A Comparative Study of the Effectiveness of Virtual Reality-Based and Text-Based Training in Sterile Preparation: Pilot Trial of Early-Stage Clinical VR Study

A Comparative Study of the Effectiveness of Virtual Reality-Based and Text-Based Training in Sterile Preparation: Pilot Trial of Early-Stage Clinical VR Study | 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 A Comparative Study of the Effectiveness of Virtual Reality-Based and Text-Based Training in Sterile Preparation: Pilot Trial of Early-Stage Clinical VR Study Satoru Esumi, Sari Nakagawa, Mai Ikemura, Yui Takezawa, Rika Ebara, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8525550/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Apr, 2026 Read the published version in Journal of Pharmaceutical Health Care and Sciences → Version 1 posted You are reading this latest preprint version Abstract · Background: This study is a pilot study evaluating the effectiveness of virtual reality (VR) applications in retraining sterile preparation techniques for injectable medications. Specifically, it focused on comparing VR-based learning with conventional text-based learning and objectively assessing students' acquisition of practical skills using standardized evaluation criteria. · Methods: Seventeen pharmacy students voluntarily participated in the study and were divided into two groups: one using a VR application for learning and the other using text-based materials. Immediately after training with their respective tools, students' aseptic preparation skills were assessed using standardized criteria (including 29 individual evaluation checkpoints) and a 5-point overall rating scale. · Results: Students who used the VR application completed tasks in a shorter time and scored higher on evaluation criteria such as operational smoothness and drug dissolution within vials. Additionally, multiple assessment items, including “Fill the aseptic smoothly and evenly, without stopping in the middle of the process,” were strongly correlated with the overall practical performance ratings of the VR group. · Conclusions: The introduction of VR applications for aseptic preparation training, which requires complex processes, suggests that VR-based learning is more effective than traditional text-based methods in helping students master procedural workflows and improving operational fluency. These findings suggest that incorporating VR technology may enhance the quality of practical pharmacy education. Additional advancements in pharmacy education incorporating VR technology are expected in the future. · Trial registration: Not applicable Practical training Virtual reality Pharmacy student Sterile preparation Figures Figure 1 Figure 2 Figure 3 Background Simulation-based learning experiences are widely used as one of the most effective training tools in education involving technology acquisition( 1 ). Simulation-based learning refers to the use of simulation environments and technologies for learning purposes, such as case-based learning, which provides learners with virtual learning experiences and realism( 2 ). More recently, three-dimensional technologies such as virtual reality (VR), augmented reality (AR), and mixed reality (MR) have been actively used in simulation-based learning( 3 ). Compared with conventional textbook-based learning, the introduction of such advanced technology into education is expected to reduce the time required for technology acquisition, the cost of teaching materials, and human resources. Simulation-based learning using VR technology has already been incorporated and reported to be useful in other medical fields, such as medicine and nursing( 4 , 5 ). However, although the development and introduction of VR in pharmacy education has lagged behind other medical fields, reports on its usefulness have increased in recent years( 6 , 7 ). This type of hands-on training education using VR reportedly contributes to higher student satisfaction and motivation for learning than actual hospital training( 8 , 9 ). However, the VR technologies described in these reports appear to employ passive educational approaches, such as viewing content through 360-degree videos, rather than active learning methods that require student interaction and engagement. In addition, previous studies have evaluated only the effects of VR on pharmacy education on the basis of surveys of students’ knowledge improvement and subjective satisfaction. A limited number of studies have evaluated the effectiveness of VR-based instructional materials that involve active learner engagement, in comparison to traditional text-based learning. We originally developed a VR application that enables pharmacy students to acquire a broad range of knowledge and skills related to dispensing techniques and patient consultation. Using this application, we initiated practical pharmacy education. Previous research has demonstrated that education using this VR application achieves high student satisfaction and is particularly effective for learning the dispensing techniques of oral liquid formulations( 10 ). However, the effectiveness of the VR application for acquiring more complex dispensing techniques has not yet been fully examined. Therefore, this study evaluated the effectiveness of a VR application in the education of students on aseptic preparation techniques for injectable drugs, which require advanced procedures. Specifically, this study aimed to determine whether the VR application could support the acquisition of complex procedural skills, such as the handling of needles and glass containers. In this instance, to minimize the risk of injury, a pilot study was conducted with a small number of students who had previously completed practical training. In Japanese pharmacy education, standardized tests are used to assess practical skills. Accordingly, this study also employed standardized scales to objectively evaluate students’ acquired skills. Specifically, the time required for each student to complete all procedures and the achievement status of each evaluation checkpoint were recorded. Furthermore, students’ overall performance across the aseptic preparation task was evaluated using a five-point comprehensive assessment score, and a two-dimensional plot was constructed to identify which checkpoint items positively contributed to comprehensive assessment score. This analysis was intended to enable a more detailed investigation of the educational effectiveness of each instructional method and to clarify which elements of the procedural steps functioned effectively or ineffectively. By introducing such an evaluation method, we believe that it will be possible to measure educational effectiveness with greater accuracy compared with subjective survey-based assessments. Furthermore, if the results of this study confirm that use of the VR application facilitates the acquisition of advanced skills in a short period, it is expected to contribute to the development of a new simulation-based learning method in practical pharmacy education. Methods Study design and participants The study recruited fourth-year students from the Faculty of Pharmaceutical Sciences, Kobe Gakuin University (Kobe, Japan), who participated on a voluntary basis; a total of 17 students were enrolled. Because injectable drug preparation involves potentially hazardous procedures, such as needle-stick injuries, the study was conducted after all participants had completed at least one prior hands-on training session using actual injectable drugs. Specifically, participants had previously undertaken four practical training sessions, consisting of two vial-based and two ampule-based preparations. This study therefore aimed to evaluate the effects of VR-based or text-based learning on the relearning and recollection of aseptic preparation procedures. Aseptic training in this study was conducted according to the following schedule. First, an introductory lecture on aseptic preparation was provided, followed by individual learning through instructional videos. Students then participated in group-based hands-on training using actual equipment and pharmaceutical materials, which lasted approximately 3.5 hours. After an interval of approximately 2–3 months, a retraining session using a VR application or text-based materials and an assessment test were conducted. Between the initial hands-on training and the retraining session, students were allowed to independently review the instructional videos and lecture materials, except during the retraining and assessment test. Learning tools: VR application and text-based material The VR application used in this study was created by ImaCreate Co. Ltd. under supervision of the authors and was serviced by Fujifilm System Service Corporation (Pharmacy Pre-Learning VR Training Service; Tokyo, Japan). In the VR application, each subsequent necessary task is shown step-by-step, and the student proceeds to the next step when he or she performs the necessary operation. The VR application was provided via all-in-one VR headsets (Meta Quest 2®). Compared to the VR material, the text material provides only a detailed textual description of the standard aseptic preparation process, is developed independently by the authors from textbooks, and lacks any visual content. Both the VR application and the text material ensured that all checkpoint items were covered in the learning process. Aseptic preparation task The same aseptic preparation task was used for both the learning session and the practical test. The injectable drugs used included a vial of VITAMEDIN® for intravenous injection (Alfresa Pharma Corp.), 20 mL plastic ampules of distilled water for injection (Otsuka Pharmaceutical Factory, Inc.), and a 100 mL bag of isotonic sodium chloride solution for injection (Terumo Corp.). The standard procedure was as follows: 5 mL of distilled water was aspirated from the ampule into a syringe. Using a negative pressure maneuver, the 5 mL of water was injected into a vial of VITAMEDIN® to dissolve its contents. The entire volume of the dissolved solution was then aspirated back into the syringe and injected into the 100 mL saline bag. The solution in the saline bag was gently mixed by inversion and visually inspected for particulate matter. This task served as the basis for both the instructional learning and the assessment of aseptic technique in this study. Evaluation schedule The participants were randomly divided into two groups: one for learning with the VR application (VR group) and the other for learning with textbook-based materials (Tx group). Each group was given 30 minutes to study the aseptic preparation task described above. The participants were randomly divided into two groups: one for learning with the VR application (VR group) and the other for learning with textbook-based materials (Tx group). Each group was given 30 minutes to study the aseptic preparation task described above. The evaluation checkpoints consisted of a total of 29 items (Table 1 ), which were assessed according to the Objective Structured Clinical Examination, a standardized practical examination taken by fourth-year pharmacy students in Japan prior to their clinical internship. In addition, a 5-point scale was used for the comprehensive evaluation score throughout the entire process, and the time required for aseptic preparation was measured and censored at 11 minutes. To minimize rater bias, the actual procedure was filmed using a video camera, and one rater was responsible for the evaluation. The rater was a faculty member with a proven track record of instructing sterile preparation of injectable drugs, and was blinded to whether the participants used the VR application or text-based learning tool. The comprehensive evaluation was conducted using a 5-point scale, based on Japan’s Objective Structured Clinical Examination (OSCE) criteria. The scale is defined as follows: 5 = Excellent performance with no errors, 4 = Good performance with minor errors, 3 = Acceptable performance with moderate errors, 2 = Poor performance with multiple errors, and 1 = Unacceptable performance. This scale was used to assess final competency of the aseptic preparation procedure. Table 1 Checkpoints for aseptic preparation tasks in this study. No. Checkpoints Succsesful subjects, n(%) P value VR group (n = 9) Tx group (n = 8) 1 Do not allow the needle tip to come into contact with anything. 8 (88.9) 5 (62.5) 0.294 2 Handle the alcohol swab cleanly with tweezers and properly disinfect the puncture site. 9 (100) 6 (75) 0.206 3 Do not touch the disinfected area, especially areas that have been wiped with alcohol. 9 (100) 8 (100) 1 4 Perform the aseptic filling process in the correct order. 4 (44.4) 3 (37.5) 1 5 Fill the aseptic smoothly and evenly, without stopping in the middle of the process. 7 (77.8) 1 (12.5) 0.0152 6 Fill the aseptic in the correct position on a clean bench (guideline: perform the operation at least 15 cm in from the edge of a clean bench). 9 (100) 8 (100) 1 7 Confirm that the prescription and items match (via pointing or by line of sight). 9 (100) 6 (75) 0.206 8 Wipe the rubber stopper of the bag with alcohol. 9 (100) 8 (100) 1 9 Turn the opening of the bag toward the back so that your hands do not touch the opening of the bag during aseptic filling. 8 (88.9) 8 (100) 1 10 Wipe the rubber stopper of the vial with an alcohol cotton swab. 9 (100) 8 (100) 1 11 Wipe the lip of the plastic ampule with a new alcohol cotton swab. 9 (100) 6 (75) 0.206 12 Confirm that the correct amount of water for injection (5 mL) has been retrieved (via pointing or by line of sight). 8 (88.9) 6 (75) 0.576 13 Insert the vertically held needle into the rubber stopper (do not insert the needle from above). 5 (55.6) 2 (25) 0.335 14 Withdraw the full volume of solution via negative pressure (keep the vial on the table with the syringe stuck in the vial, then pull the syringe plunger straight up). 8 (88.9) 4 (50) 0.131 15 Dissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake the vial and syringe with both hands). 5 (55.6) 0 (0) 0.0294 16 Confirm that the drug in the vial is dissolved (via pointing or by line of sight). 4 (44.4) 4 (50) 1 17 Retrieve the drug in the vial using negative pressure (with the syringe stuck in the vial, the vial on top, and the syringe on the bottom, pull the syringe plunger straight down). 8 (88.9) 5 (62.5) 0.294 18 Check if the vial is empty. 4 (44.4) 6 (75) 0.335 19 Discard the vial. 6 (66.7) 8 (100) 0.206 20 Remove any air from inside the syringe 8 (88.9) 6 (75) 0.576 21 Check the amount of drug retrieved in the syringe (by pointing or via line of sight). 8 (88.9) 6 (75) 0.576 22 Insert the needle vertically into the bag (do not insert the needle from above) 8 (88.9) 5 (62.5) 0.294 23 Inject the full volume of the drug solution into the bag. 9 (100) 8 (100) 1 24 Discard the needle in the sharps disposal box (do not recap it). 7 (77.8) 8 (100) 0.471 25 Wipe the opening of the bag with alcohol. 8 (88.9) 7 (87.5) 1 26 Wipe the cap with an alcohol cotton swab. 9 (100) 6 (75) 0.206 27 Place the cap on the mouth of the bag. 9(100) 7 (87.5) 0.471 28 Tilt and mix the bag (up and down, left and right). 9 (100) 6 (75) 0.206 29 Check both the front and back sides of the bag for foreign matter. 9 (100) 6 (75) 0.206 Checkpoints for aseptic preparation tasks for injectable drugs and differences in achievement between VR and Tx groups. Data were analyzed by the Fisher’s exact probability test. VR group: Students who studied with the VR tool (n = 9). Tx group: Students who used text-based learning (n = 8). Data analyses The time required for preparation was compared using the Kaplan–Meier method (log-rank test). The comparison of groups' achievement of each checkpoint item was analyzed using Fisher’s exact probability test, and the comprehensive evaluation throughout the aseptic preparation task was compared using the Mann‒Whitney U test. To identify which components of each instructional method were effective or ineffective, and to evaluate which checkpoint items had a positive impact on comprehensive evaluation scores within each instructional method, a two-dimensional plot was constructed using two variables: ( 1 ) the standardized score (with a mean of 50 and a standard deviation of 10) of Spearman’s rank correlation coefficient between each checkpoint’s achievement rate and the comprehensive evaluation score, and ( 2 ) the standardized score (with a mean of 50 and a standard deviation of 10) of the achievement rate for each checkpoint. Similar analytical methods have also been applied in the evaluation of pharmacy education, supporting their utility in assessing instructional approaches and identifying areas for improvement( 11 ). All the statistical analyses were performed with Easy R (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). More precisely, it is a modified version of the R commander designed to add statistical functions frequently used in biostatistics ( 12 ). The statistical significance level was set at 5%, and results with P < 0.1 were considered to indicate a trend. Ethical considerations This study was approved by the Kobe Gakuin University Human Research Ethics Committee (SEB23-01). All participants were informed of the study in writing, and written informed consent was obtained. All procedures involving human participants were performed in accordance with the ethical standards of institutional and national research committees and the 1964 Helsinki Declaration. Results Effect of learning aseptic preparation using the VR application on the time required for the practical examination Kaplan–Meier curves comparing the residual probability of students completing the practical tasks over time for the VR group and the Tx group are shown in Fig. 1 . The log-rank test results indicated that students in the VR group completed the assignment more expeditiously. The median completion time was 9.3 minutes for the VR group and 10.2 minutes for the Tx group ( P < 0.05). Impact of differences in learning materials on the evaluation of practical tests Table 1 presents the evaluation items used in the practical test, along with the achievement ratios (i.e., the percentage of students who indicated they had completed each item). Compared with the Tx group, the VR group demonstrated consistently greater achievement in two items: “Fill the aseptic smoothly and evenly, without stopping in the middle of the process” (P = 0.0152), and “Dissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake with both hands)” (P = 0.0294). Additionally, the mean number of checkpoint items achieved was 24.7 ± 3.5 in the VR group and 20.9 ± 4.7 in the Tx group (P = 0.09), suggesting a potential trend toward greater achievement in the VR group. The median (minimum–maximum) comprehensive evaluation score for the practical test of aseptic preparation of injectable drugs, assessed on a 5-point scale, was 4 ( 1 – 5 ) for the VR group and 2 ( 1 – 4 ) for the Tx group, indicating a higher score trend in the VR group (P = 0.075; Fig. 2 ). Relationship between comprehensive evaluation and achievement ratio of each checkpoint. A two-dimensional plot based on the correlation coefficient (standardized score) between the comprehensive evaluation score and each checkpoint, and the achievement ratio (standardized score) for each checkpoint are shown in Fig. 3 . The numerical labels attached to each plot indicate the checkpoint numbers referenced in Table 1 . The checkpoints in the first quadrant (upper right-hand corner) of the graph had a positive impact on the comprehensive evaluation due to the high achievement ratio for that item and the high correlation coefficient with the comprehensive evaluation. On the other hand, the checkpoints in the fourth quadrant (lower right-hand corner) showed a negative impact on the comprehensive evaluation due to the low achievement ratio for that item itself and its strong association with the comprehensive evaluation. Achievement ratio for each checkpoint and the Spearman’s correlation coefficient between the comprehensive evaluation score and the achievement ratio are summarized in Table 2 for clarity. Table 2 Spearman’s ρ and achievement ratios for each checkpoint item in VR and Tx groups. No. Checkpoints VR Tx Acievement ratio Spearman’s ρ Acievement ratio Spearman’s ρ 1 Do not allow the needle tip to come into contact with anything. 0.889 0.562 0.625 0.537 2 Handle the alcohol swab cleanly with tweezers and properly disinfect the puncture site. - - 0.750 0.267 3 Do not touch the disinfected area, especially areas that have been wiped with alcohol. - - - - 4 Perform the aseptic filling process in the correct order. 0.444 0.578 0.375 0.775 5 Fill the aseptic smoothly and evenly, without stopping in the middle of the process. 0.778 0.690 0.125 0.524 6 Fill the aseptic in the correct position on a clean bench (guideline: perform the operation at least 15 cm in from the edge of a clean bench). - - - - 7 Confirm that the prescription and items match (via pointing or by line of sight). - - 0.750 0.267 8 Wipe the rubber stopper of the bag with alcohol. - - - - 9 Turn the opening of the bag toward the back so that your hands do not touch the opening of the bag during aseptic filling. 0.889 -0.421 - - 10 Wipe the rubber stopper of the vial with an alcohol cotton swab. - - - - 11 Wipe the lip of the plastic ampule with a new alcohol cotton swab. - - 0.750 0.267 12 Confirm that the correct amount of water for injection (5 mL) has been retrieved (via pointing or by line of sight). 0.889 -0.421 0.750 0.667 13 Insert the vertically held needle into the rubber stopper (do not insert the needle from above). 0.556 0.889 0.250 0.800 14 Withdraw the full volume of solution via negative pressure (keep the vial on the table with the syringe stuck in the vial, then pull the syringe plunger straight up). 0.889 0.351 0.500 0.808 15 Dissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake the vial and syringe with both hands). 0.556 0.489 - - 16 Confirm that the drug in the vial is dissolved (via pointing or by line of sight). 0.444 0.711 0.500 0.462 17 Retrieve the drug in the vial using negative pressure (with the syringe stuck in the vial, the vial on top, and the syringe on the bottom, pull the syringe plunger straight down). 0.889 0.351 0.625 0.894 18 Check if the vial is empty. 0.444 0.089 0.750 -0.467 19 Discard the vial. 0.667 0.702 - - 20 Remove any air from inside the syringe 0.889 0.562 0.750 0.267 21 Check the amount of drug retrieved in the syringe (by pointing or via line of sight). 0.889 0.562 0.750 -0.067 22 Insert the needle vertically into the bag (do not insert the needle from above) 0.889 0.562 0.625 0.537 23 Inject the full volume of the drug solution into the bag. - - - - 24 Discard the needle in the sharps disposal box (do not recap it). 0.778 0.690 - - 25 Wipe the opening of the bag with alcohol. 0.889 -0.070 0.875 0.436 26 Wipe the cap with an alcohol cotton swab. - - 0.750 0.267 27 Place the cap on the mouth of the bag. - - 0.875 0.436 28 Tilt and mix the bag (up and down, left and right). - - 0.750 0.667 29 Check both the front and back sides of the bag for foreign matter. - - 0.750 0.667 Spearman’s correlation coefficients (Spearman’s ρ) and achievement ratios for each checkpoint item in VR and Tx groups. When the achievement ratio is 1 or 0, Spearman's ρ cannot be calculated, so they were omitted (–). The numbers next to each plot correspond to the checkpoint numbers listed in Table 1 . Checkpoints with an achievement ratio of 1 or 0 were excluded, as correlation coefficients could not be calculated for these items. In both the VR and text-based (Tx) groups, several checkpoints were commonly located in the fourth quadrant of the graph, indicating that lower achievement on these items was associated with lower comprehensive evaluation scores. Specifically, checkpoint 4 (performing the aseptic filling process in the correct order), checkpoint 13 (inserting the vertically held needle into the rubber stopper without approaching from above), and checkpoint 16 (confirming that the drug in the vial is dissolved, either by pointing or visual inspection) were situated in this quadrant. In addition to these shared checkpoints, the VR group exhibited two items uniquely located in the fourth quadrant: checkpoint 15 (dissolving the drug in the vial with the syringe inserted, by holding the vial on top and the syringe on the bottom, and shaking them with both hands while maintaining this position), and checkpoint 19 (discarding the vial). In contrast, four items were uniquely located in the fourth quadrant of the Tx group plot: checkpoint 1 (ensuring that the needle tip does not come into contact with any surface), checkpoint 14 (withdrawing the full volume of solution via negative pressure by keeping the vial on the table with the syringe inserted and pulling the plunger straight up), checkpoint 17 (retrieving the drug using negative pressure with the vial on top and the syringe on the bottom, pulling the plunger straight down), and checkpoint 22 (inserting the needle vertically into the bag, avoiding top-down insertion). Checkpoints located in the first quadrant—those with both high achievement rates and strong positive correlations with comprehensive evaluation scores—differed notably between the VR and Tx groups. This suggests that the checkpoint items contributing to improved performance varied depending on the learning material. In the VR group, higher comprehensive scores were associated with successful completion of checkpoint 1 (avoiding contact of the needle tip with any surface), checkpoint 5 (smooth and continuous filling), checkpoint 20 (removing air from inside the syringe), checkpoint 21 (checking the volume of the drug drawn into the syringe), checkpoint 22 (inserting the needle vertically into the bag), and checkpoint 24 (disposing of the needle without recapping it). In the Tx group, on the other hand, higher comprehensive evaluation scores were associated with successful completion of checkpoint 12 (confirming that the correct amount of water for injection [5 mL] has been retrieved, either by pointing or visual inspection), checkpoint 28 (tilting and mixing the bag up and down, left and right), and checkpoint 29 (checking both the front and back sides of the bag for foreign matter). Discussion This study examined the usefulness of VR educational applications as learning materials for the aseptic preparation of injectable drugs, a technique that pharmacy students should master. Students who learned using the VR application completed the task in a shorter time during the evaluation test. The VR group also achieved greater scores on two items of the checkpoint, while no differences were observed for the remaining items. Furthermore, both the comprehensive evaluation scores and the average number of checkpoint items achieved tended to be higher in the VR group. Previous studies examining the usefulness of VR in education have relied primarily on subjective impressions ( 8 , 13 , 14 ). In contrast, our study objectively assessed the acquisition of practical skills, representing a novel approach in the field of pharmacy education. Our findings resemble those reported in surgical training research, where VR-based learning was associated with increased procedural accuracy, reduced task duration and error rates, and increased learner confidence( 15 ). To our knowledge, this study is the first in pharmacy education to demonstrate, through objective metrics, the effectiveness of VR in supporting the development of procedural skills. The VR group completed a greater number of checkpoint items than the Tx group, suggesting that the shorter task completion time observed in the VR group was not due to the omission of procedural steps, but rather reflected improved fluency in operational execution. This interpretation is supported by the higher achievement rate for the item “Fill the aseptic smoothly and evenly, without stopping in the middle of the process” in the VR group. A similarly high achievement rate was observed for the item “Dissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake the vial and syringe with both hands).” The capacity to visualize spatial relationships and procedural techniques within the VR environment may have contributed to the successful performance of these steps. These higher individual item scores, along with the shorter task completion time, may have been reflected in the comprehensive evaluation results as well. The two-dimensional plot evaluating the relationship between the achievement ratio and the correlation coefficient with the comprehensive evaluation score revealed distinct patterns across the VR and Tx groups. To interpret the educational significance of each quadrant, we considered the distribution of items based on achievement levels and their associations with overall performance( 11 ). The items in the first quadrant, which exhibited both high achievement and strong correlations with the comprehensive evaluation scores, were regarded as priority maintenance areas. These represent critical steps that contribute meaningfully to student performance and should be preserved through consistent instructional reinforcement. Conversely, items in the second quadrant, which also had high achievement but lower correlations with overall evaluation, were interpreted as general maintenance areas—indicating steps that students performed well but that had relatively limited influence on final performance. The items in the third quadrant, characterized by low achievement and weak association with overall performance, were classified as general improvement areas, suggesting that while student proficiency in these steps was limited, their impact on overall evaluation was modest. Notably, items in the fourth quadrant, which demonstrated both low achievement and strong association with the comprehensive score, were designated as priority improvement areas. These represent key instructional targets, where enhancing student performance is expected to yield a significant improvement in overall task execution. In both groups, several procedural items located in the fourth quadrant highlighted key challenges in skill acquisition. These items included performing the aseptic filling process in the correct order, inserting the needle vertically into the vial without approaching from above, and confirming drug dissolution, suggesting that difficulties in these critical steps were linked to lower overall performance regardless of instructional method. Quadrant-specific differences also underscore the instructional characteristics of each modality. The VR group demonstrated stronger performance in steps requiring spatial coordination, procedural fluidity, and real-time judgment—skills likely supported by the immersive and visual nature of the VR environment. In contrast, the Tx group performed better in steps involving observation and verification, such as fluid measurement, solution mixing, and visual inspection for contaminants. These results imply that text-based materials may better support tasks grounded in rule-following and careful confirmation. The items that appeared exclusively in the fourth quadrant further highlighted method-specific challenges. In the VR group, lower achievement in tasks such as discarding the vial and dissolving the drug properly may have resulted from an overemphasis on dynamic procedural flow, leading students to overlook more subtle but essential steps. In the Tx group, poor performance on tasks involving negative pressure techniques and needle insertion angles likely stemmed from the absence of spatial or kinetic information in the materials. These observations suggest that VR and text-based approaches each emphasize different aspects of procedural learning and that combining them could enhance the overall effectiveness of aseptic technique education. These findings suggest that the use of VR-based learning materials provides educational effects that are comparable to or potentially superior to those of conventional text-based learning. Moreover, the VR application appears particularly effective in enhancing procedural efficiency by enabling learners to comprehend the overall structure and sequence of operations in a clear and organized manner. A previous study examining the use of an educational VR application for objective structured clinical examinations (OSCEs) in medical education also demonstrated superior educational outcomes compared to a control group. Furthermore, it supported the application of VR-based tools in assessing clinical competence, consistent with the findings of the present study( 16 , 17 ). Several limitations were identified during the study. First, this was a single-center pilot study of 17 subjects; thus, it is considered that further validation is needed for generalization. The usefulness of VR needs to be tested with more subjects in the future. Second, VR technology in pharmacy education is still in its infancy, with non-standardized content and assessment processes. Third, VR technology has limited capabilities with respect to practical skills, and VR may not fully replicate the complexities of actual pharmacy practice. Finally, accessibility may be an issue for students with disabilities or other health conditions (such as motion sickness or dizziness). While taking these issues into consideration, the use of VR technology will enable the reproduction of realistic clinical environments and repetitive learning, which have been difficult with traditional educational methods, and will greatly contribute to the enhancement of practical skills learning. Further development of pharmacy education incorporating VR is expected in the future. Conclusions The results of this study suggest that even in aseptic preparation training, which requires more complex procedures than dispensing oral medications, the VR application-based learning method is more effective than traditional text-based learning in helping students acquire procedural workflows and improve operational fluency. This practical pharmacy education approach using a VR application allows students to progress through each step by performing the actions themselves, which may make it more effective for learning procedural workflows compared with traditional text-based learning. In the future, it will be essential to conduct additional studies with a larger number of students to verify the reproducibility and reliability of these findings. Abbreviations VR Virtual Reality Tx textbook-based learning Declarations Ethics approval and consent to participate This study was approved by the Kobe Gakuin University Human Research Ethics Committee (SEB23-01). All participants were informed of the study in writing, and written informed consent was obtained. All procedures involving human participants were performed in accordance with the ethical standards of institutional and national research committees and the 1964 Helsinki Declaration. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. The VR application used in this study is commercially available as the “Pharmacy Pre-Learning VR Training Service” provided by FUJIFILM System Services Co., Ltd. Competing interests S. Esumi, S. Nakagawa, M. Ikemura, R. Ebara, M. Harada, A. Tatsumi, A. Kanmachi, Y. Hashimoto and M. Takeda-Morishita received a collaborative research fund from FUJIFILM Corporation. Y. Takezawa declares that she has no conflict of interest. Funding This work was supported by Grant-in-Aid for Educational Innovation from Kobe Gakuin University for the academic year 2024. Authors' contributions SE analyzed and visualized the data, conducted investigations, and drafted the original manuscript. SN conceptualized the study, designed the methodology, validated the results, curated the data, and contributed to reviewing and editing the manuscript. She also supervised project administration. MI contributed to the study design and investigations, and was involved in reviewing and editing the manuscript. YT, RE, MH, AT, AK and YH conducted the investigations. MT-M conceptualized and supervised the study, contributed to reviewing and editing the manuscript, and acquired the research funding. All authors read and approved the final manuscript. Acknowledgements Not applicable. Authors' information (optional) Not applicable. References Kaplan AD, Cruit J, Endsley M, Beers SM, Sawyer BD, Hancock PA. The Effects of Virtual Reality, Augmented Reality, and Mixed Reality as Training Enhancement Methods: A Meta-Analysis. Hum Factors [Internet]. 2021 Jun 1 [cited 2025 Jan 21];63(4):706–26. Available from: https://pubmed.ncbi.nlm.nih.gov/32091937/ Landon-Hays M, Peterson-Ahmad MB, Frazier AD. Learning to Teach: How a Simulated Learning Environment Can Connect Theory to Practice in General and Special Education Educator Preparation Programs. Education Sciences. 2020, Vol 10, Page 184 [Internet]. 2020 Jul 18 [cited 2025 Jan 21];10(7):184. Available from: https://www.mdpi.com/2227-7102/10/7/184/htm Takemoto J, Parmentier B, Bratelli R, Merritt T, Coyne L. Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint. Journal of Contemporary Pharmacy Practice [Internet]. 2019 Dec 1 [cited 2025 Jan 22];66(4):33–8. Available from: https://www.researchgate.net/publication/347711910_Extended_Reality_in_Patient_Care_and_Pharmacy_Practice_A_Viewpoint Smith SJ, Farra SL, Ulrich DL, Hodgson E, Nicely S, Mickle A. Effectiveness of Two Varying Levels of Virtual Reality Simulation. Nurs Educ Perspect [Internet]. 2018 Nov 1 [cited 2025 Jan 22];39(6):E10–5. Available from: https://journals.lww.com/neponline/fulltext/2018/11000/effectiveness_of_two_varying_levels_of_virtual.21.aspx Chiu PL, Li H, Yap KYL, Lam KMC, Yip PLR, Wong CL. Virtual Reality-Based Intervention to Reduce Preoperative Anxiety in Adults Undergoing Elective Surgery: A Randomized Clinical Trial. JAMA Netw Open [Internet]. 2023 [cited 2025 Jan 22];6(10):E2340588. Available from: https://pubmed.ncbi.nlm.nih.gov/37906193/ Berkman MI. History of Virtual Reality. Encyclopedia of Computer Graphics and Games [Internet]. 2018 [cited 2025 Jan 22];1–9. Available from: https://link.springer.com/referenceworkentry/ 10.1007/978-3-319-08234-9_169-1 Coyne L, Merritt TA, Parmentier BL, Sharpton RA, Takemoto JK. The Past, Present, and Future of Virtual Reality in Pharmacy Education. Am J Pharm Educ. 2019;83(3):7456. Alkhudair N, Alrayes F, Alsehli D, AlRayes S. Virtual reality in experiential pharmacy education: A quasi-experimental study. Saudi Pharmaceutical Journal: SPJ [Internet]. 2024 May 1 [cited 2025 Jan 22];32(5):102028. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10981153/ Romano D, Lynch S, Komor T, Rhodes-Keefe J, Collier R, Sprague LM. Exploring the Effect on Pharmacy Students’ Empathy Following a Simulation Using 360-Degree Video. Am J Pharm Educ [Internet]. 2025 May 1 [cited 2025 Jul 17];89(5). Available from: https://pubmed.ncbi.nlm.nih.gov/40185312/ Ikemura M, Esumi S, Nakagawa S, Tatsumi A, Hashimoto Y, Kanmachi A et al. [Development of a Virtual Reality Training Tool Promoted at Skill Acquisition in Preparatory Clinical Education for Pharmacy Students and Verification of Its Educational Effectiveness: Preparation of Liquid Medications]. Yakugaku Zasshi [Internet]. 2024 [cited 2025 Mar 18];144(11):1009–18. Available from: https://pubmed.ncbi.nlm.nih.gov/39496426/ Asai Y, Takai Y, Murasaka T, Miyake T, Nakamura T, Morikawa Y et al. Effect of a workshop for questionnaire-based surveys on research awareness and motivation among community and hospital pharmacists in Mie Prefecture. J Pharm Health Care Sci [Internet]. 2025 Dec 1 [cited 2025 Jul 28];11(1). Available from: https://pubmed.ncbi.nlm.nih.gov/40598445/ Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplantation 2013 48:3 [Internet]. 2012 Dec 3 [cited 2025 Jan 22];48(3):452–8. Available from: https://www.nature.com/articles/bmt2012244 Yang X, Mei J, Xiao S, Xi J, Cao X, Zheng Y. Pharmacy student’s perceptions, behaviours and attitudes toward virtual reality simulation. Saudi Pharm J [Internet]. 2023 Jan 1 [cited 2025 Jan 22];31(1):14–20. Available from: https://pubmed.ncbi.nlm.nih.gov/36685300/ Salem S, Cooper J, Schneider J, Croft H, Munro I. Student Acceptance of Using Augmented Reality Applications for Learning in Pharmacy: A Pilot Study. Pharmacy: Journal of Pharmacy Education and Practice [Internet]. 2020 Jul 21 [cited 2025 Mar 14];8(3):122. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7560130/ Kumar A, Saudagar AKJ, Kumar A, Alkhrijah YM, Raja L. Innovating medical education using a cost effective and scalable VR platform with AI-Driven haptics. Sci Rep [Internet]. 2025 Dec 1 [cited 2025 Jul 29];15(1). Available from: https://pubmed.ncbi.nlm.nih.gov/40685411/ Gan W, Mok TN, Chen J, She G, Zha Z, Wang H et al. Researching the application of virtual reality in medical education: one-year follow-up of a randomized trial. BMC Med Educ [Internet]. 2023 Dec 1 [cited 2025 Jan 22];23(1). Available from: https://pubmed.ncbi.nlm.nih.gov/36597093/ Mühling T, Schreiner V, Appel M, Leutritz T, König S. Comparing Virtual Reality-Based and Traditional Physical Objective Structured Clinical Examination (OSCE) Stations for Clinical Competency Assessments: Randomized Controlled Trial. J Med Internet Res [Internet]. 2025 [cited 2025 Jan 22];27. Available from: https://pubmed.ncbi.nlm.nih.gov/39793025/ Additional Declarations Competing interest reported. S. Esumi, S. Nakagawa, M. Ikemura, R. Ebara, M. Harada, A. Tatsumi, A. Kanmachi, Y. Hashimoto and M. Takeda-Morishita received a collaborative research fund from FUJIFILM Corporation. Cite Share Download PDF Status: Published Journal Publication published 15 Apr, 2026 Read the published version in Journal of Pharmaceutical Health Care and Sciences → 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8525550","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570674839,"identity":"25fedc2a-bf6f-4a11-8356-be5953f5b362","order_by":0,"name":"Satoru Esumi","email":"","orcid":"","institution":"Faculty of Pharmaceutical Sciences, Kobegakuin University","correspondingAuthor":false,"prefix":"","firstName":"Satoru","middleName":"","lastName":"Esumi","suffix":""},{"id":570674849,"identity":"e11e0396-8819-4c02-a12f-7fa9edaa5726","order_by":1,"name":"Sari Nakagawa","email":"","orcid":"","institution":"Faculty of Pharmaceutical Sciences, Kobegakuin University","correspondingAuthor":false,"prefix":"","firstName":"Sari","middleName":"","lastName":"Nakagawa","suffix":""},{"id":570674850,"identity":"a850d05f-fb3a-4705-bb4d-b13b40f09d21","order_by":2,"name":"Mai Ikemura","email":"","orcid":"","institution":"Faculty of Pharmaceutical Sciences, Kobegakuin University","correspondingAuthor":false,"prefix":"","firstName":"Mai","middleName":"","lastName":"Ikemura","suffix":""},{"id":570674851,"identity":"4c8ea4a4-bd5c-4b29-9c2c-207d22ac898d","order_by":3,"name":"Yui Takezawa","email":"","orcid":"","institution":"Faculty of Pharmaceutical Sciences, Kobegakuin University","correspondingAuthor":false,"prefix":"","firstName":"Yui","middleName":"","lastName":"Takezawa","suffix":""},{"id":570674852,"identity":"e4a0b4ae-b503-4586-9920-b8c6a3168d89","order_by":4,"name":"Rika Ebara","email":"","orcid":"","institution":"Faculty of Pharmaceutical Sciences, Kobegakuin 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07:15:49","extension":"pptx","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60577,"visible":true,"origin":"","legend":"","description":"","filename":"Figures.pptx","url":"https://assets-eu.researchsquare.com/files/rs-8525550/v1/e8a7a7fc1ac859a45fb58721.pptx"},{"id":100356489,"identity":"f886b14a-469f-47e7-bda0-569316effd18","added_by":"auto","created_at":"2026-01-16 07:11:55","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":99540,"visible":true,"origin":"","legend":"","description":"","filename":"f3ef6410c08d4994815e542113cf123c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8525550/v1/ffe6dcb65a5e188424b2d3c2.xml"},{"id":99827296,"identity":"db497681-7850-4108-93cb-d9de3cee8ce1","added_by":"auto","created_at":"2026-01-08 16:29:47","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111301,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8525550/v1/8f56fefc573b41279fe13c31.html"},{"id":99827288,"identity":"894ea335-ce6c-45d2-b968-a7a3bce2cf14","added_by":"auto","created_at":"2026-01-08 16:29:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27235,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves for time to complete assessment tasks for different learning methods.\u003c/p\u003e\n\u003cp\u003eThe solid line shows the residual rate over time for students who studied with the VR application (VR group, n = 9), and the dashed line shows the residual rate over time for students who studied with the text (Tx group, n = 8). The residual rate decreases as each group of students finishes their task. Data were compared using the Kaplan-Meier method followed by the log-rank test. The significance level was set at P\u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8525550/v1/8ef2055bb5c8c06502a37e62.png"},{"id":100356303,"identity":"1369b333-dcf6-43ca-a8bf-86603898d8cd","added_by":"auto","created_at":"2026-01-16 07:02:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":14323,"visible":true,"origin":"","legend":"\u003cp\u003eThe influence of different learning methods on the comprehensive evaluation.\u003c/p\u003e\n\u003cp\u003eThe degree of completion of the technique throughout the task was rated on a 5-point scale for each student and is shown in a histogram by group. Data were analyzed with the Mann-Whitney U test. The significance level was set at P\u0026lt;.05, and results with P \u0026lt; 0.1 were considered to indicate a trend.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8525550/v1/ff3f850cb8072de3c796b48b.png"},{"id":99827290,"identity":"bf7bffca-2a97-4b33-a988-c34258638eb7","added_by":"auto","created_at":"2026-01-08 16:29:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":46507,"visible":true,"origin":"","legend":"\u003cp\u003eTwo-dimensional plot of checkpoint achievement and correlation with comprehensive evaluation.\u003c/p\u003e\n\u003cp\u003eFigure 3A shows the VR group, and Figure 3B the Tx (text-based learning) group. Each panel displays a two-dimensional plot based on two axes: the standardized achievement ratio for each checkpoint (y-axis) and the standardized Spearman’s rank correlation coefficient between the comprehensive evaluation score and each checkpoint achievement (x-axis). The numerical labels (e.g., 1, 2, …) indicate checkpoint numbers corresponding to those listed in Table 1. Checkpoints in the upper right quadrant (Q1) demonstrate both high achievement rates and strong positive correlations with the comprehensive evaluation, suggesting these steps contribute positively to overall performance and should be prioritized for maintenance. In contrast, those in the lower right quadrant (Q4) exhibit low achievement rates but high correlation with overall performance, indicating priority improvement areas—students who failed these steps often received low overall ratings.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8525550/v1/c31c1eda88ff61268a3d4b32.png"},{"id":107350781,"identity":"d22844b0-d7e0-4a00-9d89-4c5aecd27d09","added_by":"auto","created_at":"2026-04-20 16:04:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":646983,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8525550/v1/c80e5085-cae7-4355-99e6-19d4c33e1089.pdf"}],"financialInterests":"Competing interest reported. S. Esumi, S. Nakagawa, M. Ikemura, R. Ebara, M. Harada, A. Tatsumi, A. Kanmachi, Y. Hashimoto and M. Takeda-Morishita received a collaborative research fund from FUJIFILM Corporation.","formattedTitle":"\u003cp\u003eA Comparative Study of the Effectiveness of Virtual Reality-Based and Text-Based Training in Sterile Preparation: Pilot Trial of Early-Stage Clinical VR Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eSimulation-based learning experiences are widely used as one of the most effective training tools in education involving technology acquisition(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Simulation-based learning refers to the use of simulation environments and technologies for learning purposes, such as case-based learning, which provides learners with virtual learning experiences and realism(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). More recently, three-dimensional technologies such as virtual reality (VR), augmented reality (AR), and mixed reality (MR) have been actively used in simulation-based learning(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Compared with conventional textbook-based learning, the introduction of such advanced technology into education is expected to reduce the time required for technology acquisition, the cost of teaching materials, and human resources.\u003c/p\u003e \u003cp\u003eSimulation-based learning using VR technology has already been incorporated and reported to be useful in other medical fields, such as medicine and nursing(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, although the development and introduction of VR in pharmacy education has lagged behind other medical fields, reports on its usefulness have increased in recent years(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This type of hands-on training education using VR reportedly contributes to higher student satisfaction and motivation for learning than actual hospital training(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, the VR technologies described in these reports appear to employ passive educational approaches, such as viewing content through 360-degree videos, rather than active learning methods that require student interaction and engagement. In addition, previous studies have evaluated only the effects of VR on pharmacy education on the basis of surveys of students\u0026rsquo; knowledge improvement and subjective satisfaction. A limited number of studies have evaluated the effectiveness of VR-based instructional materials that involve active learner engagement, in comparison to traditional text-based learning.\u003c/p\u003e \u003cp\u003eWe originally developed a VR application that enables pharmacy students to acquire a broad range of knowledge and skills related to dispensing techniques and patient consultation. Using this application, we initiated practical pharmacy education. Previous research has demonstrated that education using this VR application achieves high student satisfaction and is particularly effective for learning the dispensing techniques of oral liquid formulations(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, the effectiveness of the VR application for acquiring more complex dispensing techniques has not yet been fully examined. Therefore, this study evaluated the effectiveness of a VR application in the education of students on aseptic preparation techniques for injectable drugs, which require advanced procedures. Specifically, this study aimed to determine whether the VR application could support the acquisition of complex procedural skills, such as the handling of needles and glass containers. In this instance, to minimize the risk of injury, a pilot study was conducted with a small number of students who had previously completed practical training.\u003c/p\u003e \u003cp\u003eIn Japanese pharmacy education, standardized tests are used to assess practical skills. Accordingly, this study also employed standardized scales to objectively evaluate students\u0026rsquo; acquired skills. Specifically, the time required for each student to complete all procedures and the achievement status of each evaluation checkpoint were recorded. Furthermore, students\u0026rsquo; overall performance across the aseptic preparation task was evaluated using a five-point comprehensive assessment score, and a two-dimensional plot was constructed to identify which checkpoint items positively contributed to comprehensive assessment score. This analysis was intended to enable a more detailed investigation of the educational effectiveness of each instructional method and to clarify which elements of the procedural steps functioned effectively or ineffectively. By introducing such an evaluation method, we believe that it will be possible to measure educational effectiveness with greater accuracy compared with subjective survey-based assessments. Furthermore, if the results of this study confirm that use of the VR application facilitates the acquisition of advanced skills in a short period, it is expected to contribute to the development of a new simulation-based learning method in practical pharmacy education.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThe study recruited fourth-year students from the Faculty of Pharmaceutical Sciences, Kobe Gakuin University (Kobe, Japan), who participated on a voluntary basis; a total of 17 students were enrolled. Because injectable drug preparation involves potentially hazardous procedures, such as needle-stick injuries, the study was conducted after all participants had completed at least one prior hands-on training session using actual injectable drugs. Specifically, participants had previously undertaken four practical training sessions, consisting of two vial-based and two ampule-based preparations. This study therefore aimed to evaluate the effects of VR-based or text-based learning on the relearning and recollection of aseptic preparation procedures.\u003c/p\u003e \u003cp\u003eAseptic training in this study was conducted according to the following schedule. First, an introductory lecture on aseptic preparation was provided, followed by individual learning through instructional videos. Students then participated in group-based hands-on training using actual equipment and pharmaceutical materials, which lasted approximately 3.5 hours. After an interval of approximately 2\u0026ndash;3 months, a retraining session using a VR application or text-based materials and an assessment test were conducted. Between the initial hands-on training and the retraining session, students were allowed to independently review the instructional videos and lecture materials, except during the retraining and assessment test.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLearning tools: VR application and text-based material\u003c/h3\u003e\n\u003cp\u003eThe VR application used in this study was created by ImaCreate Co. Ltd. under supervision of the authors and was serviced by Fujifilm System Service Corporation (Pharmacy Pre-Learning VR Training Service; Tokyo, Japan). In the VR application, each subsequent necessary task is shown step-by-step, and the student proceeds to the next step when he or she performs the necessary operation. The VR application was provided via all-in-one VR headsets (Meta Quest 2\u0026reg;). Compared to the VR material, the text material provides only a detailed textual description of the standard aseptic preparation process, is developed independently by the authors from textbooks, and lacks any visual content. Both the VR application and the text material ensured that all checkpoint items were covered in the learning process.\u003c/p\u003e\n\u003ch3\u003eAseptic preparation task\u003c/h3\u003e\n\u003cp\u003eThe same aseptic preparation task was used for both the learning session and the practical test. The injectable drugs used included a vial of VITAMEDIN\u0026reg; for intravenous injection (Alfresa Pharma Corp.), 20 mL plastic ampules of distilled water for injection (Otsuka Pharmaceutical Factory, Inc.), and a 100 mL bag of isotonic sodium chloride solution for injection (Terumo Corp.). The standard procedure was as follows:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e5 mL of distilled water was aspirated from the ampule into a syringe.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUsing a negative pressure maneuver, the 5 mL of water was injected into a vial of VITAMEDIN\u0026reg; to dissolve its contents.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe entire volume of the dissolved solution was then aspirated back into the syringe and injected into the 100 mL saline bag.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe solution in the saline bag was gently mixed by inversion and visually inspected for particulate matter.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis task served as the basis for both the instructional learning and the assessment of aseptic technique in this study.\u003c/p\u003e\n\u003ch3\u003eEvaluation schedule\u003c/h3\u003e\n\u003cp\u003eThe participants were randomly divided into two groups: one for learning with the VR application (VR group) and the other for learning with textbook-based materials (Tx group). Each group was given 30 minutes to study the aseptic preparation task described above. The participants were randomly divided into two groups: one for learning with the VR application (VR group) and the other for learning with textbook-based materials (Tx group). Each group was given 30 minutes to study the aseptic preparation task described above. The evaluation checkpoints consisted of a total of 29 items (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), which were assessed according to the Objective Structured Clinical Examination, a standardized practical examination taken by fourth-year pharmacy students in Japan prior to their clinical internship. In addition, a 5-point scale was used for the comprehensive evaluation score throughout the entire process, and the time required for aseptic preparation was measured and censored at 11 minutes. To minimize rater bias, the actual procedure was filmed using a video camera, and one rater was responsible for the evaluation. The rater was a faculty member with a proven track record of instructing sterile preparation of injectable drugs, and was blinded to whether the participants used the VR application or text-based learning tool. The comprehensive evaluation was conducted using a 5-point scale, based on Japan\u0026rsquo;s Objective Structured Clinical Examination (OSCE) criteria. The scale is defined as follows: 5\u0026thinsp;=\u0026thinsp;Excellent performance with no errors, 4\u0026thinsp;=\u0026thinsp;Good performance with minor errors, 3\u0026thinsp;=\u0026thinsp;Acceptable performance with moderate errors, 2\u0026thinsp;=\u0026thinsp;Poor performance with multiple errors, and 1\u0026thinsp;=\u0026thinsp;Unacceptable performance. This scale was used to assess final competency of the aseptic preparation procedure.\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\u003eCheckpoints for aseptic preparation tasks in this study.\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCheckpoints\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSuccsesful subjects, n(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVR group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTx group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not allow the needle tip to come into contact with anything.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHandle the alcohol swab cleanly with tweezers and properly disinfect the puncture site.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not touch the disinfected area, especially areas that have been wiped with alcohol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerform the aseptic filling process in the correct order.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFill the aseptic smoothly and evenly, without stopping in the middle of the process.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFill the aseptic in the correct position on a clean bench (guideline: perform the operation at least 15 cm in from the edge of a clean bench).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfirm that the prescription and items match (via pointing or by line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the rubber stopper of the bag with alcohol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTurn the opening of the bag toward the back so that your hands do not touch the opening of the bag during aseptic filling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the rubber stopper of the vial with an alcohol cotton swab.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the lip of the plastic ampule with a new alcohol cotton swab.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfirm that the correct amount of water for injection (5 mL) has been retrieved (via pointing or by line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsert the vertically held needle into the rubber stopper (do not insert the needle from above).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithdraw the full volume of solution via negative pressure (keep the vial on the table with the syringe stuck in the vial, then pull the syringe plunger straight up).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake the vial and syringe with both hands).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfirm that the drug in the vial is dissolved (via pointing or by line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrieve the drug in the vial using negative pressure (with the syringe stuck in the vial, the vial on top, and the syringe on the bottom, pull the syringe plunger straight down).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck if the vial is empty.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscard the vial.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemove any air from inside the syringe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck the amount of drug retrieved in the syringe (by pointing or via line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsert the needle vertically into the bag (do not insert the needle from above)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInject the full volume of the drug solution into the bag.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscard the needle in the sharps disposal box (do not recap it).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.471\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the opening of the bag with alcohol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the cap with an alcohol cotton swab.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlace the cap on the mouth of the bag.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.471\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTilt and mix the bag (up and down, left and right).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck both the front and back sides of the bag for foreign matter.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCheckpoints for aseptic preparation tasks for injectable drugs and differences in achievement between VR and Tx groups. Data were analyzed by the Fisher\u0026rsquo;s exact probability test. VR group: Students who studied with the VR tool (n\u0026thinsp;=\u0026thinsp;9). Tx group: Students who used text-based learning (n\u0026thinsp;=\u0026thinsp;8).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData analyses\u003c/h3\u003e\n\u003cp\u003eThe time required for preparation was compared using the Kaplan\u0026ndash;Meier method (log-rank test). The comparison of groups' achievement of each checkpoint item was analyzed using Fisher\u0026rsquo;s exact probability test, and the comprehensive evaluation throughout the aseptic preparation task was compared using the Mann‒Whitney U test. To identify which components of each instructional method were effective or ineffective, and to evaluate which checkpoint items had a positive impact on comprehensive evaluation scores within each instructional method, a two-dimensional plot was constructed using two variables: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the standardized score (with a mean of 50 and a standard deviation of 10) of Spearman\u0026rsquo;s rank correlation coefficient between each checkpoint\u0026rsquo;s achievement rate and the comprehensive evaluation score, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the standardized score (with a mean of 50 and a standard deviation of 10) of the achievement rate for each checkpoint. Similar analytical methods have also been applied in the evaluation of pharmacy education, supporting their utility in assessing instructional approaches and identifying areas for improvement(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll the statistical analyses were performed with Easy R (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). More precisely, it is a modified version of the R commander designed to add statistical functions frequently used in biostatistics (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The statistical significance level was set at 5%, and results with \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.1 were considered to indicate a trend.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the Kobe Gakuin University Human Research Ethics Committee (SEB23-01). All participants were informed of the study in writing, and written informed consent was obtained. All procedures involving human participants were performed in accordance with the ethical standards of institutional and national research committees and the 1964 Helsinki Declaration.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003eEffect of learning aseptic preparation using the VR application on the time required for the practical examination\u003c/b\u003e \u003c/p\u003e \u003cp\u003eKaplan\u0026ndash;Meier curves comparing the residual probability of students completing the practical tasks over time for the VR group and the Tx group are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The log-rank test results indicated that students in the VR group completed the assignment more expeditiously. The median completion time was 9.3 minutes for the VR group and 10.2 minutes for the Tx group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eImpact of differences in learning materials on the evaluation of practical tests\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the evaluation items used in the practical test, along with the achievement ratios (i.e., the percentage of students who indicated they had completed each item). Compared with the Tx group, the VR group demonstrated consistently greater achievement in two items: \u0026ldquo;Fill the aseptic smoothly and evenly, without stopping in the middle of the process\u0026rdquo; (P\u0026thinsp;=\u0026thinsp;0.0152), and \u0026ldquo;Dissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake with both hands)\u0026rdquo; (P\u0026thinsp;=\u0026thinsp;0.0294). Additionally, the mean number of checkpoint items achieved was 24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5 in the VR group and 20.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 in the Tx group (P\u0026thinsp;=\u0026thinsp;0.09), suggesting a potential trend toward greater achievement in the VR group.\u003c/p\u003e \u003cp\u003eThe median (minimum\u0026ndash;maximum) comprehensive evaluation score for the practical test of aseptic preparation of injectable drugs, assessed on a 5-point scale, was 4 (\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) for the VR group and 2 (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) for the Tx group, indicating a higher score trend in the VR group (P\u0026thinsp;=\u0026thinsp;0.075; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eRelationship between comprehensive evaluation and achievement ratio of each checkpoint.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA two-dimensional plot based on the correlation coefficient (standardized score) between the comprehensive evaluation score and each checkpoint, and the achievement ratio (standardized score) for each checkpoint are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The numerical labels attached to each plot indicate the checkpoint numbers referenced in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The checkpoints in the first quadrant (upper right-hand corner) of the graph had a positive impact on the comprehensive evaluation due to the high achievement ratio for that item and the high correlation coefficient with the comprehensive evaluation. On the other hand, the checkpoints in the fourth quadrant (lower right-hand corner) showed a negative impact on the comprehensive evaluation due to the low achievement ratio for that item itself and its strong association with the comprehensive evaluation. Achievement ratio for each checkpoint and the Spearman\u0026rsquo;s correlation coefficient between the comprehensive evaluation score and the achievement ratio are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for clarity.\u003c/p\u003e \u003cp\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\u003eSpearman\u0026rsquo;s ρ and achievement ratios for each checkpoint item in VR and Tx groups.\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=\"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=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCheckpoints\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eTx\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAcievement ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpearman\u0026rsquo;s ρ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAcievement ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpearman\u0026rsquo;s ρ\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not allow the needle tip to come into contact with anything.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHandle the alcohol swab cleanly with tweezers and properly disinfect the puncture site.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not touch the disinfected area, especially areas that have been wiped with alcohol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerform the aseptic filling process in the correct order.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFill the aseptic smoothly and evenly, without stopping in the middle of the process.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.524\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFill the aseptic in the correct position on a clean bench (guideline: perform the operation at least 15 cm in from the edge of a clean bench).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfirm that the prescription and items match (via pointing or by line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the rubber stopper of the bag with alcohol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTurn the opening of the bag toward the back so that your hands do not touch the opening of the bag during aseptic filling.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the rubber stopper of the vial with an alcohol cotton swab.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the lip of the plastic ampule with a new alcohol cotton swab.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfirm that the correct amount of water for injection (5 mL) has been retrieved (via pointing or by line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.667\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsert the vertically held needle into the rubber stopper (do not insert the needle from above).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithdraw the full volume of solution via negative pressure (keep the vial on the table with the syringe stuck in the vial, then pull the syringe plunger straight up).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.808\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake the vial and syringe with both hands).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfirm that the drug in the vial is dissolved (via pointing or by line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.462\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrieve the drug in the vial using negative pressure (with the syringe stuck in the vial, the vial on top, and the syringe on the bottom, pull the syringe plunger straight down).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck if the vial is empty.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.467\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscard the vial.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRemove any air from inside the syringe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck the amount of drug retrieved in the syringe (by pointing or via line of sight).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.067\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsert the needle vertically into the bag (do not insert the needle from above)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInject the full volume of the drug solution into the bag.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscard the needle in the sharps disposal box (do not recap it).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the opening of the bag with alcohol.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWipe the cap with an alcohol cotton swab.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.267\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlace the cap on the mouth of the bag.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTilt and mix the bag (up and down, left and right).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.667\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck both the front and back sides of the bag for foreign matter.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.667\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSpearman\u0026rsquo;s correlation coefficients (Spearman\u0026rsquo;s ρ) and achievement ratios for each checkpoint item in VR and Tx groups. When the achievement ratio is 1 or 0, Spearman's ρ cannot be calculated, so they were omitted (\u0026ndash;).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe numbers next to each plot correspond to the checkpoint numbers listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Checkpoints with an achievement ratio of 1 or 0 were excluded, as correlation coefficients could not be calculated for these items. In both the VR and text-based (Tx) groups, several checkpoints were commonly located in the fourth quadrant of the graph, indicating that lower achievement on these items was associated with lower comprehensive evaluation scores. Specifically, checkpoint 4 (performing the aseptic filling process in the correct order), checkpoint 13 (inserting the vertically held needle into the rubber stopper without approaching from above), and checkpoint 16 (confirming that the drug in the vial is dissolved, either by pointing or visual inspection) were situated in this quadrant.\u003c/p\u003e \u003cp\u003eIn addition to these shared checkpoints, the VR group exhibited two items uniquely located in the fourth quadrant: checkpoint 15 (dissolving the drug in the vial with the syringe inserted, by holding the vial on top and the syringe on the bottom, and shaking them with both hands while maintaining this position), and checkpoint 19 (discarding the vial). In contrast, four items were uniquely located in the fourth quadrant of the Tx group plot: checkpoint 1 (ensuring that the needle tip does not come into contact with any surface), checkpoint 14 (withdrawing the full volume of solution via negative pressure by keeping the vial on the table with the syringe inserted and pulling the plunger straight up), checkpoint 17 (retrieving the drug using negative pressure with the vial on top and the syringe on the bottom, pulling the plunger straight down), and checkpoint 22 (inserting the needle vertically into the bag, avoiding top-down insertion).\u003c/p\u003e \u003cp\u003eCheckpoints located in the first quadrant\u0026mdash;those with both high achievement rates and strong positive correlations with comprehensive evaluation scores\u0026mdash;differed notably between the VR and Tx groups. This suggests that the checkpoint items contributing to improved performance varied depending on the learning material. In the VR group, higher comprehensive scores were associated with successful completion of checkpoint 1 (avoiding contact of the needle tip with any surface), checkpoint 5 (smooth and continuous filling), checkpoint 20 (removing air from inside the syringe), checkpoint 21 (checking the volume of the drug drawn into the syringe), checkpoint 22 (inserting the needle vertically into the bag), and checkpoint 24 (disposing of the needle without recapping it). In the Tx group, on the other hand, higher comprehensive evaluation scores were associated with successful completion of checkpoint 12 (confirming that the correct amount of water for injection [5 mL] has been retrieved, either by pointing or visual inspection), checkpoint 28 (tilting and mixing the bag up and down, left and right), and checkpoint 29 (checking both the front and back sides of the bag for foreign matter).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the usefulness of VR educational applications as learning materials for the aseptic preparation of injectable drugs, a technique that pharmacy students should master. Students who learned using the VR application completed the task in a shorter time during the evaluation test. The VR group also achieved greater scores on two items of the checkpoint, while no differences were observed for the remaining items. Furthermore, both the comprehensive evaluation scores and the average number of checkpoint items achieved tended to be higher in the VR group. Previous studies examining the usefulness of VR in education have relied primarily on subjective impressions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In contrast, our study objectively assessed the acquisition of practical skills, representing a novel approach in the field of pharmacy education. Our findings resemble those reported in surgical training research, where VR-based learning was associated with increased procedural accuracy, reduced task duration and error rates, and increased learner confidence(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). To our knowledge, this study is the first in pharmacy education to demonstrate, through objective metrics, the effectiveness of VR in supporting the development of procedural skills.\u003c/p\u003e \u003cp\u003eThe VR group completed a greater number of checkpoint items than the Tx group, suggesting that the shorter task completion time observed in the VR group was not due to the omission of procedural steps, but rather reflected improved fluency in operational execution. This interpretation is supported by the higher achievement rate for the item \u0026ldquo;Fill the aseptic smoothly and evenly, without stopping in the middle of the process\u0026rdquo; in the VR group. A similarly high achievement rate was observed for the item \u0026ldquo;Dissolve the drug in the vial (with the syringe inserted into the vial, hold the vial on top and the syringe on the bottom, then retain this positioning and shake the vial and syringe with both hands).\u0026rdquo; The capacity to visualize spatial relationships and procedural techniques within the VR environment may have contributed to the successful performance of these steps. These higher individual item scores, along with the shorter task completion time, may have been reflected in the comprehensive evaluation results as well.\u003c/p\u003e \u003cp\u003eThe two-dimensional plot evaluating the relationship between the achievement ratio and the correlation coefficient with the comprehensive evaluation score revealed distinct patterns across the VR and Tx groups. To interpret the educational significance of each quadrant, we considered the distribution of items based on achievement levels and their associations with overall performance(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The items in the first quadrant, which exhibited both high achievement and strong correlations with the comprehensive evaluation scores, were regarded as priority maintenance areas. These represent critical steps that contribute meaningfully to student performance and should be preserved through consistent instructional reinforcement. Conversely, items in the second quadrant, which also had high achievement but lower correlations with overall evaluation, were interpreted as general maintenance areas\u0026mdash;indicating steps that students performed well but that had relatively limited influence on final performance. The items in the third quadrant, characterized by low achievement and weak association with overall performance, were classified as general improvement areas, suggesting that while student proficiency in these steps was limited, their impact on overall evaluation was modest. Notably, items in the fourth quadrant, which demonstrated both low achievement and strong association with the comprehensive score, were designated as priority improvement areas. These represent key instructional targets, where enhancing student performance is expected to yield a significant improvement in overall task execution.\u003c/p\u003e \u003cp\u003eIn both groups, several procedural items located in the fourth quadrant highlighted key challenges in skill acquisition. These items included performing the aseptic filling process in the correct order, inserting the needle vertically into the vial without approaching from above, and confirming drug dissolution, suggesting that difficulties in these critical steps were linked to lower overall performance regardless of instructional method.\u003c/p\u003e \u003cp\u003eQuadrant-specific differences also underscore the instructional characteristics of each modality. The VR group demonstrated stronger performance in steps requiring spatial coordination, procedural fluidity, and real-time judgment\u0026mdash;skills likely supported by the immersive and visual nature of the VR environment. In contrast, the Tx group performed better in steps involving observation and verification, such as fluid measurement, solution mixing, and visual inspection for contaminants. These results imply that text-based materials may better support tasks grounded in rule-following and careful confirmation.\u003c/p\u003e \u003cp\u003eThe items that appeared exclusively in the fourth quadrant further highlighted method-specific challenges. In the VR group, lower achievement in tasks such as discarding the vial and dissolving the drug properly may have resulted from an overemphasis on dynamic procedural flow, leading students to overlook more subtle but essential steps. In the Tx group, poor performance on tasks involving negative pressure techniques and needle insertion angles likely stemmed from the absence of spatial or kinetic information in the materials. These observations suggest that VR and text-based approaches each emphasize different aspects of procedural learning and that combining them could enhance the overall effectiveness of aseptic technique education.\u003c/p\u003e \u003cp\u003eThese findings suggest that the use of VR-based learning materials provides educational effects that are comparable to or potentially superior to those of conventional text-based learning. Moreover, the VR application appears particularly effective in enhancing procedural efficiency by enabling learners to comprehend the overall structure and sequence of operations in a clear and organized manner. A previous study examining the use of an educational VR application for objective structured clinical examinations (OSCEs) in medical education also demonstrated superior educational outcomes compared to a control group. Furthermore, it supported the application of VR-based tools in assessing clinical competence, consistent with the findings of the present study(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral limitations were identified during the study. First, this was a single-center pilot study of 17 subjects; thus, it is considered that further validation is needed for generalization. The usefulness of VR needs to be tested with more subjects in the future. Second, VR technology in pharmacy education is still in its infancy, with non-standardized content and assessment processes. Third, VR technology has limited capabilities with respect to practical skills, and VR may not fully replicate the complexities of actual pharmacy practice. Finally, accessibility may be an issue for students with disabilities or other health conditions (such as motion sickness or dizziness). While taking these issues into consideration, the use of VR technology will enable the reproduction of realistic clinical environments and repetitive learning, which have been difficult with traditional educational methods, and will greatly contribute to the enhancement of practical skills learning. Further development of pharmacy education incorporating VR is expected in the future.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results of this study suggest that even in aseptic preparation training, which requires more complex procedures than dispensing oral medications, the VR application-based learning method is more effective than traditional text-based learning in helping students acquire procedural workflows and improve operational fluency. This practical pharmacy education approach using a VR application allows students to progress through each step by performing the actions themselves, which may make it more effective for learning procedural workflows compared with traditional text-based learning. In the future, it will be essential to conduct additional studies with a larger number of students to verify the reproducibility and reliability of these findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVirtual Reality\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTx\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etextbook-based learning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Kobe Gakuin University Human Research Ethics Committee (SEB23-01). All participants were informed of the study in writing, and written informed consent was obtained. All procedures involving human participants were performed in accordance with the ethical standards of institutional and national research committees and the 1964 Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. The VR application used in this study is commercially available as the \u0026ldquo;Pharmacy Pre-Learning VR Training Service\u0026rdquo; provided by FUJIFILM System Services Co., Ltd.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS. Esumi, S. Nakagawa, M. Ikemura, R. Ebara, M. Harada, A. Tatsumi, A. Kanmachi, Y. Hashimoto and M. Takeda-Morishita received a collaborative research fund from FUJIFILM Corporation. Y. Takezawa declares that she has no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Grant-in-Aid for Educational Innovation from Kobe Gakuin University for the academic year 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSE analyzed and visualized the data, conducted investigations, and drafted the original manuscript. SN conceptualized the study, designed the methodology, validated the results, curated the data, and contributed to reviewing and editing the manuscript. She also supervised project administration. MI contributed to the study design and investigations, and was involved in reviewing and editing the manuscript. YT, RE, MH, AT, AK and YH conducted the investigations. MT-M conceptualized and supervised the study, contributed to reviewing and editing the manuscript, and acquired the research funding. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKaplan AD, Cruit J, Endsley M, Beers SM, Sawyer BD, Hancock PA. The Effects of Virtual Reality, Augmented Reality, and Mixed Reality as Training Enhancement Methods: A Meta-Analysis. Hum Factors [Internet]. 2021 Jun 1 [cited 2025 Jan 21];63(4):706\u0026ndash;26. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/32091937/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/32091937/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLandon-Hays M, Peterson-Ahmad MB, Frazier AD. Learning to Teach: How a Simulated Learning Environment Can Connect Theory to Practice in General and Special Education Educator Preparation Programs. Education Sciences. 2020, Vol 10, Page 184 [Internet]. 2020 Jul 18 [cited 2025 Jan 21];10(7):184. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mdpi.com/2227-7102/10/7/184/htm\u003c/span\u003e\u003cspan address=\"https://www.mdpi.com/2227-7102/10/7/184/htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakemoto J, Parmentier B, Bratelli R, Merritt T, Coyne L. Extended Reality in Patient Care and Pharmacy Practice: A Viewpoint. Journal of Contemporary Pharmacy Practice [Internet]. 2019 Dec 1 [cited 2025 Jan 22];66(4):33\u0026ndash;8. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/347711910_Extended_Reality_in_Patient_Care_and_Pharmacy_Practice_A_Viewpoint\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/347711910_Extended_Reality_in_Patient_Care_and_Pharmacy_Practice_A_Viewpoint\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith SJ, Farra SL, Ulrich DL, Hodgson E, Nicely S, Mickle A. Effectiveness of Two Varying Levels of Virtual Reality Simulation. Nurs Educ Perspect [Internet]. 2018 Nov 1 [cited 2025 Jan 22];39(6):E10\u0026ndash;5. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.lww.com/neponline/fulltext/2018/11000/effectiveness_of_two_varying_levels_of_virtual.21.aspx\u003c/span\u003e\u003cspan address=\"https://journals.lww.com/neponline/fulltext/2018/11000/effectiveness_of_two_varying_levels_of_virtual.21.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiu PL, Li H, Yap KYL, Lam KMC, Yip PLR, Wong CL. Virtual Reality-Based Intervention to Reduce Preoperative Anxiety in Adults Undergoing Elective Surgery: A Randomized Clinical Trial. JAMA Netw Open [Internet]. 2023 [cited 2025 Jan 22];6(10):E2340588. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/37906193/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/37906193/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerkman MI. History of Virtual Reality. Encyclopedia of Computer Graphics and Games [Internet]. 2018 [cited 2025 Jan 22];1\u0026ndash;9. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://link.springer.com/referenceworkentry/\u003c/span\u003e\u003cspan address=\"https://link.springer.com/referenceworkentry/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-319-08234-9_169-1\u003c/span\u003e\u003cspan address=\"10.1007/978-3-319-08234-9_169-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoyne L, Merritt TA, Parmentier BL, Sharpton RA, Takemoto JK. The Past, Present, and Future of Virtual Reality in Pharmacy Education. Am J Pharm Educ. 2019;83(3):7456.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlkhudair N, Alrayes F, Alsehli D, AlRayes S. Virtual reality in experiential pharmacy education: A quasi-experimental study. Saudi Pharmaceutical Journal: SPJ [Internet]. 2024 May 1 [cited 2025 Jan 22];32(5):102028. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC10981153/\u003c/span\u003e\u003cspan address=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC10981153/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomano D, Lynch S, Komor T, Rhodes-Keefe J, Collier R, Sprague LM. Exploring the Effect on Pharmacy Students\u0026rsquo; Empathy Following a Simulation Using 360-Degree Video. Am J Pharm Educ [Internet]. 2025 May 1 [cited 2025 Jul 17];89(5). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/40185312/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/40185312/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIkemura M, Esumi S, Nakagawa S, Tatsumi A, Hashimoto Y, Kanmachi A et al. [Development of a Virtual Reality Training Tool Promoted at Skill Acquisition in Preparatory Clinical Education for Pharmacy Students and Verification of Its Educational Effectiveness: Preparation of Liquid Medications]. Yakugaku Zasshi [Internet]. 2024 [cited 2025 Mar 18];144(11):1009\u0026ndash;18. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/39496426/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/39496426/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsai Y, Takai Y, Murasaka T, Miyake T, Nakamura T, Morikawa Y et al. Effect of a workshop for questionnaire-based surveys on research awareness and motivation among community and hospital pharmacists in Mie Prefecture. J Pharm Health Care Sci [Internet]. 2025 Dec 1 [cited 2025 Jul 28];11(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/40598445/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/40598445/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanda Y. Investigation of the freely available easy-to-use software \u0026lsquo;EZR\u0026rsquo; for medical statistics. Bone Marrow Transplantation 2013 48:3 [Internet]. 2012 Dec 3 [cited 2025 Jan 22];48(3):452\u0026ndash;8. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nature.com/articles/bmt2012244\u003c/span\u003e\u003cspan address=\"https://www.nature.com/articles/bmt2012244\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang X, Mei J, Xiao S, Xi J, Cao X, Zheng Y. Pharmacy student\u0026rsquo;s perceptions, behaviours and attitudes toward virtual reality simulation. Saudi Pharm J [Internet]. 2023 Jan 1 [cited 2025 Jan 22];31(1):14\u0026ndash;20. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/36685300/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/36685300/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalem S, Cooper J, Schneider J, Croft H, Munro I. Student Acceptance of Using Augmented Reality Applications for Learning in Pharmacy: A Pilot Study. Pharmacy: Journal of Pharmacy Education and Practice [Internet]. 2020 Jul 21 [cited 2025 Mar 14];8(3):122. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC7560130/\u003c/span\u003e\u003cspan address=\"https://pmc.ncbi.nlm.nih.gov/articles/PMC7560130/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar A, Saudagar AKJ, Kumar A, Alkhrijah YM, Raja L. Innovating medical education using a cost effective and scalable VR platform with AI-Driven haptics. Sci Rep [Internet]. 2025 Dec 1 [cited 2025 Jul 29];15(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/40685411/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/40685411/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGan W, Mok TN, Chen J, She G, Zha Z, Wang H et al. Researching the application of virtual reality in medical education: one-year follow-up of a randomized trial. BMC Med Educ [Internet]. 2023 Dec 1 [cited 2025 Jan 22];23(1). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/36597093/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/36597093/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM\u0026uuml;hling T, Schreiner V, Appel M, Leutritz T, K\u0026ouml;nig S. Comparing Virtual Reality-Based and Traditional Physical Objective Structured Clinical Examination (OSCE) Stations for Clinical Competency Assessments: Randomized Controlled Trial. J Med Internet Res [Internet]. 2025 [cited 2025 Jan 22];27. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/39793025/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/39793025/\" targettype=\"URL\" 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":true,"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":"Practical training, Virtual reality, Pharmacy student, Sterile preparation","lastPublishedDoi":"10.21203/rs.3.rs-8525550/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8525550/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e· \u003cstrong\u003eBackground:\u003c/strong\u003e This study is a pilot study evaluating the effectiveness of virtual reality (VR) applications in retraining sterile preparation techniques for injectable medications. Specifically, it focused on comparing VR-based learning with conventional text-based learning and objectively assessing students' acquisition of practical skills using standardized evaluation criteria.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eMethods:\u003c/strong\u003e Seventeen pharmacy students voluntarily participated in the study and were divided into two groups: one using a VR application for learning and the other using text-based materials. Immediately after training with their respective tools, students' aseptic preparation skills were assessed using standardized criteria (including 29 individual evaluation checkpoints) and a 5-point overall rating scale.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eResults:\u003c/strong\u003e Students who used the VR application completed tasks in a shorter time and scored higher on evaluation criteria such as operational smoothness and drug dissolution within vials. Additionally, multiple assessment items, including “Fill the aseptic smoothly and evenly, without stopping in the middle of the process,” were strongly correlated with the overall practical performance ratings of the VR group.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eConclusions:\u003c/strong\u003e The introduction of VR applications for aseptic preparation training, which requires complex processes, suggests that VR-based learning is more effective than traditional text-based methods in helping students master procedural workflows and improving operational fluency. These findings suggest that incorporating VR technology may enhance the quality of practical pharmacy education. Additional advancements in pharmacy education incorporating VR technology are expected in the future.\u003c/p\u003e\n\u003cp\u003e· \u003cstrong\u003eTrial registration: \u003c/strong\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"A Comparative Study of the Effectiveness of Virtual Reality-Based and Text-Based Training in Sterile Preparation: Pilot Trial of Early-Stage Clinical VR Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 16:29:42","doi":"10.21203/rs.3.rs-8525550/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":"17b3c4f1-3045-4b17-8535-31faffe8893e","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:01:47+00:00","versionOfRecord":{"articleIdentity":"rs-8525550","link":"https://doi.org/10.1186/s40780-026-00571-5","journal":{"identity":"journal-of-pharmaceutical-health-care-and-sciences","isVorOnly":false,"title":"Journal of Pharmaceutical Health Care and Sciences"},"publishedOn":"2026-04-15 15:58:10","publishedOnDateReadable":"April 15th, 2026"},"versionCreatedAt":"2026-01-08 16:29:42","video":"","vorDoi":"10.1186/s40780-026-00571-5","vorDoiUrl":"https://doi.org/10.1186/s40780-026-00571-5","workflowStages":[]},"version":"v1","identity":"rs-8525550","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8525550","identity":"rs-8525550","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}