Perceptions of Virtual Reality Integration in Nursing and Midwifery Education: Insights from Educators

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Despite its potential, limited evidence exists on educators’ perceptions of VR integration, particularly in resource-variable contexts. Objective This study explored nursing and midwifery educators’ perceptions of VR integration within their clinical training, examining perceived benefits, implementation challenges, and strategies for sustainable curricular incorporation. Methods A qualitative descriptive design guided by Kirkpatrick’s Four-Level Training Evaluation Model was employed, the study conducted four focus group discussions with 22 nurse educators from two purposively selected South African universities, one urban with established VR infrastructure and one rural institution with limited resources. Data were analysed using reflexive thematic analysis. Results Four themes emerged: (1) immersive educational benefits and enhanced student learning; (2) high-value applications and curricular integration; (3) essential facilitation strategies for sustainability and (4) implementation challenges and barriers. VR was perceived as a powerful complementary tool, not a replacement for clinical practice. Conclusion Sustainable VR integration requires intentional pedagogical alignment, institutional support, and policy embedding. Findings inform best-practice guidelines for VR adoption in nursing and midwifery education across diverse contexts. 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F1000Research 2026, 15 :717 ( https://doi.org/10.12688/f1000research.178786.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Perceptions of Virtual Reality Integration in Nursing and Midwifery Education: Insights from Educators [version 1; peer review: awaiting peer review] Mohale T.K. https://orcid.org/0009-0006-5354-816X 1 , Gumede E.Z. 2 , ten Ham-Baloyi W. 3 , Baloyi O.B. https://orcid.org/0000-0002-7125-2681 4 Mohale T.K. https://orcid.org/0009-0006-5354-816X 1 , Gumede E.Z. 2 , ten Ham-Baloyi W. 3 , Baloyi O.B. https://orcid.org/0000-0002-7125-2681 4 PUBLISHED 12 May 2026 Author details Author details 1 Advance Nursing Science, University of Venda, Thohoyandou, Limpopo, 0950, South Africa 2 School of Nursing & Public Health, University of KwaZulu-Natal - Howard College Campus, Durban, KwaZulu-Natal, 4041, South Africa 3 Department of Nursing Science, Nelson Mandela University Faculty of Health Sciences, Port Elizabeth, Eastern Cape, 6001, South Africa 4 Department of Nursing, Walter Sisulu University Faculty of Health Sciences, Mthatha, Eastern Cape, 5100, South Africa Mohale T.K. Roles: Conceptualization, Data Curation, Investigation, Writing – Original Draft Preparation Gumede E.Z. Roles: Formal Analysis, Supervision, Validation, Writing – Review & Editing ten Ham-Baloyi W. Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Review & Editing Baloyi O.B. Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW Abstract Background Virtual Reality (VR) is increasingly recognised as a promising tool in health professions education, offering immersive environments that support clinical skills development and decision-making. Despite its potential, limited evidence exists on educators’ perceptions of VR integration, particularly in resource-variable contexts. Objective This study explored nursing and midwifery educators’ perceptions of VR integration within their clinical training, examining perceived benefits, implementation challenges, and strategies for sustainable curricular incorporation. Methods A qualitative descriptive design guided by Kirkpatrick’s Four-Level Training Evaluation Model was employed, the study conducted four focus group discussions with 22 nurse educators from two purposively selected South African universities, one urban with established VR infrastructure and one rural institution with limited resources. Data were analysed using reflexive thematic analysis. Results Four themes emerged: (1) immersive educational benefits and enhanced student learning; (2) high-value applications and curricular integration; (3) essential facilitation strategies for sustainability and (4) implementation challenges and barriers. VR was perceived as a powerful complementary tool, not a replacement for clinical practice. Conclusion Sustainable VR integration requires intentional pedagogical alignment, institutional support, and policy embedding. Findings inform best-practice guidelines for VR adoption in nursing and midwifery education across diverse contexts. READ ALL READ LESS Keywords Keywords: Virtual Reality; nursing education; midwifery education; educator perceptions; Kirkpatrick model. Corresponding Author(s) Mohale T.K. ( [email protected] ) Close Corresponding author: Mohale T.K. Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 T.K. M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: T.K. M, E.Z. G, W. tHB and O.B. B. Perceptions of Virtual Reality Integration in Nursing and Midwifery Education: Insights from Educators [version 1; peer review: awaiting peer review] . F1000Research 2026, 15 :717 ( https://doi.org/10.12688/f1000research.178786.1 ) First published: 12 May 2026, 15 :717 ( https://doi.org/10.12688/f1000research.178786.1 ) Latest published: 12 May 2026, 15 :717 ( https://doi.org/10.12688/f1000research.178786.1 ) Introduction The rapidly evolving landscape of immersive technologies has introduced Virtual Reality (VR) as a promising pedagogical tool in health professions education. VR involves the creation of artificial, interactive three-dimensional worlds in which learners can practise clinical skills, rehearse decision-making, and experience rare or high-risk situations in a safe and controlled environment ( Smyth et al., 2023 ). Researchers suggest that VR enhances knowledge retention, clinical skills, development of high-order thinking skills (HOTS) and learner confidence while reducing the risk to patients and lowering the need for expensive physical simulation set-ups ( Liu et al., 2023 ). In nursing and midwifery education, VR applications range from anatomy visualisation and basic clinical skills practice to immersive scenarios for communication, teamwork and emergency response ( Chan et al., 2024 ). Systematic reviews and meta-analyses report generally positive effects of VR and virtual simulation on learning outcomes, particularly psychomotor skills, clinical reasoning and learner satisfaction, though effect sizes and the strength of evidence vary by study design and outcome measured ( Cho & Kim, 2024 ; Park et al., 2024 ). For example, one review found that immersive VR education for nursing students significantly improved knowledge acquisition (SMD = 0.59, 95% CI 0.28–0.90, p < .001) and confidence (SMD = 0.70, 95% CI 0.05–1.35, p = .03) compared to traditional teaching methods ( Park et al., 2024 ). Educators’ buy-in is crucial for successful integration of VR into curricula. Studies exploring educators and clinician perceptions indicate generally favourable attitudes toward VR’s potential to enhance realism, increase student engagement, and allow repeated deliberate practice ( Fealy et al., 2019 ; Padilha et al., 2019 ). At the same time, educators report practical concerns of VR integration including high cost, difficulty accessing hardware/software, technical support needs, as well as workload implications, and uncertainty about alignment with assessment and accreditation frameworks ( Saab et al., 2021 ). In midwifery specifically, high student satisfaction but inconsistent evidence for knowledge gains is reported on, underscoring the role of pedagogical design and educator facilitation in determining educational impact (Sinurat et al., 2025) . While VR demonstrates potential to enrich nursing and midwifery education, several gaps limit confident, wide-scale adoption. First, much of the existing evidence originates from single-site studies in high-income settings; there is limited data on feasibility, acceptability and outcomes in diverse contexts and resource-constrained programs ( Foronda et al., 2020 ). Second, research often focuses on student perspectives and short-term outcomes, with fewer studies examining educators’ experiences, curricular integration strategies, or long-term effects on competency and practice ( Chang & Lai, 2021 ). Third, practical barriers procurement costs, IT infrastructure, staff training, and curriculum alignment remain poorly described from the educator viewpoint, yet these factors directly determine whether VR moves from pilot projects to sustainable teaching practice ( Kardong-Edgren et al., 2019 ; Coyne et al., 2021 ). Finally, there is limited, contemporary evidence specifically describing educators’ perceptions of VR integration. Specifically, there is paucity of literature related to educators’ values towards VR integration into nursing and midwifery education, how they evaluate its pedagogical value, what barriers and facilitators they experience during implementation, and how they believe VR should be aligned with existing curricula and assessment ( Fealy et al., 2019 ; Saab et al., 2021 ). Without this educator-centred knowledge, institutions risk investing in technology that is underused, poorly integrated, or misaligned with educational goals. Methodology Study design This paper draws on a broader PhD-by-publication project that employed a qualitative descriptive design to explore nursing and midwifery educators’ perceptions of virtual reality (VR) integration in their teaching practice. Within this focus, the project examined educators’ views on perceived benefits, concerns, key implementation barriers, and suggested strategies for effective curricular integration. The overarching aim of the broader project was to develop best-practice guidelines for incorporating VR into nursing and midwifery education. However, this paper underpinned by Kirkpatrick’s Four-Level Training Evaluation Model, specifically focuses on educators’ perceptions, highlighting how they experience VR integration and identify practical strategies for its use in teaching. This qualitative approach provided rich, detailed insights into educators’ experiences and perspectives, allowing for in-depth understanding of both benefits and challenges in VR integration. Study setting The study was conducted at two purposively selected universities in South Africa to capture diverse contextual experiences in nursing education. The first site was an urban university in the Free State province with well-established virtual reality (VR) infrastructure and a strong technological environment. The second site was a rural university in Limpopo province, classified as a historically disadvantaged institution and characterised by limited exposure to VR due to infrastructural and resource constraints. Both universities are accredited by the Council on Higher Education (CHE), the South African Qualifications Authority (SAQA), the South African Nursing Council (SANC), and the Department of Higher Education and Training (DHET) to offer clinical training in the R174 general nursing and midwifery programme. Study participants and sample size The study targeted nurse and midwifery educators who were registered with the South African Nursing Council (SANC) and actively involved in clinical teaching within the two selected universities. Eligible participants were required to have a minimum of three years’ experience in clinical nursing or midwifery education to ensure sufficient expertise in training students. A non-probability purposive sampling approach was used to recruit participants, focusing on educators directly engaged in clinical modules. Out of a total population of 22 eligible educators across both institutions. Educators who were not registered with SANC, not employed at the selected universities, or not involved in clinical teaching were excluded from the study. Data collection Data were collected through three semi-structured focus group discussions (FGDs) guided by an interview guide. One open ended question was asked ‘ What are your perceptions/views regarding the use of VR in nursing and midwifery education? The FGDs aimed to explore nursing and midwifery educators’ perceptions, challenges, and recommendations regarding the integration of virtual reality (VR) into their teaching curricula. The central focus was on educators’ views of the benefits and potential applications of VR in nursing and midwifery education, with probing questions such as whether there were specific areas or topics where VR could be particularly effective. Twenty-two nurse and midwifery educators, representing the full population of lecturers involved in clinical training within the two selected universities, participated in the discussions. All FGDs were conducted in English, the medium of instruction at both institutions, to facilitate natural dialogue and accurate expression of concepts. Sessions were held in pre-booked boardrooms at the respective universities to provide a familiar, comfortable, and distraction-free environment. The first FGD, conducted on 25 September 2025, included six participants and lasted 55 minutes. The second FGD, held on 21 October 2025, involved six participants and lasted one hour and 22 minutes. The third FGD took place on 7 November 2025 with five participants and lasted 41 minutes, whilst the fourth and final FGD took place on 13 th November with 5 participants, lasting for 45 minutes. All discussions were audio-recorded and transcribed verbatim. The duration of the FGDs fell within the typical range for qualitative research, with 45–90 minutes generally considered sufficient to explore topics in depth without causing participant fatigue ( Rabiee, 2004 ). Shorter sessions (30–45 minutes) may limit the depth of discussion ( Smith, 2015 ), while longer sessions (90–120 minutes) are better suited to complex topics or larger participant groups ( Krueger & Casey, 2015 ). The 60-minute duration chosen for this study was appropriate given the moderate group size (5–6 participants) and the detailed, technical nature of the topic: VR integration in nursing and midwifery education. Aligned with best practice guidance, skilled facilitation and high participant engagement ensured that rich, detailed data were collected within these time frames ( Guest, Namey & McKenna, 2017 ). Data collection continued until thematic saturation was achieved. After the second FGD, preliminary analysis indicated that participants were providing nuanced details, often supported with specific examples from their clinical teaching practice. Multiple perspectives emerged on the potential benefits and challenges of integrating VR, and participants engaged in an interactive discussion, clarifying and expanding on one another’s viewpoints. In the third focus group discussion, similar details from previous FGD were reemerging. The fourth FGD was conducted to confirm saturation, yielding no new themes. The combination of focused discussion, detailed examples, diverse perspectives, and dynamic interaction confirmed that the data were both comprehensive and sufficiently rich to address the study objectives. For reporting purposes, the discussions are referred to as FGD1, FGD2, FGD3 and FGD4, and each participant was assigned a unique alphanumeric code (e.g., FGD2-speaker 5). Ethical considerations Ethical approval was obtained from the University of KwaZulu-Natal Research Ethics Committee (BREC/00008434/2025), and institutional permission was secured from both universities. The study adhered to ethical principles of respect for persons, beneficence, non-maleficence, justice, and autonomy ( Beauchamp & Childress, 2019 ). Participants received a detailed information sheet explaining the study’s purpose, procedures, potential risks and benefits, the right to withdraw at any time, and measures to ensure confidentiality. Written informed consent was obtained prior to participation, ensuring autonomy. In compliance with the Protection of Personal Information Act (POPI-A, 2013), participants were fully informed about the purpose of collecting their personal information, and their data were handled with strict confidentiality ( University of South Africa, 2020 ). To ensure privacy, all data, including audio recordings and transcripts, were anonymised and linked to unique participant codes (e.g., FGD01, speaker03). Identifying information was removed during transcription, and all files were securely stored on password-protected institutional servers, accessible only to the core research team. In reporting findings, direct quotes were attributed solely to these participant codes to safeguard the principle of non-maleficence ( Saunders et al., 2015 ). Furthermore, the focus group discussions were conducted in private, convenient, and comfortable locations to promote respect for persons and beneficence ( Manti & Licari, 2018 ). Participants were reminded of their shared responsibility for confidentiality, further supporting justice and allowing them to share experiences openly and safely. Data analysis Data was analyzed using reflexive thematic analysis ( Braun & Clarke, 2017 ). Audio recordings were transcribed verbatim by TM. The primary researcher (TM) worked closely with the main supervisor (OB), with both independently approaching each analytic step and meeting periodically to discuss and reach consensus. The transcripts and initial analysis were also shared with co-supervisors (ZG and WTB), who independently reviewed the data. All parties ultimately discussed and agreed on the final themes. The analysis process involved repeated reading of transcripts, line-by-line coding of relevant segments, grouping codes into candidate themes, and refining themes for coherence and distinctiveness. Selected quotes were used to illustrate each theme in the findings. Reflexive notes were maintained throughout to document analytic decisions and ensure transparency. Trustworthiness Trustworthiness was established through multiple strategies that employed the criteria of credibility, dependability, confirmability, and transferability ( Nowell et al., 2017 ). Credibility was enhanced by prolonged engagement with participants, member checking, and probing questions during focus groups to confirm accurate interpretation. Dependability was supported by detailed audit trails and peer debriefing with the main supervisor (OB) and co-supervisors (ZG and WTB). Confirmability was maintained by independent review of transcripts and codes by the researcher (TM) and supervisors, ensuring findings reflected participants’ perspectives rather than researcher bias. Transferability was facilitated by purposive sampling across urban and rural universities and detailed descriptions of context and participants, allowing readers to assess applicability to similar settings. Results Profile of the participants Of the 22 participants involved across four focus group discussions held at two universities, all were academic staff involved in the clinical training of nursing and midwifery students. The cohort comprised 12 nursing and midwifery educators, 6 doctoral-qualified nursing and midwifery educators, senior lecturers, and 4 full professors. The 12 lecturers all held master’s degrees in nursing or related fields, and each possessed between three to five years of experience (averaging four years) as nurse educators specifically engaged in clinical training. The 6 doctoral-level senior lecturers each held a PhD in Nursing Science and brought substantial experience, ranging from 10 to 15 years (averaging 12.5 years), in student education and clinical supervision. The 4 full professors represented the most senior cohort, each with a conservative estimated average of over 25 years of dedicated experience as nursing and midwifery educators actively involved in clinical training. Collectively, the participants brought a profound depth of perspective rooted in direct academic and clinical instructional practice, with an overall mean of approximately 10.1 years of experience in clinical nursing and midwifery education. In this study, four main themes were extracted; namely, immersive educational benefits with subthemes (1.1) increased engagement, excitement, and memory (1.2) safe, accessible practice for high-stakes scenarios (1.3) bridging theory-practice and building competence. Enhanced student learning, high-value applications and curricular integration with subthemes (2.1) priority applications in midwifery and nursing (2.2), a complementary tool, not a replacement. Essential facilitation. Strategies for sustainability with sub-themes (3.1) securing institutional buy-in and building support (3.2) investment in training and dedicated support (3.3) policy and structural integration and implementation challenges and barriers with sub-themes (4.1) resource constraints (4.2) educator readiness and resistance (4.3) pedagogical and health considerations (see Table 1 ). Table 1. Themes and sub-themes identified from nursing and midwifery educators. Theme Sub themes Theme 1: Immersive educational benefits and enhanced student learning 1.1 Increased engagement, excitement, and memory 1.2 Safe, accessible practice for high-stakes scenarios 1.3 Bridging theory-practice and building competence Theme 2: High-value applications and curricular integration 2.1 Priority applications in midwifery and nursing 2.2 A Complementary tool, not a replacement Theme 3: Essential facilitation strategies for sustainability 3.1 Securing institutional buy-in and building support 3.2 Investment in training and dedicated support 3.3 Policy and structural integration Theme 4: Implementation challenges and barriers 4.1 Resource constraints 4.2 Educator readiness and resistance 4.3 Pedagogical and health considerations Theme 1: Immersive educational benefits and enhanced student learning The educators from both institutions perceived VR as transformative. According to them, VR provided students with an immediate and memorable encounter with clinical environments. Thus, creating a sense of “being there” that traditional teaching methods rarely achieve. Sub-theme 1.1: Increased engagement, excitement, and memory According to the data sources, educators reported that VR increased students’ engagement and excitement. This, according to them, ensured stronger and longer memory retention and lifelong recall. The students’ initial reactions were described by the educators as enthusiastic, with many recalling specific visual details and scenarios well beyond the VR session itself. As indicated by the educators, this sustained memory recall suggests that VR supports deeper cognitive processing, thereby making learning experiences more memorable than traditional classroom engagement. This is evident in the following extracts: • Extract 1: “I put on those goggles … there’s a world opening up … to this day, I can remember exactly what I saw.” / “They came out with eyes round and big … ‘Wow mam, did you see this?’”(FGD 02, Speaker 3) • Extract 2: “I was fascinated by it because it seems as if I stood right inside the person’s lungs… And to this day, I can remember exactly what I saw. And I can also tell you the emotion that I had.” (FGD 01, Speaker 4) Sub-theme 1.2: Safe, accessible practice for high-stakes scenarios The data sources further indicated that VR offers a safer, accessible platform by exposing students to clinical case studies and scenarios that are often not readily available in clinical settings. This VR experience offered students a safe space to practice critical clinical skills without fear of harming patients. It was during these VR practice sessions that the students were observed exercising their higher-order thinking skills (HOTS), practising clinical decision-making, problem-solving, and clinical reasoning in safer environments. As illustrated in the following quotes, this experience was beneficial in preparing students for emergencies they may encounter infrequently but must manage competently in practice: • Extract 1: “I think it could be very valuable because that could be to provide a very safe environment to engage in VR applicable to scenarios where we have aggressive patients.” (FGD 01, Speaker 3) • Extract 2: “You can make mistakes, nothing will happen, no baby will die, but here you feel as if it’s authentic and real.” (FGD 01, Speaker 4) Extract 3: “And it also gives them opportunity to see things that they may never see in their lifetime, complications.” (FGD 01, Speaker 2). Sub-theme: 1.3 Bridging theory-practice and building competence In this study VR was perceived by the educators from both institutions as an effective way of bridging the theory-practice gap. According to them VR enables students to visualize and apply their theoretical knowledge into meaningful ways, through its ability of situating complex and complicated concepts into realistic clinical contexts. Below is what they had to say: • Extract 1: “It surely does bring the integration between what I learned and what I do…” (FGD 01, Speaker 4) • Extract 2: “I think if maybe there was virtual reality simulation maybe the student… would go to the clinical area having been exposed.” (FGD 03, Speaker 7) Furthermore, participants observed an increased level of confidence and better preparedness from the students, which, according to them indicated that VR supports the development of practical competence and clinical reasoning skills. The following extracts provide evidence to this statement: • Extract 1: “I feel virtual reality is going to give the student that confidence… when they go to the reality of it, still records as the same reality that they had virtually to their brain and their self-esteem.” (FGD 03, Speaker 6) • Extract 2: “It will assist in terms of… critical thinking… if they see an emergency and then they are there, it will be much better because they will know what to do.” (FGD 03, Speaker 5). Theme 2: High-value applications and curricular integration Educators from both institutions described virtual reality as most impactful when strategically integrated into nursing and midwifery curricula, rather than used as a stand-alone innovation. Two sub-categories emerged under this category as indicated below. 2.1 Priority applications in midwifery and nursing The data sources highlighted specific areas within nursing and midwifery training curricula where VR was perceived a much-needed, impactful teaching and learning strategy. These specific areas were but not limited to complex and complicated clinical procedures, obstetric emergencies and areas where student exposure during clinical placements was perceived as inaccessible or inconsistent. The below narratives confirm this: • Extract 1: “Basically almost all procedures related to midwifery… normal delivery… shoulder dystocia… cord prolapse.” (FGD 01, Speaker 5) • Extract 2: “PPH, eclampsia, all those emergencies, if we can create a platform for them… to act saving that patient, it will make them to be confident and decrease anxiety.” (FGD 03, Speaker 2) 2.2 A complementary tool, not a replacement As much as VR was preferred by all the educators from both institutions, they persistently alluded that VR should be seen as a complementary teaching and learning tool and not necessarily a complete replacement for traditional teaching methods or clinical practice. In this study it emerged that VR is beneficial when integrated within lectures, simulation laboratories and clinical placement rather than when it is used as standalone. Evidence from the educators suggest that integration of VR into teaching and learning prepares the student for authentic real-world clinical practice. The following extracts attest to this: • Extract 1: “It can’t replace, but they can go together… We can go for virtual reality that we are using videos. It can replace the videos, but it can’t replace the part where they have to do it themselves.” (FGD 02, Speaker 4) • Extract 2: “What’s important is the balance… it must also be calculated within your curriculum… which I support that they must both be interlinked.” (FGD 02, Speaker 5) Theme 3: Essential facilitation strategies for sustainability Intentional facilitation at the institutional level was mentioned by the data sources as a key to long term sustainability of VR in nursing and midwifery education. Organisational support, adequate academic training, and alignment with policy were highlighted by the participants as pivotal in ensuring effective integration of VR into the current nursing and midwifery education and beyond. Without the above enablers VR remained at risk of remaining short-lived and fragmented within the institutions of higher learning. The three sub-themes which emerged under this theme will be further elaborated below: 3.1 Securing institutional buy-in and building support Institutional buy-in was mentioned by all the participants as a critical factor in ensuring successful implementation of VR. Data sources perceived institutional executive leadership as key gatekeepers to the successful roll-out of VR. According to the data sources, institutional executives have influence over access to resources, allowing the integration of VR into the curriculum as well as their final and overall acceptance of VR as a legitimate teaching and learning approach. The subsequent extracts provide evidence to this: • Extract 1: “If management doesn’t buy into it, it won’t work … they hold the resources. FGD 02, Speaker 6)” • Extract 2: “If we are not intentional about the resource, then you won’t see the success of it.” (FGD 01, Speaker 5) 3.2 Investment in training and dedicated support Educators highlighted the importance of ongoing training and technical support to enable effective use of VR. Confidence in the use of technology influences educators’ willingness to adopt and adapt it into teaching. Hence availability of dedicated support personnel would reduce their frustrations and disruptions as shown in the following extracts: • Extract 1: “Continuous professional development will assist.” / “We’ve got wonderful champions … they can guide us.” / “If management doesn’t buy into it, it won’t work … they hold the resources.”(FGD 04, Speaker 3). • Extract 2: “The willingness. These kids are millennial and we are not. And then we need to bridge the gap because we have to be trained to do it.” (FGD 02, Speaker 4) 3.3 Policy and structural integration Although one of the institutions was using VR, educators from both institutions mentioned a dire need for VR to be formally acknowledged and integrated in institutional policies and curricular structures, both at undergraduate and postgraduate levels. According to them the absence of structural and institutional integration will render VR as inconsistent and vulnerable with the ultimate termination. These concerns are evident from the following quotes: • Extract 1: “We need to ensure that we make VR part of the culture… by putting it as one of our key performance area into our job description.” (FGD 01, Speaker 5) • Extract 2: “The policies… they must be policies that are talking to how do we integrate technology.” (FGD 02, Speaker 2) Theme 4: Implementation challenges and barriers Several challenges that hindered the effective and efficient implementation of VR were identified by the educators. These will be elaborated in the following three sub-themes. 4.1 Resource constraints Finances, old and poorly maintained infrastructure and scarcity of equipment emerged as the key barriers for the successful implementation of VR. These constraints were perceived to hinder the scalability and routine use and integration of VR within the curricula. Some of the participants stated this: • Extract 1: “How am I going to allow 65 students? We’ve got five to six goggles.” / “To have an adequate experience, you need a really good scenario … planning is a challenge.” (FGD 04, Speaker 4) • Extract 2: “Maintenance could be a problem… the person that maintains it definitely does not live in the province.” (FGD 03, Speaker 6) 4.2 Educator readiness and resistance The level of educator’s readiness and acceptance varied across the educators. Some of the educators verbalized excitement and readiness, while others were reluctant in integrating VR unto their day-day teaching and learning. The below statements attest to this: • Extract 1 (Excitement) : “There’s a neuroscience to it that speaks to me… what it does to the brain and the students’ engagement emotionally, there’s a benefit.” (FGD 01, Speaker 4) • Extract 2 (Resistance) : “Sometimes you find resistance from the lecturers to integrate… lack of information. Sometimes, we don’t want to try new things. We want to stay in our comfort zone.” (FGD 01, Speaker 2). Those who verbalized reluctance, mentioned their lack of trust and uncertainty from the institutions in ensuring sustainability. Furthermore, they mentioned their own limited technological confidence and workload challenges which often limit their kevel of creativity and trying new things. The below statement supports their level of reluctance and resistance: • Extract 1 : “If we are not intentional about the resource, then you won’t see the success of it.” (FGD 01, Speaker 5) • Extract 2 : “The willingness. These kids are millennial and we are not. And then we need to bridge the gap because we have to be trained to do it.” (FGD 02, Speaker 4) 4.3 Pedagogical and health considerations Some of the participants raised health-related and pedagogical considerations which may negatively impact the integration of VR into nursing and midwifery education, teaching and learning. Some of the concerns raised included proper alignment of VR activities with the varied students’ needs. Educators also mentioned that VR may cause visual strain as well as dizziness, which may need extra careful facilitation. Below is how participants elaborated on this: • Extract 2: “We have to monitor session length. Some students report dizziness or eye strain. Facilitators need to be aware of these effects and know how to mitigate them.”(FGD 02, Speaker 5) • Extract 2: “Debriefing is important.” / “We must develop standards on how to implement VR.”(FGD 04, Speaker 2) Discussion This study, underpinned by Donald Kirkpatrick’s Four-Level Training Evaluation Model, explored how educators perceived virtual reality (VR) integration in nursing and midwifery education. The study findings indicate that VR is not only an innovative educational tool, but a pedagogically powerful tool capable of developing in the student’s higher order thinking skills (HOTS). Through its ability to engage students in their own learning, VR entails various educational benefits, including enhanced clinical competence, and preparedness for practice as outlined in Theme One of this study. Despite the vitality of VR as an educational tool, the study findings further highlights that the educational value and sustainability of VR is dependent on an intentional, relevant and responsive curricular, supportive institutional policies, buy-in and readiness of educator’s educator readiness. Hinged within Kirkpatrick’s model, the findings detail the understanding of how VR impacts educational outcomes across reaction, learning, behaviour, and results levels, similarly highlighting context specific factors which influence how it is received and implemented. At the Reaction level, educators described VR as generating high levels of engagement, excitement, emotional immersion, and memorability among students. According to all participants students demonstrated a high level of enthusiasm to VR experiences, often expressing amazement coupled with lifelong learning. Aligned with the literature, such reactions by students suggest that, unlike traditional teaching methods, VR offers memorable learning experiences which are often too abstract to teach or those which are not readily available in the clinical practice ( Yoon et al., 2024 ). Consistent with the conceptual framework, such positive memorable reactions represent the initial mechanism through which VR exerts its pedagogical influence. VR engages students emotionally, giving them a sense of ‘being there’. Aligned with study findings of ( Ryan et al., 2022 ), it is this sense of emotional engagement that captures students’ attention, fosters motivation to learn, and stimulates curiosity, which are critical precursors to the development of HOTS and immersive cognitive processing. As described by the educators, the sustainability in memory recall enhanced by VR indicates that VR may support meaningful lifelong learning and not merely short-term memorization. It emerged in this study that students not only recall what they witnessed but also reports how they felt throughout the VR experience. Which points VR can integrate both affective and cognitive learning processes. This study finding aligns with ( Ryan et al., 2022 ), whom in their study reported that emotionally engaging learning environments enhance retention and understanding. From a theoretical perspective, the strong reaction to VR validates its relevance at the first level of Kirkpatrick’s model and underscores the importance of learner experience in determining the success of educational innovations. In the absence of positive reactions, learning and behavioural outcomes are unlikely to be evident ( Jeffries, 2022 ). Thus, the study findings emphasize on the importance of VR in establishing a strong foundation for learning through its ability to foster engagement and emotional immersion. At the Learning level participants perceived VR as particularly effective in its knowledge acquisition, skills development and development of HOTS. Consistent with Baloyi and Mtshali (2018) , the study findings, VR creates an emotionally safe learning environment which enables students to safely practice complex and complicated clinical skills without fear of endangering the patients. This was perceived by the educators as much-needed and valuable in nursing and midwifery education, where opportunities to manage rare or critical events, such as obstetric emergencies, are often limited or inconsistent in real clinical settings. Hence, the study participants believed and supported the use of VR, which according to them enhances experiential learning allowing students to learn through trial, error, and reflection for-on- and in action. Educators also highlighted VR’s role in bridging the longstanding theory–practice gaps in nursing and midwifery education. Through its ability to situate abstract theoretical concepts in real life situations, VR enables students to visualise abstract knowledge and apply it in practice-oriented ways. This finding is particularly significant, as the theory–practice gap has been widely recognised as a long-standing challenge in healthcare professions education ( Carvello et al., 2024 ). In keeping with the study’s conceptual framework VR, is a mediating mechanism that translates abstract theoretical learning into applied practical understanding. The perceived increase in student confidence and preparedness further suggests that VR supports not only cognitive learning but also the development of professional self-efficacy ( Ahmed et al.,2025 ). Through its ability to enhance the development of HOTS such as clinical reasoning, decision-making, and problem-solving, there is hope that VR may contribute to deeper levels of learning aligned with nursing and midwifery professional competence rather than rote skill acquisition. The current study educators’ observations that students appeared better prepared to respond and recognize emergencies suggest that VR enhances learners’ ability to integrate knowledge, assess situations, and act effectively and appropriately ( Cho & Kim, 2024 ) At the Learning level of Kirkpatrick’s model, these findings provide strong evidence that VR is perceived to facilitate comprehensive learning across cognitive, affective, and psychomotor domains ( Wang et al., 2026 ). At the Behaviour level, the findings suggest that VR has the potential to influence how students apply what they have learned in real-world clinical settings. As indicated in the study findings, students who had been exposed to VR scenarios demonstrated increased readiness, situational awareness and confidence, when faced with similar situations in the authentic clinical practice. According to ( Jeffries, 2022 ) this perceived transfer of learning from the virtual environment to clinical practice is a critical indicator of educational effectiveness, as it reflects the extent to which learning translates into observable behavioural change. Of significant importance the study findings also highlight that behavioural transfer is not automatic. Hence, educators persistently emphasised that VR should be integrated as a complementary tool rather than a replacement for traditional teaching methods and clinical practice, implemented where appropriate to individual learning needs. This underscores the importance of curricular alignment in ensuring that VR learning is reinforced and contextualised within broader educational pathways ( Browne et al., 2021 ). Such alignment not only strengthens learning transfer but also enhances the sustainability of VR within nursing and midwifery education by embedding it meaningfully into existing structures rather than positioning it as a standalone innovation. Within the conceptual framework, VR is positioned as part of a blended learning ecosystem, where lectures, simulation laboratories, clinical placements, and VR experiences are interlinked to support progressive skill development. Literature further echoes that when VR is isolated from these structures, its impact on behaviour may be limited ( smythSchuelke et al., 2022 ). The educators’ emphasis on balance reflects their understanding that multiple learning modalities are necessary to develop clinical competence and that no single modality is adequate on its own. Consequently, behavioural practical competence results from using VR along with other clinical structures which reflect actual clinical demands rather than just from exposure to the technology. It therefore goes without a doubt that Kirkpatrick’s model’s Behaviour level is useful in assessing both the occurrence of learning and its practical application ( Jeffries, 2022 ). At the Results level, educators reflected on the overall implications of VR integration for nursing and midwifery education and the healthcare systems. According to them, effective VR integration holds the possibility to contribute towards improved graduate competence, enhanced educational quality (SDG, goal 4), and better preparedness to manage maternal and neonatal health challenges (SDG, goal 3). These perceived outcomes align with the far-reaching goals of nursing and midwifery education, which include producing competent, confident practitioners capable of delivering safe and effective care ( SANC, 2013 ; ICM, 2025 ). However, the findings also reveal that achieving such outcomes is dependent upon institutional and structural enablers. According to the educator’s institutional buy-in, leadership involvement and support, and resource availability and allocation are critical determinants of VR’s sustainability. Without leadership support, and formal recognition and integration VR within curricula and policies, VR initiatives were perceived as vulnerable, fragmented, and unsustainable. This highlights the complexity and systemic nature of educational innovation, where individual enthusiasm alone is not sufficient enough to sustain transformation ( Rogers, 2003 ). Educator training and dedication, available technical support also emerged as essential for sustainability. Educators acknowledged that their confidence in using VR influenced their willingness to adopt it and integrate it creatively and successfully into teaching and learning. All educators in this study expressed their willingness to adopt VR. However, they also highlighted that workload pressures, generational differences, and limited technological expertise were identified as barriers that could hinder adoption to the use of VR if not addressed through ongoing and continuous professional development. Within the conceptual framework, these factors function as enablers or hindering conditions that shape the meaningfulness of VR at both the institutional and system levels. Institutional policies and structural integration further arose as critical components of VR sustainability. As indicated by the educators VR should be formally embedded within institutional policies, workload models, and performance frameworks. According to them such integration would normalise VR as part of academic culture rather than positioning it as an optional or experimental tool be used whenever and however. At the Results level of Kirkpatrick’s model, these findings underscore that the ultimate impact of VR extends beyond individual learners to encompass organisational practices and educational systems ( Ross, 2025 ). It further emerged in this study that VR integration occurs within a multifaceted resource constrained context. These were, but not limited to, economic factors, poor infrastructure, and limited equipment, which were perceived by the study sources as significant obstacles to scalability and equitable access. Additionally, health-related considerations, such as visual strain and dizziness, highlighted the need for careful pedagogical design, session monitoring, and structured debriefing. These concerns do not nullify the value of VR, but rather emphasise the importance of responsible and evidence-informed implementation ( Smyth et al., 2023 ). Taken together, the findings provide strong support for the use of Kirkpatrick’s Four-Level Training Evaluation Model as a guiding framework for understanding VR integration in nursing and midwifery education. Strengths and limitations A key strength was the inclusion of participants across varying levels of academic seniority and experience, ensuring diverse yet informed perspectives. Conducting focus group discussions across two universities further enriched the data through interactive dialogue and cross-institutional comparison, enhancing contextual transferability. However, the use of non-probability purposive sampling, the relatively small sample size (n = 22), and the inclusion of educators from only two universities limit generalisability. Additionally, focus group dynamics and the professional seniority of participants may have introduced social desirability bias. Future studies should include larger, multi-institutional samples and consider mixed methods approaches to enhance generalisability, reduce potential bias, and strengthen the evidence base for clinical nursing and midwifery education. Conclusions The findings of this study highlight that VR is perceived by educators as a high-impact pedagogical tool with the potential to transform nursing and midwifery education. However, its effectiveness and success, is not only inherent in the technology itself, but within the conditions under which it is implemented. When VR is pedagogically aligned, institutionally supported, and embedded within curricular and policy frameworks, it is perceived to enhance engagement, deepen learning, support behavioural transfer, and contribute to improved educational outcomes, especially for high-stakes scenarios rarely encountered in practice. Conversely, when these enabling conditions are absent, VR risks remaining an underutilised or unsustainable tool. These findings highlight the need for a systems-oriented approach to VR integration, one that recognises the interconnected roles of pedagogy, institutions, educators, and policy in shaping educational change. Data availability statement The data underlying this study are available in figshare at https://doi.org/10.6084/m9.figshare.31990089 ( Mohale, 2026 ). The dataset includes transcripts of the focus group discussions. All personal identifiers have been removed to ensure participant confidentiality. 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PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 12 May 2026 ADD YOUR COMMENT Comment Author details Author details 1 Advance Nursing Science, University of Venda, Thohoyandou, Limpopo, 0950, South Africa 2 School of Nursing & Public Health, University of KwaZulu-Natal - Howard College Campus, Durban, KwaZulu-Natal, 4041, South Africa 3 Department of Nursing Science, Nelson Mandela University Faculty of Health Sciences, Port Elizabeth, Eastern Cape, 6001, South Africa 4 Department of Nursing, Walter Sisulu University Faculty of Health Sciences, Mthatha, Eastern Cape, 5100, South Africa Mohale T.K. Roles: Conceptualization, Data Curation, Investigation, Writing – Original Draft Preparation Gumede E.Z. Roles: Formal Analysis, Supervision, Validation, Writing – Review & Editing ten Ham-Baloyi W. Roles: Conceptualization, Methodology, Supervision, Validation, Writing – Review & Editing Baloyi O.B. Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 12 May 2026, 15:717 https://doi.org/10.12688/f1000research.178786.1 Copyright © 2026 T.K. M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article T.K. M, E.Z. G, W. tHB and O.B. B. Perceptions of Virtual Reality Integration in Nursing and Midwifery Education: Insights from Educators [version 1; peer review: awaiting peer review] . F1000Research 2026, 15 :717 ( https://doi.org/10.12688/f1000research.178786.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: AWAITING PEER REVIEW AWAITING PEER REVIEW ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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