a fixed viewpoint with no interactive functions, creating clinical scenarios in the form of panoramic videos to provide a visual learning experience that improved the participants\u0026rsquo; understanding of obstetrical nursing procedures and the contexts where they are performed (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The control group followed the same SLT-based learning process as the experimental group but the SVVR delivered content through immersive viewing in which the participants learned about labour care through passive observation and did not engage in real-time interaction or hands-on practice (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of educational programmes between VR-SHFS and SVVR\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVR-SHFS (Experimental group)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSVVR (Control group)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDual-perspective model: mother-to-nurse perspective switch with interactive engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDual-perspective video: mother-to-nurse perspective switch with no interaction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystem technology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHaptic feedback, real-time assessment, synchronised visual-audio feedback, motion tracking, 1:1 simulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e360\u0026deg; panoramic video with visual-audio immersion, lacking haptic feedback\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHands-on labour care skills: massage, birth ball, acupressure, breathing guidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePassive observation of labour care techniques via a 360\u0026deg; video\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInteractivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh: Free operation with real-time feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow: Passive viewing, no engagement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmersion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh: Synchronised haptic, visual, and auditory feedback integrated with motion tracking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate: Visual-audio immersion, no haptic feedback\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReal-time assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegrated assessment for real-time feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-guided reflection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLearning duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 min (15 min maternal\u0026thinsp;+\u0026thinsp;15 min nurse\u0026thinsp;+\u0026thinsp;5 min assessment)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 min (15 min maternal\u0026thinsp;+\u0026thinsp;15 min nurse)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Health monitoring for virtual reality\u003c/h2\u003e \u003cp\u003eTo ensure the participants\u0026rsquo; health and comfort during the VR learning process, each session was limited to 15 minutes, followed by a 10-minute break to reduce potential visual fatigue and discomfort caused by prolonged HMD use. The participants were evaluated for any prior experiences of dizziness, blurred vision, or nausea and were closely monitored during the learning process. The process was immediately paused and they were allowed to rest if any discomfort arose. Additionally, the participants were asked to perform eye relaxation exercises or take a short walk to alleviate fatigue during the break (Choi et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). A 5-minute orientation session was provided to familiarise the participants with the VR environment before the learning process began. This included instructions on wearing the HMD properly, operating the controller, and navigating the user interface, as well as information about potential discomfort and guidance on coping with it (G\u0026uuml;ng\u0026ouml;r et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data collection and procedure\u003c/h2\u003e \u003cp\u003eThis study was conducted in August 2023 following ethics approval for human research (No. NCCU-REC-202306-E068). The researchers developed the VR-SHFS and SVVR systems and all participants provided written informed consent. The data were collected on the participants\u0026rsquo; knowledge, empathy, and nursing skills at three time points in a controlled environment to ensure data accuracy and consistency: (1) T0 baseline, (2) T1 immediately after the intervention when the empathy level was measured following the session focused on the labouring woman\u0026rsquo;s perspective, and knowledge and nursing skills were evaluated following the session focused on the nurse\u0026rsquo;s perspective; and (3) T2 two months after the intervention when learning retention and system usability were measured. Focus groups were conducted after T2 to explore the participants\u0026rsquo; learning experiences and elicit suggestions for system improvement. The study flow diagram is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Instruments\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.6.1 Demographic characteristics questionnaire\u003c/h2\u003e \u003cp\u003eSince VR may induce motion sickness (Chang et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), a questionnaire was administered to assess the participant\u0026rsquo;s health status and medical history of conditions such as vertigo, epilepsy, visual or auditory impairments, and panic disorder to ensure that all participants met the physical requirements necessary to engage in VR-based learning activities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.6.2 Jefferson Scale of Empathy - Healthcare Providers, Chinese version (JSE-HP)\u003c/h2\u003e \u003cp\u003eThe Chinese version of the Jefferson Scale of Empathy-Health Professionals (JSE-HP) (Cheng et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) translated from the original American English version, adapted for cultural relevance, and validated was used in this study. The JSE-HP consisted of 20 items measured on a 7-point Likert scale (1 = \u0026lsquo;strongly disagree\u0026rsquo; and 7 = \u0026lsquo;strongly agree\u0026rsquo;), with a total score ranging from 20 to 140 and higher scores indicating greater empathy. The scale comprised three dimensions: perspective taking (10 questions), compassionate care (8 questions), and standing in the patient\u0026rsquo;s shoes (2 questions) explaining 52.40% of the total variance. Cronbach\u0026rsquo;s α was 0.89 for perspective taking, 0.84 for compassionate care, and 0.73 for standing in the patient\u0026rsquo;s shoes, with an overall reliability of 0.90 and a split-half reliability of 0.93. The scale had a Cronbach\u0026rsquo;s α of 0.88\u0026ndash;0.90, confirming its suitability for assessing empathy development.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.6.3 Labour care knowledge scale (LCKS)\u003c/h2\u003e \u003cp\u003e A labour care knowledge scale (LCKS) was developed to assess the participants\u0026rsquo; knowledge of non-pharmacological pain relief methods and techniques (Ouma et al. \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Srisopa et al. \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It consisted of 10 multiple-choice questions designed based on clinical scenarios, with each correct response awarded one point, resulting in a total score of 10. Different versions of the LCKS were administered at the three measurement points to reduce familiarity bias whilst ensuring content and difficulty consistency across all versions. The content validity was assessed by two labour ward nurses, one obstetrician, and two academic professors and the content validity index was 1.0, indicating significantly high content validity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.6.4 Nursing skills assessment\u003c/h2\u003e \u003cp\u003eThe objective structured clinical examination (OSCE) was used to assess the participants\u0026rsquo; labour care skills. It involved physical evaluation and the execution and guidance of non-pharmacological pain relief techniques in a standardised simulated clinical setting. The participants were asked to complete all designated tasks within 15 minutes, and their performance with respect to care skills, care guidance, and nurse-patient communication ability was evaluated by two experienced nurse educators using a standardised proforma. The examiners had to reach a consensus score to ensure the consistency and objectivity of the assessment. The total score was 52 with a pass mark of 32 (Angoff \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1971\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e2.6.5 System usability scale (SUS)\u003c/h2\u003e \u003cp\u003eThe system usability scale (SUS) (Brooke \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1996\u003c/span\u003e) was employed to evaluate the usability and user satisfaction of the VR-SHFS and SVVR learning systems and consisted of 10 items measured on a 5-point Likert scale. The odd-numbered items (1, 3, 5, 7, and 9) are positively worded and are scored minus 1 by the respondent, whereas the even-numbered items (2, 4, 6, 8, and 10) are negatively worded and are scored 5 minus. The total SUS score was obtained by summing all item scores and multiplying by 2.5, resulting in a range of 0 to 100 with higher scores indicating better system usability (Bangor et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e2.6.6 Focus group\u003c/h2\u003e \u003cp\u003eFocus groups were conducted after T2 to explore the participants\u0026rsquo; experiences with the dual-perspective learning mode, in particular, their understanding and application of the perspectives of the labouring woman and nurse, overall impressions about the learning systems, and suggestions for improvement. The semi-structured design involved the following questions:\u003c/p\u003e \u003cp\u003e(1) From the labouring woman\u0026rsquo;s perspective, what emotions or needs did you perceive?\u003c/p\u003e \u003cp\u003e(2) From the nurse\u0026rsquo;s perspective, did you apply any insight gained from the labouring woman\u0026rsquo;s perspective? Please describe your application of such insight in specifics.\u003c/p\u003e \u003cp\u003e(3) During simulated clinical communication, which features of the system were most helpful to you? What aspects of the system need to be improved?\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Statistical analysis\u003c/h2\u003e \u003cp\u003eThe data were analysed using IBM SPSS 25.0, with generalised estimating equations (GEE) used to examine the effects of time points, group allocation, and their interaction on the participants\u0026rsquo; knowledge, empathy, and nursing skills (Liang and Zeger \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1986\u003c/span\u003e). An independent samples t-test was conducted to compare the usability of the VR-SHFS and SVVR systems and a p\u0026thinsp;\u0026lt;\u0026thinsp;.05 was considered significant. Thematic analysis was conducted to identify the main themes from the focus groups (Creswell \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Houghton et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) which were audio-recorded and transcribed before being coded separately by two qualitative research experts. Peer review was conducted to ensure the consistency and reliability of the qualitative analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Demographics and health characteristics\u003c/h2\u003e \u003cp\u003eIn total, 80 nursing students were recruited and randomly assigned to the experimental (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40) and control (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40) groups. There was no significant difference in the mean age between groups with a similar sex distribution (90% female and 10% male) and no participants had a relevant medical history (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and health profile of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental (\u003cem\u003en\u003c/em\u003e=40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eControl (\u003cem\u003en\u003c/em\u003e=40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.478\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (10.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNone reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: \u003cem\u003et\u003c/em\u003e values are provided for continuous variables (age). The gender distribution is identical between the groups (90% female, 10% male), and no statistical test was performed for gender.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe medical history includes dizziness, epilepsy, visual impairments, hearing impairments, cognitive impairments, and panic disorder. No cases were reported in either group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Assessment of empathy\u003c/h2\u003e \u003cp\u003eAs shown in Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, there was no significant difference between groups in their empathy score at baseline (T0) but the experimental group\u0026rsquo;s score increased immediately after the intervention (T1) and remained higher than the control group two months after the intervention (T2). The GEE analysis showed significant time/group interactions at T1 (β\u0026thinsp;=\u0026thinsp;8.97, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.014) and T2 (β\u0026thinsp;=\u0026thinsp;10.47, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003), indicating that the increase in empathy was noticeably greater in the experimental group than in the control group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Knowledge of labour care\u003c/h2\u003e \u003cp\u003eAt baseline (T0), there were no significant differences in the group\u0026rsquo;s labour care knowledge but the experimental group\u0026rsquo;s score increased immediately after the intervention (T1), further increasing two months after the intervention (T2) and was significantly higher than the control group (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, the GEE model analysis showed significant time/group interactions at T2 (β\u0026thinsp;=\u0026thinsp;1.60, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) but not at T1 (β\u0026thinsp;=\u0026thinsp;0.25, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.435), suggesting that the experimental group demonstrated superior knowledge retention than the control group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Nursing skills performance\u003c/h2\u003e \u003cp\u003eThere were no significant differences in the group\u0026rsquo;s nursing skills at baseline (T0), with the experimental group\u0026rsquo;s score significantly increasing immediately after the intervention (T1) and remaining considerably higher than the control group two months after the intervention (T2) (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The GEE analysis showed significant time/group interactions between time and group at T1 (β\u0026thinsp;=\u0026thinsp;8.57, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and T2 (β\u0026thinsp;=\u0026thinsp;13.65, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating that the experimental group\u0026rsquo;s nursing skills markedly improved over time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Usability of the VR learning systems\u003c/h2\u003e \u003cp\u003eThe overall usability score of the VR-SHFS was significantly higher (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.026) than the SVVR system (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Of all positively worded items, the VR-SHFS attained higher scores in \u0026lsquo;I would frequently use this system\u0026rsquo; (4.95 vs. 3.77, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), \u0026lsquo;The system\u0026rsquo;s functions are well integrated\u0026rsquo; (4.92 vs. 3.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and \u0026lsquo;I feel confident using the system\u0026rsquo; (4.90 vs. 4.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), scoring lower score in \u0026lsquo;The system's functions are inconsistent\u0026rsquo; (1.30 vs. 2.75, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating better functionality consistency. However, the VR-SHFS scored higher in items related to the operational burden, suggesting a higher learning barrier whereas the SVVR was easier to use, attaining significantly higher scores in \u0026lsquo;The system is easy to use\u0026rsquo; (4.45 vs. 4.05, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.014) and \u0026lsquo;Most people would quickly learn to use it\u0026rsquo; (4.65 vs. 4.20, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.009).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics for knowledge, empathy and skills\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-Dimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e8.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e8.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.92\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e8.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmpathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e100.23\u0026thinsp;\u0026plusmn;\u0026thinsp;10.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e118.85\u0026thinsp;\u0026plusmn;\u0026thinsp;10.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e119.10\u0026thinsp;\u0026plusmn;\u0026thinsp;11.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e102.02\u0026thinsp;\u0026plusmn;\u0026thinsp;15.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e111.67\u0026thinsp;\u0026plusmn;\u0026thinsp;10.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e110.42\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerspective taking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e59.01\u0026thinsp;\u0026plusmn;\u0026thinsp;7.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e65.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e64.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e60.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e62.42\u0026thinsp;\u0026plusmn;\u0026thinsp;6.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e61.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCompassionate care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e34.67\u0026thinsp;\u0026plusmn;\u0026thinsp;6.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e44.35\u0026thinsp;\u0026plusmn;\u0026thinsp;6.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e44.57\u0026thinsp;\u0026plusmn;\u0026thinsp;7.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e34.82\u0026thinsp;\u0026plusmn;\u0026thinsp;8.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e40.97\u0026thinsp;\u0026plusmn;\u0026thinsp;5.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e41.01\u0026thinsp;\u0026plusmn;\u0026thinsp;5.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStanding in the patient's shoes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e9.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e9.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e8.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e8.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e23.95\u0026thinsp;\u0026plusmn;\u0026thinsp;8.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e46.15\u0026thinsp;\u0026plusmn;\u0026thinsp;5.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e45.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e24.25\u0026thinsp;\u0026plusmn;\u0026thinsp;9.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e37.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e32.52\u0026thinsp;\u0026plusmn;\u0026thinsp;7.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: T0\u0026thinsp;=\u0026thinsp;Baseline; T1\u0026thinsp;=\u0026thinsp;Immediately after the intervention; T2\u0026thinsp;=\u0026thinsp;Two months after the intervention. Experimental group \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40; Control group \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneralised estimating equation analysis of time effects on knowledge, empathy and skills across groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEstimated\u003c/p\u003e \u003cp\u003eparameter\u003c/p\u003e \u003cp\u003e(β)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStandard\u003c/p\u003e \u003cp\u003eerror\u003c/p\u003e \u003cp\u003e(SE)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWald χ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep-\u003c/em\u003evalue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1149.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e40.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u0026times; T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.435\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u0026times; T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmpathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e106.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1834.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;7.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u0026times; T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u0026times; T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e243.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.881\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e285.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e107.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u0026times; T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup \u0026times; T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e161.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: T0\u0026thinsp;=\u0026thinsp;Baseline; T1\u0026thinsp;=\u0026thinsp;Immediately after the intervention; T2\u0026thinsp;=\u0026thinsp;Two months after the intervention.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003e Reference group: control group.\u003c/p\u003e \u003cp\u003e \u003csup\u003eb\u003c/sup\u003e Reference point: pre-test (T0).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of usability scores between VR-SHFS and SVVR systems\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsability item\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVR-SHFS (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSVVR\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. I think I would frequently use this system.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.95\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.638\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. I found the system unnecessarily complex.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;2.703\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. I thought the system was easy to use.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;2.504\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. I think I would need technical support to use this system.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;8.350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. I found the various functions of this system well-integrated.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. I think the various functions of this system are inconsistent.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Most people would learn to use this system quickly.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;2.695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. I found the system very cumbersome to use.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;2.580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. I felt very confident using this system.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. I needed to learn a lot of things before I could start using this system.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;5.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e74.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e71.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: Odd-numbered items (1, 3, 5, 7, 9) are scored as \"score minus 1\", and even-numbered items (2, 4, 6, 8, 10) as \"5 minus the score\". The total score is then multiplied by 2.5, resulting in a range of 0 to 100.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Qualitative analysis of learning experiences\u003c/h2\u003e \n\u003cp\u003eFive main themes emerged from the focus groups as follows:\u003c/p\u003e\n\u003cp\u003e(1)\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Improved empathy\u003c/p\u003e\n\u003cp\u003eThe high level of immersion and interactivity offered by the VR-SHFS allowed the participants to better understand the anxiety and discomfort experienced by labouring women, ultimately enhancing their empathy:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;When experiencing the labouring woman\u0026rsquo;s perspective, I could feel her helplessness and anxiety, especially when she was alone in the labour room\u0026rsquo; (P03, VR-SHFS).\u003c/li\u003e\n \u003cli\u003e\u0026lsquo;Through VR, I started thinking about how to change my tone when talking with the labouring woman to reduce her tension\u0026rsquo; (P11, VR-SHFS).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBy contrast, SVVR presented the learning content through 360\u0026deg; videos and lacked interactivity:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;It felt like watching a video\u0026mdash;I couldn\u0026rsquo;t truly experience what the labouring woman was feeling\u0026rsquo; (P49, SVVR).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e(2) \u0026nbsp; \u0026nbsp; \u0026nbsp;Improved communication skills\u003c/p\u003e\n\u003cp\u003eThe real-time interactivity offered by the VR-SHFS enabled the participants to improve their nurse-patient communication skills:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;When I switched to an encouraging approach, such as \u0026ldquo;Try taking a deep breath, it will help you relax\u0026rdquo;, the labouring woman responded more positively\u0026rsquo; (P07, VR-SHFS).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAlthough SVVR lacked interactivity, it allowed the participants to observe how the nurse communicated with the labouring woman:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;Although I couldn\u0026rsquo;t engage in actual conversation, I could see how the nurse reassured an anxious labouring woman, which was helpful for clinical practice\u0026rsquo; (P52, SVVR).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e(3) \u0026nbsp; \u0026nbsp; \u0026nbsp;Improved technical competence\u003c/p\u003e\n\u003cp\u003eThe haptic feedback and motion tracking technology offered by the VR-SHFS enabled the participants to practise labour care skills:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;VR allowed me to actually use the birth ball and change the labouring woman\u0026rsquo;s posture based on system feedback to relieve her discomfort\u0026rsquo; (P25, VR-SHFS).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBy contrast, SVVR relied primarily on observation and the participants could not perform the tasks:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;The video demonstrated nursing techniques, but I couldn\u0026rsquo;t practise them myself, and this was a limitation\u0026rsquo; (P60, SVVR).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e(4) \u0026nbsp; \u0026nbsp; \u0026nbsp;Improved learning motivation\u003c/p\u003e\n\u003cp\u003eThe real-time assessment and certificates awarded by the VR-SHFS improved the participants\u0026rsquo; learning motivation and sense of accomplishment:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;Receiving a certificate after completing the training gave me a sense of achievement and made the learning experience feel more valuable\u0026rsquo; (P37, VR-SHFS).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSome participants felt the videos in SVVR enhanced their learning interest:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;The 360-degree videos helped me understand pain relief techniques and gave me a clearer sense of obstetrical nursing\u0026rsquo; (P68, SVVR).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e(5) \u0026nbsp; \u0026nbsp; \u0026nbsp;Discomfort and system issues\u003c/p\u003e\n\u003cp\u003eSome participants reported that prolonged use of VR equipment caused discomfort such as dizziness and eye fatigue:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;I felt a bit dizzy after wearing it for too long, and my eyes got really tired looking at the VR screen for an extended time\u0026rsquo; (P05, VR-SHFS).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOthers stated that the VR-SHFS occasionally experienced delays or tracking inaccuracies which made it difficult to use:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026lsquo;Sometimes the hand tracking wasn\u0026rsquo;t accurate, and the virtual display didn\u0026rsquo;t match actual movements\u0026rsquo; (P21, VR-SHFS).\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe effects of the VR-SHFS and SVVR systems on nursing students\u0026rsquo; acquisition of labour care skills, knowledge application, and empathy development were assessed, indicating that the VR-SHFS offering high immersion, synchronous haptic feedback, and real-time interaction significantly enhanced the students\u0026rsquo; learning outcomes. This aligns with Eidenberger (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) who found that multi-sensory synchronisation strengthens VR immersion, with haptic synchronisation exerting the strongest effects. Furthermore, Wang et al. (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) argued that simultaneous stimulation of cutaneous and kinaesthetic receptors improves haptic feedback realism, allowing learners to acquire skills more precisely. The motion tracking and haptic feedback offered by the VR-SHFS enabled students to experience physiological limitations from the labouring woman\u0026rsquo;s perspective and adjust their nursing behaviour in real-time, reinforcing the \u0026lsquo;experience-reflection-application\u0026rsquo; learning process (Choshi \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Gibbs and Priest \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Whilst SVVR provided an immersive visual and auditory experience, it had limited efficacy in skill and empathy development because of a lack of interactivity (Chang et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Young et al. \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This was consistent with the findings of Basri et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) who reported that SVVR has limited effects on social skills training for autistic adolescents and recommended the addition of interactive elements. SVVR participants learn primarily through passive observation, making it difficult to emotionally connect with the labouring woman (Donnelly et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Jiang et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Whilst 360\u0026deg; videos can deliver knowledge, their lack of interactivity makes it difficult to encourage emotional connection and they must be combined with interactive elements to encourage deep learning (Ulrich et al. \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The present study contributed to the existing literature by showing that VR-based learning should integrate interactive mechanisms and haptic feedback to improve clinical competence.\u003c/p\u003e \u003cp\u003eThe dual-perspective learning mode in the VR-SHFS effectively enhanced nursing students\u0026rsquo; empathy and aligns with the SLT which argues that learning should occur in actual clinical settings, where participation facilitates the internalisation of knowledge and skills (Lave and Wenger \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). The VR-SHFS provides an FPP to experience the physiological and psychological stresses of the labouring woman before switching to the nurse\u0026rsquo;s perspective to engage in clinical care and interaction, thereby improving the participant\u0026rsquo;s understanding of maternal needs and empathy development. Moreover, VR-based role-playing exercises implemented from the nurse\u0026rsquo;s perspective can enhance emotional connection and the performance of clinical tasks (Dubovi and Itzhaki \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ma et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) but FPP alone does not ensure empathy development. The VR-SHFS compared favourably with SVVR because its combination of real-time interaction, immersive haptic feedback, and dynamic perspective switching allowed the students to not only \u0026lsquo;see\u0026rsquo; the needs of the labouring woman but also \u0026lsquo;feel\u0026rsquo; them and apply what they had learnt. Similarly, Salminen et al. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and Young et al. (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that multi-modal technologies which deliver haptic, auditory, and physiological feedback can enhance the effects of VR on emotional interaction, thereby developing learners\u0026rsquo; empathy.\u003c/p\u003e \u003cp\u003eThe VR-SHFS participants maintained strong learning outcomes even two months after the intervention, particularly labour pain management techniques. This sustained effect may be attributed to VR-SHFS's integration of synchronous haptic feedback and motion tracking technology, enabling learners to practise maternal positioning adjustments, birthing ball exercises, massage for pain relief, and guided breathing techniques within a virtual environment. This interactive approach facilitates the internalisation and application of acquired skills, enhancing procedural accuracy and clinical competency. This finding aligns with those of Butt et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and Jung et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) who showed that VR training with haptic feedback can improve the motivation to acquire nursing skills and competence. Additionally, VR training with haptic feedback can enhance competence in nursing skills, particularly for invasive procedures (Cho and Kim \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Choi et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Plotzky et al. \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, it is unclear whether the learning outcomes gained through the VR-SHFS can be sustained beyond six months and translated into clinical practice. Although Kim and Park (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) maintained that VR training may have long-term effects on clinical skill retention, reinforcement training is required to ensure successful skill transfer to clinical settings. In the case of the SVVR participants, skill application was limited (Chang et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Jallad and Işık \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) because the VR system primarily delivered 360\u0026deg; videos to teach labour pain relief techniques but provided no hands-on exercises.\u003c/p\u003e \u003cp\u003eThis study compared the usability and learning satisfaction of the VR-SHFS and SVVR systems with the former being deemed more favourable in terms of system integration and learner confidence. However, due to its greater technical complexity, the VR-SHFS required more time to learn and additional technical support. This is consistent with the findings of Rim and Shin (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and Jallad and Işık (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) who reported that whilst haptic feedback enhances skill acquisition, inadequate support may negatively influence the learning experience. Although the VR-SHFS has significant advantages in skill acquisition and empathy development, SVVR remains applicable in certain contexts, for example, as a foundational learning tool for learners with limited technical proficiency or in educational settings with limited resources. SVVR was deemed more favourable regarding usability and adaptability due to its intuitive operation and lower learning difficulty. Likewise, Chang et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) reported that simple and intuitive VR designs can reduce learners\u0026rsquo; technology-related anxiety, making them particularly suitable for beginners. Therefore, future studies should develop a phased learning model in which SVVR is used to establish fundamental concepts, followed by a VR-SHFS for high-interactivity skills training.\u003c/p\u003e \u003cp\u003eThe real-time assessment built in the VR-SHFS fosters learning engagement and motivation (Liu et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Yan \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The real-time scoring and awarding of certificates enabled the students to track their progress, thereby increasing their willingness to engage in self-directed learning. Indeed, the students perceived real-time feedback as helpful in quickly identifying and addressing mistakes, whilst certificates reinforced their sense of achievement. By contrast, SVVR lacked real-time feedback so the students relied more on video content to engage in learning, hindering personalised learning and the sense of accomplishment (Demircan et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, some students reported experiencing physical discomfort when using VR equipment, such as dizziness, eye strain, and the burden of wearing the device (Choi et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Additionally, some students mentioned occasional system delays and inaccurate hand tracking which affected the smoothness of operation. Mubarrat et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) identified motion tracking accuracy and response delay as critical factors affecting the VR experience; this is particularly relevant in healthcare training which requires precise operation (Cho and Kim \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Vaughan and Gabrys \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Future studies should improve the comfort of VR equipment, enhance motion tracking and delay control, and integrate adaptive learning mechanisms and physiological sensing technologies to adjust learning difficulty dynamically.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Research limitations and recommendations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the participants were recruited from one educational institution, resulting in a relatively homogeneous sample, which may affect the generalisability of the findings. Future studies should recruit students from different educational systems and academic levels, or clinical nurses, to assess the applicability and efficacy of VR training across different learner populations. Second, the follow-up period spanned two months post-intervention so future studies should explore the influence of VR training on skill retention and clinical application over an extended follow-up period. Some limitations in the technical aspect of VR equipment should also be discussed. Several participants reported discomfort when wearing VR equipment for an extended time, and they also stated that motion-tracking errors and system latency hindered learning. Enhancing equipment comfort, increasing motion-tracking accuracy, and reducing system latency may improve the learning experience and technical feasibility of VR. Finally, future studies should compare long-term learning outcomes between VR training and clinical simulation training to assess the applicability and sustained influence of VR in the context of nursing education.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThe VR-SHFS demonstrated efficacy in enhancing nursing students\u0026rsquo; skills, empathy, and knowledge application whilst maintaining short-term learning outcomes. Further research is needed to explore long-term skill retention, equipment comfort, and technical optimisation to ensure the sustained benefits of the system for clinical training. Moreover, the VR-SHFS integrating synchronous haptic and motion tracking technology can be used in emergency training such as cardiopulmonary resuscitation, airway management, and trauma care to enhance skill precision and the ability to perform clinical tasks, thereby expanding the innovative application and value of VR in nursing education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eThe authors extend their gratitude to the nursing student participants for their time and patience in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003ePJC designed all experiments and drafted the main manuscript; WKL contributed VR technology; all authors reviewed and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eNational Science and Technology Council, Taiwan, under Project Numbers NSTC 112-2637-H-161-002 and NSTC 113-2637-H-161-001.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003eData for scientific purposes can be obtained from the authors on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e The authors declares that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e Before participant recruitment, this study received ethical approval from the National Chengchi University Research Ethics Committee (No. NCCU-REC-202306-E068).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAktas S, Pasinlioglu T (2020) The effect of empathy training on the empathic communication skills of midwives and the birth satisfaction of mothers giving birth with these midwives: A quasi-experimental study. J Eval Clin Pract 1(1):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jep.13523\u003c/span\u003e\u003cspan address=\"10.1111/jep.13523\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlMekkawi M, El Khalil R (2022) Undergraduate nursing students' readiness to practice: Views of the senior students in the United Arab Emirates. Nurse Educ 47(4):E86\u0026ndash;E90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NNE.0000000000001153\u003c/span\u003e\u003cspan address=\"10.1097/NNE.0000000000001153\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngoff WH (1971) Scales, norms and equivalent scores. In: Thorndike RL (ed) Educational Measurement, 2nd edn. American Council on Education, Washington, DC, pp 508\u0026ndash;600\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBangor A, Kortum PT, Miller JT (2008) An empirical evaluation of the System Usability Scale. Int J Hum Comput Interact 24(6):574\u0026ndash;594. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10447310802205776\u003c/span\u003e\u003cspan address=\"10.1080/10447310802205776\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasri MAF, Ismail WSW, Nor NK, Tohit NM, Samad FDA, Ahmad MN et al (2024) Development of a social communication skills intervention using video modeling and spherical video-based virtual reality for high-functioning autism spectrum disorder youth: A preliminary study. IEEE Access 12:77976\u0026ndash;77987. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1109/ACCESS.2024.3407114\u003c/span\u003e\u003cspan address=\"10.1109/ACCESS.2024.3407114\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBotvinick M, Cohen J (1998) Rubber hands \u0026lsquo;feel\u0026rsquo; touch that eyes see. Nature 391:756. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/35784\u003c/span\u003e\u003cspan address=\"10.1038/35784\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradford HM, Farley CL, Escobar M, Heitzler ET, Tringali T, Walker KC (2021) Rapid curricular innovations during COVID-19 clinical suspension: Maintaining student engagement with simulation experiences. J Midwifery Womens Health 66(3):366\u0026ndash;371. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jmwh.13246\u003c/span\u003e\u003cspan address=\"10.1111/jmwh.13246\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrooke J (1996) SUS-A quick and dirty usability scale. Usability Eval Ind 189(194):4\u0026ndash;7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButt AL, Kardong-Edgren S, Ellertson A (2018) Using game-based virtual reality with haptics for skill acquisition. Clin Simul Nurs 16:25\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ecns.2017.09.010\u003c/span\u003e\u003cspan address=\"10.1016/j.ecns.2017.09.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang CY, Sung HY, Guo JL, Chang BY, Kuo FR (2022) Effects of spherical video-based virtual reality on nursing students\u0026rsquo; learning performance in childbirth education training. Interact Learn Environ 30(3):400\u0026ndash;416. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10494820.2019.1661854\u003c/span\u003e\u003cspan address=\"10.1080/10494820.2019.1661854\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang E, Kim HT, Yoo B (2020) Virtual reality sickness: A review of causes and measurements. Int J Hum Comput Interact 36(17):1658\u0026ndash;1682. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10447318.2020.1778351\u003c/span\u003e\u003cspan address=\"10.1080/10447318.2020.1778351\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang SC, Hsu TC, Chen YN, Jong MSY (2020) The effects of spherical video-based virtual reality implementation on students\u0026rsquo; natural science learning effectiveness. Interact Learn Environ 28(7):915\u0026ndash;929. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10494820.2018.1548490\u003c/span\u003e\u003cspan address=\"10.1080/10494820.2018.1548490\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen PJ, Liou WK (2023) Constructing an immersive virtual reality obstetric nursing learning system to improve the learning achievement of nursing students' cognition, affection, and skills. J Scholarsh Teach Learn 3(2):79\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7007/JSoTL.202306_3(2).0004\u003c/span\u003e\u003cspan address=\"10.7007/JSoTL.202306_3(2).0004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen SH, Chen SC, Lee SC, Chang YL, Yeh KY (2017) Impact of interactive situated and simulated teaching program on novice nursing practitioners' clinical competence, confidence, and stress. Nurse Educ Today 55:11\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2017.04.025\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2017.04.025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng JF, Lai YM, Livneh H, Tsai TY (2011) Establishing reliability and validity of the Chinese version of the Jefferson Scale of Empathy (Healthcare Providers Version). J Nurs 58(2):41\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.6224/JN.58.2.41\u003c/span\u003e\u003cspan address=\"10.6224/JN.58.2.41\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho MK, Kim MY (2024) Enhancing nursing competency through virtual reality simulation among nursing students: A systematic review and meta-analysis. Front Med 11:1351300. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fmed.2024.1351300\u003c/span\u003e\u003cspan address=\"10.3389/fmed.2024.1351300\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi J, Thompson CE, Choi J, Waddill CB, Choi S (2022) Effectiveness of immersive virtual reality in nursing education: Systematic review. Nurse Educ 47(3):E57\u0026ndash;E61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NNE.0000000000001117\u003c/span\u003e\u003cspan address=\"10.1097/NNE.0000000000001117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoshi M (2024) Addressing challenges in undergraduate community health nursing clinical: Kolb's Experiential Learning Theory. J Nurs Educ 1\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3928/01484834-20240513-02\u003c/span\u003e\u003cspan address=\"10.3928/01484834-20240513-02\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW (2003) A framework for design. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, pp 9\u0026ndash;11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemircan B, Kıyak Y, Aştı T (2024) The effect of role play prepared with video support on ethical decision-making and motivation levels of nursing students: A quasi-experimental study. Nurs Ethics 09697330241287866. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/09697330241287\u003c/span\u003e\u003cspan address=\"10.1177/09697330241287\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonnelly F, McLiesh P, Bessell SA (2020) Using 360 video to enable affective learning in nursing education. J Nurs Educ 59(7):409\u0026ndash;412. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3928/01484834-20200617-11\u003c/span\u003e\u003cspan address=\"10.3928/01484834-20200617-11\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDubovi I, Itzhaki M (2023) Playing the role of a nurse in a virtual reality simulation: A safe environment for emotion management. Nurse Educ 48(1):13\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NNE.0000000000001269\u003c/span\u003e\u003cspan address=\"10.1097/NNE.0000000000001269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEhrsson HH, Spence C, Passingham RE (2004) That's my hand! Activity in premotor cortex reflects feeling of ownership of a limb. Science 305(5685):875\u0026ndash;877. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1126/science.109701\u003c/span\u003e\u003cspan address=\"10.1126/science.109701\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEidenberger H (2018) Smell and touch in the Virtual Jumpcube. Multimed Syst 24(6):695\u0026ndash;709. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00530-018-0592-y\u003c/span\u003e\u003cspan address=\"10.1007/s00530-018-0592-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForonda C, Gattamorta K, Snowden K, Bauman EB (2014) Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study. Nurse Educ Today 34(6):e53\u0026ndash;e57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2013.10.007\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2013.10.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGibbs M, Priest H (2010) Exploring the physical health needs of people with learning disabilities: Facilitation student engagement in learning, using Kolb\u0026rsquo;s experiential learning cycle. Nurse Educ Pract 10(3):115\u0026ndash;118. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nepr.2009.04.005\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2009.04.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026uuml;ng\u0026ouml;r S, Yava A, Koyuncu A (2024) Designing and implementing a training program on surgical hand scrubbing, wearing surgical cap and surgical mask, gowning, and gloving using HMD-based virtual reality technologies for nursing students: An exploration of student perceptions. Front Med 11:1364465. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fmed.2024.1364465\u003c/span\u003e\u003cspan address=\"10.3389/fmed.2024.1364465\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoughton C, Casey D, Shaw D, Murphy K (2013) Rigour in qualitative case-study research. Nurse Res 20(4):2\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7748/nr2013.03.20.4.12.e326\u003c/span\u003e\u003cspan address=\"10.7748/nr2013.03.20.4.12.e326\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJallad ST, Işık B (2024) The effectiveness of immersive virtual reality simulation as an innovative learning strategy for acquisition of clinical skills in nursing education: Experimental design. Games Health J. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/g4h.2023.01\u003c/span\u003e\u003cspan address=\"10.1089/g4h.2023.01\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenkins Barnard P, Saylor J, Graber J, Trinkaus D (2024) Educational outcomes in undergraduate nursing: A systematic review. J Nurs Educ 63(6):380\u0026ndash;386. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3928/01484834-20240404-06\u003c/span\u003e\u003cspan address=\"10.3928/01484834-20240404-06\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang Z, Zhang Y, Chiang FK (2024) Meta-analysis of the effect of 360‐degree videos on students' learning outcomes and non‐cognitive outcomes. Br J Educ Technol 55(6):2423\u0026ndash;2456. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/bjet.13464\u003c/span\u003e\u003cspan address=\"10.1111/bjet.13464\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung EY, Park DK, Lee YH, Jo HS, Lim YS, Park RW (2012) Evaluation of practical exercises using an intravenous simulator incorporating virtual reality and haptics device technologies. Nurse Educ Today 32(4):458\u0026ndash;463. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2011.05.012\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2011.05.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim Y, Park HY (2024) Effects of virtual reality training on clinical skill performance in nursing students: A systematic review, meta-analysis and meta‐regression. Int J Nurs Pract 30(6):e13284. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ijn.13284\u003c/span\u003e\u003cspan address=\"10.1111/ijn.13284\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLave J, Wenger E (1991) Situated learning: Legitimate peripheral participation. Cambridge Univ\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang KY, Zeger SL (1986) Longitudinal data analysis using generalized linear models. Biometrika 73(1):13\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/biomet/73.1.13\u003c/span\u003e\u003cspan address=\"10.1093/biomet/73.1.13\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Yang Y, Bai X, Chen Y, Mo L (2022) Do immediate external rewards really enhance intrinsic motivation? Front Psychol 13:853879. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpsyg.2022.853879\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2022.853879\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMa Z, Huang KT, Yao L (2021) Feasibility of a computer role-playing game to promote empathy in nursing students: The role of immersiveness and perspective. Cyberpsychol Behav Soc Netw 24(11):750\u0026ndash;755. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/cyber.2020.037\u003c/span\u003e\u003cspan address=\"10.1089/cyber.2020.037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelo M, Gon\u0026ccedil;alves G, Monteiro P, Coelho H, Vasconcelos-Raposo J, Bessa M (2020) Do multisensory stimuli benefit the virtual reality experience? A systematic review. IEEE Trans Vis Comput Graph 28(2):1428\u0026ndash;1442. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1109/TVCG.2020.3010088\u003c/span\u003e\u003cspan address=\"10.1109/TVCG.2020.3010088\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoller AB, Welsh J, Gross MM, Petzold M, Ayebare E, Chipeta E et al (2021) Assessment of midwifery care providers intrapartum care competencies, in four sub-Saharan countries: A mixed-method study protocol. Reprod Health 18:1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12978-021-01109-8\u003c/span\u003e\u003cspan address=\"10.1186/s12978-021-01109-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoraes EMBD, Carvalho DRDS, Sandars J, Ozahata TM, Patel R, Cecilio-Fernandes D, Santos TM (2024) Unravelling the differences between observation and active participation in simulation-based education. Med Teach 1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/0142159X.2024.2396381\u003c/span\u003e\u003cspan address=\"10.1080/0142159X.2024.2396381\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMubarrat S, Chowdhury S, Fernandes A (2024) Evaluating visual-spatiotemporal co-registration of a physics-based virtual reality haptic interface. IEEE Access 12:57017\u0026ndash;57032. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1109/ACCESS.2024.3391186\u003c/span\u003e\u003cspan address=\"10.1109/ACCESS.2024.3391186\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOuma EG, Orango O, Were E, Omwodo KA (2024) Labour pain relief practice by maternal health care providers at a tertiary facility in Kenya: An institution-based descriptive survey. PLoS ONE 19(3):e0299211. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0299211\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0299211\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlotzky C, Lindwedel U, Sorber M, Loessl B, K\u0026ouml;nig P, Kunze C et al (2021) Virtual reality simulations in nurse education: A systematic mapping review. Nurse Educ Today 101:104868. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2021.104868\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2021.104868\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolit DF, Beck CT (2021) Nursing research: Generating and assessing evidence for nursing practice, 11th edn. Lippincott Williams \u0026amp; Wilkins\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRim D, Shin H (2021) Effective instructional design template for virtual simulations in nursing education. Nurse Educ Today 96:104624. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2020.104624\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2020.104624\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalminen M, J\u0026auml;rvel\u0026auml; S, Ruonala A, Harjunen VJ, Hamari J, Jacucci G, Ravaja N (2022) Evoking physiological synchrony and empathy using social VR with biofeedback. IEEE Trans Affect Comput 13(2):746\u0026ndash;755. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1109/TAFFC.2019.2958657\u003c/span\u003e\u003cspan address=\"10.1109/TAFFC.2019.2958657\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShadiev R, Yang L, Huang YM (2022) A review of research on 360-degree video and its applications to education. J Res Technol Educ 54(5):784\u0026ndash;799. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15391523.2021.1928572\u003c/span\u003e\u003cspan address=\"10.1080/15391523.2021.1928572\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrisopa P, Cong X, Russell B, Lucas R (2021) The role of emotion regulation in pain management among women from labor to three months postpartum: An integrative review. Pain Manag Nurs 22(6):783\u0026ndash;790. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.pmn.2021.05.011\u003c/span\u003e\u003cspan address=\"10.1016/j.pmn.2021.05.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTemple F, Carlsson Lalloo E, Berg M, Berg U, Munyali D\u0026eacute;sir\u0026eacute; A, Nyakio O et al (2024) Evaluating the implementation of person-centred care and simulation-based learning in a midwifery education programme in the Democratic Republic of Congo: A study protocol. Glob Health Action 17(1):2370097. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/16549716.2024.2370097\u003c/span\u003e\u003cspan address=\"10.1080/16549716.2024.2370097\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUlrich F, Helms NH, Frandsen UP, Rafn AV (2021) Learning effectiveness of 360 video: Experiences from a controlled experiment in healthcare education. Interact Learn Environ 29(1):98\u0026ndash;111. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10494820.2019.1579234\u003c/span\u003e\u003cspan address=\"10.1080/10494820.2019.1579234\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaughan N, Gabrys B (2020) Scoring and assessment in medical VR training simulators with dynamic time series classification. Eng Appl Artif Intell 94:103760. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.engappai.2020.103760\u003c/span\u003e\u003cspan address=\"10.1016/j.engappai.2020.103760\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVillegas N, Cianelli R, Cerisier K, Fernandez-Pineda M, Jacobson F, Lin HH et al (2021) Development and evaluation of a telehealth-based simulation to improve breastfeeding education and skills among nursing students. Nurse Educ Pract 57:103226. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nepr.2021.103226\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2021.103226\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang D, Ohnishi K, Xu W (2019) Multimodal haptic display for virtual reality: A survey. IEEE Trans Ind Electron 67(1):610\u0026ndash;623. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1109/TIE.2019.2920602\u003c/span\u003e\u003cspan address=\"10.1109/TIE.2019.2920602\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWighus M, Bj\u0026oslash;rk IT (2018) An educational intervention to enhance clinical skills learning: Experiences of nursing students and teachers. Nurse Educ Pract 29:143\u0026ndash;149. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nepr.2018.01.004\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2018.01.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan Z (2020) Self-assessment in the process of self-regulated learning and its relationship with academic achievement. Assess Eval High Educ 45(2):224\u0026ndash;238. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/02602938.2019.1629390\u003c/span\u003e\u003cspan address=\"10.1080/02602938.2019.1629390\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoung GW, O\u0026rsquo;Dwyer N, Smolic A (2022) Exploring virtual reality for quality immersive empathy building experiences. Behav Inf Technol 41(16):3415\u0026ndash;3431. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/0144929X.2021.1993336\u003c/span\u003e\u003cspan address=\"10.1080/0144929X.2021.1993336\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Virtual reality, Synchronous haptic feedback, Dual-Perspective, Labour care, Empathy, Nursing students","lastPublishedDoi":"10.21203/rs.3.rs-6220812/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6220812/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLabour care involving clinical decision-making and pain management is challenging for nursing students. Existing virtual teaching methods, such as spherical video-based virtual reality (SVVR), predominantly rely on visual and auditory stimuli, thus they provide no haptic feedback or interactivity. This study aimed to develop and evaluate a virtual reality synchronous haptic feedback system (VR-SHFS) to improve nursing students\u0026rsquo; skills, knowledge, and empathy development regarding labour care. A randomised controlled trial was conducted with nursing students randomly assigned to experimental (VR-SHFS, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40) and control (SVVR, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;40) groups. The experimental group engaged in haptic feedback and dual-perspective learning, whereas the control group learnt through 360\u0026deg; panoramic videos. Learning outcomes were assessed at the baseline (T0), immediately (T1) and two months (T2) after the intervention. Learning satisfaction was evaluated using the system usability scale (SUS) and a focus group. The data analysis revealed that the VR-SHFS group demonstrated significantly improved labour care skills and empathy at T1 and T2, as well as knowledge application at T2 compared to the SVVR group. From the students\u0026rsquo; perspective, VR-SHFS can enhance clinical realism through haptic feedback and interactive learning, facilitating skill transfer, although there is a need for additional instructions and more time to become familiar with the system. VR learning approaches that integrate haptic feedback and dual perspectives effectively improve nursing students\u0026rsquo; learning outcomes in labour care and outperform those based on SVVR. Improved VR technology and its interactive mechanism may further enhance learning outcomes and broaden clinical application.\u003c/p\u003e","manuscriptTitle":"Development and Evaluation of Synchronous Haptic Feedback Simulation in Dual-Perspective Virtual Reality for Labour Care: A Situated Learning-Based Randomised Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-17 11:09:53","doi":"10.21203/rs.3.rs-6220812/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a015f3b9-38b5-4236-b647-873a1ee43693","owner":[],"postedDate":"April 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-02T01:23:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-17 11:09:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6220812","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6220812","identity":"rs-6220812","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}