The effect of Virtual Reality Integrated Exercise on the Subjective Exercise Experience, Resilience, and Coping Style for clinical medical students

The effect of Virtual Reality Integrated Exercise on the Subjective Exercise Experience, Resilience, and Coping Style for clinical medical students | 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 The effect of Virtual Reality Integrated Exercise on the Subjective Exercise Experience, Resilience, and Coping Style for clinical medical students Chao Chen, Chuang Yan, Hailong Chang, Jie Ma, Feng Bao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6948814/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Exercise demonstrates substantial practical value and exerts statistically significant positive effects on mental health promotion. Meanwhile, virtual reality technology has emerged as the creative methodology in psychological research. The integration of virtual reality with exercise represents a growing trend that drives advancements in the field of students’ development. The aim of this study was to investigate the effects of virtual reality integrated exercise intervention on clinical medical students' psychological outcomes. And to assess if there was a difference in students’ subjective exercise experience, resilience, and coping styles between those who participated in virtual reality integrated exercise teaching intervention compared to those who participated in a traditional teaching strategy. Methods The study enrolled 81 clinical medical students from North China University of Science and Technology, randomly allocated to either the intervention group (n=40) or control group (n=41). The control group participated in traditional physical education (table tennis), while the intervention group participated in a virtual reality integrated exercise program. Data collection tools included the Resilience questionnaires, Coping style questionnaires, Subjective exercise experience questionnaires, which were completed one week before and after the intervention by each clinical student. The data were analyzed through independent t-tests, paired t-tests, and pearson’s correlation. The significance level was set at P<0.05. Results The average positive happiness scores were significantly higher in the intervention group compared to the control group in the post-test, p<0.05. The intervention group demonstrated significantly reduced psychological distress scores relative to control group in post-testing. All three indicators related to resilience have significantly improved after participated in virtual reality integrated exercise. The positive coping scores of intervention group were higher than the control group, p<0.05. The student’s positive happiness scores was significantly positively correlated with fortitude scores and optimistic scores and positive coping scores in the post-test, p<0.05. Conclusions The findings of this study demonstrate that virtual reality integrated exercise approach effectively enhanced clinical medical students' subjective exercise experience, resilience, and coping styles. Furthermore, the subjective exercise experience serves as a critical determinant of both resilience and coping styles. Given these positive outcomes, it is recommended that this integrated method can be as the course for clinical medical students’ university learning. Virtual Reality Exercise. Subjective Exercise Experience Resilience Coping Style Figures Figure 1 Introduction Clinical work is widely recognized as a demanding profession, both physically and mentally, often characterized by staffing shortages and numerous clinical challenges. Developing good exercise habits and maintaining positive psychology during university education significantly impacts their professional growth[ 1 ]. It was found that when face external pressures and unpredictable events, positive psychological state can help clinical medical students to establish a mindset to overcome difficulties, as well as motivate them to continuously pursue high-quality healthcare competencies[ 2 ]. Students with negative psychological traits often have problems in academics, interpersonal interactions and emotional adjustment, with extreme thoughts and problematic behaviors that are detrimental to their long-term development. Universities should prioritize assessing medical students’ coping styles and health literacy, gain a comprehensive understanding of their psychological well-being, leverage institutional educational resources effectively, and implement targeted health education programs to enhance their mental health[ 3 ]. University health education initiatives should not only enhance medical students' health literacy but also emphasize effective strategies for managing negative emotions. By fostering adaptive coping mechanisms, these efforts can promote the adoption of healthy lifestyles and support sustained physical and psychological well-being among medical students[ 4 ]. The study of resilience originated in the 1970s, with researchers initially focusing on investigating both intrinsic trait factors and external protective environmental factors. Current definitions in resilience research predominantly center on two core elements negative and positive adaptation. As the previous study showed that resilience is the result of the combination of innate individual characteristics and learned adaptations, representing a dynamic capacity to effectively cope with adverse life experiences including stress, adversity[ 5 ]. The variability of resilience validates the rationality of its process-based dynamic definition. Empirical studies have effectively utilized resilience as both an indicator of psychological intervention efficacy and a marker of mental health status. This approach has facilitated the development of targeted, health-promoting interventions aimed at enhancing resilience, with demonstrated effectiveness in practical applications[ 6 ]. clinical medical students in China will encounter significant physical and psychological stressors in their professional practice. However, current medical education predominantly emphasizes technical skill acquisition while providing inadequate training in stress management. This imbalance has resulted in low resilience levels among this student population[ 7 ]. Therefore, the universities should implement targeted training programs to cultivate adaptive personality traits and foster positive psychological dispositions, thereby enhancing students' resilience capabilities. Coping style refers to an individual's characteristic cognitive and behavioral strategies for managing adverse external stimuli, aimed at maintaining psychological equilibrium during stressful experiences[ 8 ]. The study findings demonstrated that individuals' selected coping strategies can effectively mitigate the adverse effects of stress-induced emotional responses. When confronting stressful events, behavioral and cognitive adjustments serve to attenuate negative psychological impacts, thereby reducing stress reactivity and promoting restoration of psychological equilibrium[ 9 ]. Owing to substantial variations in physiological characteristics, personality traits, cognitive styles, and developmental backgrounds, individuals demonstrate diverse coping styles, which can be either positive or negative[ 10 ]. According to conservation of resources theory, individuals employing positive coping style acquire and preserve greater psychological resources. This resource accumulation enables active cognitive-behavioral adjustments to internal and external demands during stressful encounters, thereby alleviating stress responses and facilitating successful adaptation[ 11 ]. Prior to entering clinical work, students must have the robust psychological attributes and the capacity to maintain positive psychological states in professional settings. This necessitates developing high-level resilience and positive coping styles during their academic training, competencies that require targeted educational interventions[ 12 ]. The International Society for Sport Psychology published a position statement entitled “Physical Activity and Psychological Benefits” back in 1994, stating that physical activity has a positive effect on psychological activity[ 13 ]. Related studies indicate that exercise-induced positive happiness and reduced psychological distress have significantly effect on enhance emotional well-being by amplifying positive emotions while mitigating negative affective states, including anxiety and depression[ 14 ]. As a mental health intervention program, exercise not only help people stay fit and shape beautiful bodies, but more importantly, it can potentially guide people to form positive, optimistic psychological cognition and thoughts. Especially from a methodological perspective, exercise demonstrates substantial practical value and exerts statistically significant positive effects on mental health promotion, which the effects are both empirically and clinically relevant[ 15 ]. In the field of psychology, there is growing demand for interdisciplinary innovation and integration in order to shift traditional psychological regulation methods from two-dimensional visual auditory single sensory simulation training to practical multi-channel sensory simulation scenario training. Consequently, virtual reality technology has emerged as a creative methodology in psychological research[ 16 ]. The integration of virtual reality with exercise represents a growing trend that not only enhances the intrinsic value of athletic activities but also drives advancements in the field of exercise for health[ 17 ]. Relevant studies has shown that exercise holds significant value in promoting psychological well-being, including the alleviation of depression, anxiety, and other negative emotional states. However, existing research has paid few attention to investigating the psychological characteristics and future career needs of clinical medical students. While numerous studies have explored the relationship between exercise and isolated psychological factors, however, there fewer study have examined its association with multiple interrelated psychological dimensions. Therefore, the aim of this study was to investigate the effects of virtual reality integrated exercise intervention on clinical medical students' psychological outcomes. And to assess if there was a difference in students’ subjective exercise experience, resilience, and coping styles between those who participated in virtual reality integrated exercise teaching intervention compared to those who participated in a traditional teaching strategy. Furthermore, based on experimental results, we will analyze the relationships between changes in subjective exercise experience, resilience, and coping styles to identify underlying mechanisms. Materials and methods Design This is one of the interventional studies demonstrating the virtual reality integrated exercise program for clinical medical students in university physical education, after obtaining approval from the ethics committee of North China University of Science and Technology (NSTCU2024-8-19), and registered in NSTCU(NSTC20248191103C5). This 4-month pre-post intervention study quantitatively assessed changes in subjective exercise experience, resilience, and coping styles among participants before and after a physical education program. clinical medical students from North China University of Science and Technology served as experimental subjects in this study, which aimed to evaluate the differential effects of various university exercise teaching strategy on promoting mental health. Firstly, we examines the effects of virtual reality integrated exercise on the subjective exercise experience, resilience, and coping style of clinical medical students. Secondly, to examine the interrelationships between subjective exercise experience, resilience, and coping styles. All students registered for the elective exercise course were included in the study, which were divided into intervention group and control group. The control group maintained their regular traditional exercise teaching strategy, while the intervention group participated in an innovative teaching strategy of virtual reality combined with power cycling. The different exercise intensities and virtual reality scenarios were set up for the intervention group, which they were systematically involved in a 16 week exercise program. Procedure In this study, two classes of clinical major students from North China University of Science and Technology were selected as participants. Prior to the experiment, individuals with pre-existing physical injuries or mobility impairments were excluded from participation. Following the exclusion criteria, a total of 81 eligible students were enrolled in the study, with 40 assigned to the intervention group and 41 to the control group. The experiment was conducted from September to December 2024, with both the intervention and control groups participating in a 16-week exercise teaching program. The control group participated in traditional exercise teaching progarm (table tennis), while the intervention group participated in a virtual reality integrated exercise program. Both the intervention and control groups followed identical warm-up and relaxation protocols during each session. While the exercise sessions were equal in length, their content differed between groups. The intervention group's program required participants to wear virtual reality glasses during power cycling exercises. Each session comprised three structured components: Low-intensity cycling in an enjoyable virtual scenarios; Moderate-to-high-intensity cycling in a challenging virtual scenarios; Low-intensity cycling in a nature-themed virtual scenarios. Participants were required to adapt to varying exercise intensities and virtual scenarios until completing the prescribed exercise tasks. During the experiment period, participants completed psychological assessments at two time points: resilience, coping style, subjective exercise experience questionnaires were administered one week before the intervention; all questionnaires (resilience, coping style, and subjective exercise experience) were readministered one week post-intervention. Ultimately, data from all 81 participants (40 in the intervention group and 41 in the control group) were compiled and analyzed using statistical methods. Measurements Resilience questionnaires The resilience questionnaires was designed by Conner and Davidson, and it was revised by Chinese researcher Yu Xiaonan and Zhang Jianxin. It includes three dimensions: fortitude, self-improvement, and optimism. The questionnaires included 25 questions which responses were recorded on a Likert scale with 1 indicating “strongly disagree” and 5 indicating “strongly agree”[ 18 ]. The procedures for assessing reliability and validity in resilience tests were employed. The results revealed acceptable reliability and content validity (Cronbach’s α = 0.80 and Scale-CVI = 0.83). Coping style questionnaires The coping style questionnaires was simplified and modified by Xie Yaning based on china's actual condition. It is used to evaluate the coping styles that individuals are accustomed to when facing difficulties. This questionnaires consists of positive coping style and negative coping style, with a total of 20 items. The responses were recorded on a Likert scale from 0 to 3, and the higher the average score, the more stronger tendency toward this coping style[ 19 ]. The same procedures for assessing reliability and validity in coping style tests were employed, which the results revealed acceptable reliability and content validity (Cronbach’s α = 0.89 and Scale-CVI = 0.82), confirming its robustness for empirical use. Subjective exercise experience questionnaires This study employed the Subjective Exercise Experiences Scale, a well-validated instrument originally developed by McAuley and subsequently culturally adapted and psychometrically refined by Wang Mengyang, to evaluate participants' exercise-induced psychological states[ 20 ]. The subjective exercise experience questionnaires included three aspects: positive happiness, psychological distress, fatigue, which consists of 12 questions ranged from 1 to 7, with higher scores in the positive happiness dimension indicating more favorable exercise experiences. Conversely, higher scores in psychological distress and fatigue reflect poorer emotional and physical states, respectively. Cronbach’s reliability coefficient and test-retest reliability of the scale were 0.75 and 0.79, which indicated that it had good reliability and validity. Statistical analysis The collected data were systematically entered into a computerized database and subsequently analyzed using IBM SPSS Statistics software (version 26.0, IBM Corp., Armonk, NY, USA) for statistical processing. Descriptive statistics were presented as frequencies and percentages for categorical variables. Continuous variables were compared between groups using independent t-tests, while within-group comparisons (pre-test vs. post-test) were assessed using paired t-tests. Statistical significance was set at p < 0.05 (two-tailed). Additionally, Pearson’s correlation analysis was conducted to examine the relationships among subjective exercise experience, resilience, and coping style. Results Eighty-one clinical medical students from North China University of Science and Technology participated in the experiments. All participants were sophomore, with 78% of students under 21 years old and 22% between 22 and 23 years old. Among the participants, 63% were male and 37% female. None of the students had participated in the virtual reality integrated exercise teaching program prior to this study. Table 1 demographic characteristics of the participants(n = 81) Items No. % Gender male 51 63 female 30 37 Age ≤ 21 63 78 22–23 18 22 ≥ 24 Whether experienced virtual reality integrated exercise yes 0 0 no 81 100 Academic year (n) 2rd 81 100 3th The primary objective of this study was to evaluate the efficacy of a virtual reality integrated exercise in enhancing subjective exercise experience among clinical medical students. Independent sample t tests and paired samples t-test were used to analyze the differences in subjective exercise experience between the the groups (Table 2 ). Positive happiness scores were significantly higher in the intervention group (20.87 ± 3.77) than in the control group (16.62 ± 3.06) at post-test, p < 0.05. Post-test results revealed significantly higher positive happiness scores in the intervention group (20.87 ± 3.77) compared to the control group (16.62 ± 3.06), with this difference reaching statistical significance (p < 0.05). The intervention group demonstrated significantly reduced psychological distress scores relative to control group in post-testing. However, unlike the positive happiness and psychological distress scores, there was no significant difference in students' fatigue scores in the pre-test and post-test, p < 0.05, respectively. In summary, while neither form of exercise alleviated subjective fatigue, the virtual reality integrated exercise intervention demonstrated significant benefits in enhancing positive happiness and reducing psychological distress. Table 2 Comparison of subjective exercise experience before and after the intervention Items Control group Intervention group P -value Positive happiness pre-test 15.10 ± 2.98 15.39 ± 3.25 0.731 post-test 16.62 ± 3.06 20.87 ± 3.77 0.037 P -value 0.122 0.025 Psychological distress pre-test 13.19 ± 2.18 12.65 ± 2.93 0.391 post-test 12.92 ± 2.83 8.16 ± 3.18 0.025 P -value 0.673 0.039 Fatigue pre-test 18.23 ± 3.05 18.37 ± 3.89 0.811 post-test 18.05 ± 2.88 17.62 ± 3.50 0.533 P -value 0.675 0.385 The results showed that the virtual reality integrated exercise program produced significantly better outcomes in almost all aspects of clinical medical students’ resilience, as shown in Table 3 . Post-test fortitude scores were significantly higher in the intervention group (45.37 ± 7.91) compared to the control group (39.85 ± 6.13), p < 0.05. The average self-improvement scores of the intervention group and control group were increased in the post-test, but the intervention group obtained significantly better test results 29.06 ± 3.93 and 25.79 ± 4.01, p < 0.05, respectively. The intervention group showed significantly higher post-test optimism scores (13.89 ± 2.51) compared to the control group (11.28 ± 1.98; p < 0.05). In a word, all three indicators related to resilience have significantly improved after participated in virtual reality integrated exercise. Table 3 Comparison of resilience before and after the intervention Items Control group Intervention group P -value Fortitude pre-test 38.12 ± 7.52 39.52 ± 6.36 0.358 post-test 39.85 ± 6.13 45.37 ± 7.91 0.035 P -value 0.512 0.023 Self-improvement pre-test 24.60 ± 3.28 24.81 ± 4.23 0.752 post-test 25.79 ± 4.01 29.06 ± 3.93 0.031 P -value 0.603 0.040 Optimistic pre-test 10.32 ± 2.10 10.08 ± 1.80 0.796 post-test 11.28 ± 1.98 13.89 ± 2.51 0.037 P -value 0.682 0.026 This study aimed to evaluate the effects of virtual reality integrated exercise on coping styles among clinical medical students. Between-group differences were assessed using independent samples t-tests, while within-group changes were examined through paired samples t-tests. Paired t-tests indicated no significant change in positive coping scores for the control group (p > 0.05), while the intervention group showed significant improvement from pre-test to post-test (p < 0.05). Independent samples t-tests revealed significantly higher positive coping scores in the intervention group (2.56 ± 0.71) compared to the control group (2.11 ± 0.50), p < 0.05. Independent samples t-tests revealed a significantly greater reduction in negative coping scores for the intervention group (1.22 ± 0.28) compared to the control group (1.56 ± 0.35), p < 0.05. Table 4 Comparison of coping style and after the intervention Items Control group Intervention group P -value Positive coping pre-test 1.98 ± 0.41 2.03 ± 0.56 0.751 post-test 2.11 ± 0.50 2.56 ± 0.71 0.047 P -value 0.385 0.039 Negative coping pre-test 1.62 ± 0.37 1.59 ± 0.39 0.826 post-test 1.56 ± 0.35 1.22 ± 0.28 0.031 P -value 0.296 0.036 This study demonstrated the effectiveness of virtual reality-integrated exercise in enhancing subjective exercise experience, psychological resilience, and coping strategies. Base on these findings we further examined the relationship between the subjective exercise experience, and the resilience and coping style. As shown in Table 5 , the students' positive happiness scores were significantly positively correlated with fortitude scores, optimistic scores, and positive coping scores in the post-test, p < 0.05. The student's positive happiness scores demonstrated a significant negative correlation with negative coping scores in the post-test (p < 0.05). The results indicated that the student’s fatigue scores were not significantly correlated with most indicators, except for fortitude. A significant positive correlation was observed between psychological distress scores and both optimism and positive coping scores in the pre-test (p < 0.05). Additionally, students' psychological distress scores remained significantly positively correlated with optimism in the post-test (p < 0.05). The experimental results revealed a significant negative correlation between psychological distress and students' coping styles in the pre-test. In contrast, post-test results demonstrated an attenuation of this association, indicating a weakening of the initial relationship. Table 5 Correlation between subjective exercise experience and resilience and coping style (n = 40) Items Positive happiness Fatigue Psychological distress Pre Post Pre Post Pre Post Fortitude 0.205 0.326* 0.238 0.315* −0.165 −0.118 Self-improvement 0.173 0.224 0.128 0.153 −0.102 −0.059 Optimistic 0.210 0.397* 0.117 0.102 −0.337* −0.290* Positive coping 0.195 0.431* 0.139 0.181 −0.316* −0.187 Negative coping −0.187 −0.386* −0.108 −0.136 0.233 0.171 *: Statistically significant at p < 0.05 Discussion The effect of virtual reality integrated exercise on subjective exercise experience Subjective exercise experience refers to an individual's self-evaluated affective and cognitive responses following physical activity participation. These personally mediated perceptions serve as critical psychological feedback mechanisms influencing future exercise engagement. The results of the study showed that positive happiness in subjective exercise experience of the intervention group was elevated, and psychological distress were reduced after the experiment, which indicated that virtual reality integrated exercise had the effect on promote subjective exercise experience of clinical medical students. Consistent with existing evidence, empirical studies have demonstrated that structured exercise interventions can facilitate positive psychological states, enhance self-efficacy beliefs and promote overall mental health. Positive affective states generated during physical activity can disrupt negative emotional cycles characteristic of depression[ 21 ]. Students in the intervention group completed different intensities of exercise in a virtual scene, which could help students to manage their anxiety and obtain more successful experiences. virtual reality integrated exercise helped to clinical medical students experience the joy of exercise, avoiding the frequency of psychological troubles and promoting mental health. The results of a systematic review indicated that physical education extends beyond knowledge acquisition, encompassing the development of motivation, skill competencies, and self-efficacy all essential components for health improvement through exercise[ 22 ]. The results of our experiment showed that the fatigue did not change before and after the experiment in both groups, and the fatigue feeling caused by exercise did not change due to the form of exercise. Previous studies have also confirmed that exercise fatigue is a normal physiological phenomenon, and has no significant effect on the promotion of human physical and mental health[ 23 ]. In summary, while virtual reality integrated exercise has been shown to boost happiness and alleviate psychological distress, it appears to have no significant effect on exercise-induced fatigue. The effect of virtual reality integrated exercise on resilience Resilience reflects an individual's positive psychological capacity, which are the ability of individuals to maintain stable emotions and behavioral responses through self regulation, self control, and positive coping when facing challenges and stressors[ 24 ]. Related studies have shown that sports can help improve individuals' resilience, enabling them to cope with stress and difficulties in a positive way, thereby maintaining a good level of mental health[ 25 ]. Our study demonstrated that both tennis and virtual reality integrated with cycling effectively improved students' resilience, confirming the positive impact of exercise on resilience development. Notably, virtual reality integrated with cycling required participants to regulate their emotions in immersive virtual environments while simultaneously maintaining physical endurance through progressively increasing exercise intensity. This dual stimulation combining emotional control and physical challenge significantly enhanced students' resilience compared to traditional exercise. The results of a systematic review indicated that medical students with higher resilience levels could effectively mobilize psychological resources to cope with adversity negative events. This adaptive capacity helped mitigate adverse emotional responses and minimized disruptions to their academic engagement[ 26 ][ 27 ]. Adversity coping theory suggests that individuals who develop resilience through painful experiences can more effectively cope with challenges in future life[ 28 ]. In this study, we employed virtual reality technology to simulate adverse scenarios coupled with high-intensity exercise, simultaneously exposing clinical medical students to controlled physiological and psychological stressors[ 29 ]. Through repeated challenge-exposure and successful adversity overcoming, this intervention demonstrated measurable improvements in participants' resilience levels[ 30 ]. Enhancing resilience levels in clinical medical students fosters their ability to maintain a persistent, positive mindset when facing academic and professional challenges. The effect of virtual reality integrated exercise on coping style Coping styles represent individuals' characteristic of cognitive, emotional, and behavioral responses to stressful situations or challenges, which encompass both positive and negative coping strategies[ 31 ]. Our study revealed that clinical medical students who engaged in virtual reality integrated exercise interventions demonstrated significant improvements in positive coping styles, concurrently showing a reduction in negative coping styles. The study demonstrated that the virtual reality integrated with cycling approach is a cognitive behavioral intervention method, which encourages individuals to reassess their criteria for coping with challenges, promoting self criticism reduction and the exploration of new solutions to problems. The training approach set by our research requires clinical medical students to complete tasks while progressively increasing levels of exercise intensity and psychological stress, which necessitates that students adopt appropriate strategies to manage both psychological pressure and high intensity physical demands[ 32 ]. The results demonstrate that the virtual reality integrated with cycling intervention facilitated the development of adaptive cognition, enhancing participants' stress coping capacity through the cultivation of positive psychological capital. This psychological reinforcement subsequently promoted the acquisition of effective stress management strategies. Furthermore, through effective coping, and confrontation techniques, students can enhance their problem-solving cognitive abilities and diminish feelings of helplessness, ultimately enabling more effective response capability of academic and clinical challenges[ 33 ]. Relationship between subjective exercise experience with coping style and resilience Related studies have shown that positive affective experiences during exercise are significantly associated with improved physiological outcomes, thereby facilitating the attainment of health promotion objectives through physical activity interventions[ 34 ]. Our study demonstrated that exercise is interconnected with three key psychological constructs, which the subjective exercise experience is the affective and perceptual outcomes of physical activity engagement, the coping styles is the cognitive-behavioral tendencies in response to exercise associated challenges, the resilience is the adaptive capacity to recover from and adjust to exercise-related stressors. These elements collectively shape an individual’s exercise behavior. A significantly correlation existed between positive happiness and resilience, self-improvement, and positive coping styles for clinical medical students who participate in virtual reality integrated with cycling. This suggests that exercise experiences supported by virtual reality technology can help improve clinical medical students' resilience and coping styles. Consistent with our findings, prior research demonstrates that creating personalized virtual scenarios through virtual reality technology can enhance students' positive psychological experiences, improve emotional perception and adaptability. Exercise experience serves as a critical determinant of cognitive-behavioral orientation, significantly influencing subsequent decision making processes and behavioral choices[ 35 ]. Compared to pre-test levels, clinical medical students showed a significantly decrease in psychological distress, accompanied by a weakened negative correlation between psychological distress and optimism as well as positive coping styles. The findings indicate that integrating virtual reality with cycling can effectively mitigate psychological distress among students while fostering greater optimism and promoting the adoption of more constructive coping strategies. The study proposes that virtual reality integrated with cycling may not only alter clinical medical students' subjective exercise experiences, but also transform their perspectives and approaches to stress management. The findings suggest this intervention cultivates resilience, equipping students with enhanced coping capacities to withstand the rigors of clinical training while building the emotional stamina essential for sustained professional success. Virtual reality technology creates immersive psychological engagement, while exercise provides authentic kinesthetic perception. The synergistic integration of virtual reality and physical exercise amplifies the depth of psychological engagement while reinforcing implicit memory formation. In conclusion, virtual reality integrated exercise can provide students with a positive exercise experience, which in turn contributes to enhanced resilience and optimized coping styles. Limitations and strengths Several limitations should be acknowledged in this study. Although the results indicated that participants were enthusiastic about engaging in studies, however, the psychological characteristics and personality traits of individuals may potentially impacting the validity of the findings. This study requested participants to refrain from extracurricular exercise activities to prevent potential confounding effects from varying exercise participation levels. However, as independent individuals, students' after-school activities could not be strictly controlled. Future research could address these limitations by employing more controlled environments, selecting a broader array of participants, enhancing technological support. This study specifically focuses on integrating virtual reality technology with cycling. Future research could explore its application to other exercise modalities. Furthermore, future study could explore virtual reality-enhanced exercise interventions targeting comorbid psychological distress in medical students, potentially yielding multidimensional mental health benefits. Conclusion The findings of this study demonstrate that virtual reality integrated exercise approach have effect on clinical medical students' subjective exercise experience, resilience, and coping styles. This form of exercise not only allows students to gain a positive exercise experience but also enhances their resilience and improves coping style. Additionally, the subjective exercise experience serves as a critical determinant of both resilience and coping styles, contributes to the improvement of these ability. Given these positive outcomes, it is recommended that this integrated method can be as the course for clinical medical students’ university learning. Declarations Acknowledgements The authors of this study would like to appreciate all participants. Author contributions Chao Chen contributed to the conception of the study and wrote the manuscript. Chuang Yan performed the data analyses. Feng Bao contributed to analysis and manuscript preparation. Jie Ma helped perform the analysis with constructive discussions. Hailong Chang contributed to the data collection and conception of the study. Funding This study was supported by the 2023-2024 Hebei Province Higher Education Teaching Reform Research and Practice Project (2023GJJG563), Tangshan Normal University Scientific Research (Discipline Construction) Project (20252121052). Data availability The data used to support the findings of this study are included within the article. Ethical approval This study was approved by the Ethics Committee of North China University of Science and Technology (NSTCU2024-8-19), and the clinical trial number is (NSTC20248191103C5). Participants signed a written informed consent form before taking part in the study, in accordance with the guidelines of the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Pedrelli P, Nyer M, Yeung A, Zulauf C, Wilens T. College students: Mental Health problems and treatment considerations. Acad Psychiatry. 2015;39:503–11. 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Does low resilience causes to greater psychological impairment?[J]. Psychiatr Prax, 2015, 42(4): 197-201. Zhang Chonghui, Hu Hong, Wang Qun. Theory and Practice of Adversity Coping Psychological Training Paradigm - Taking the Psychological Training Case of Fencing Team as an Example . Journal of Xi'an Sport University, 2013; 30:3 88- 395. Cassidy S. Resilience building in students: the role of academic self-efficacy. Front Psychol. 2015;6:1781. Oh VKS, Sarwar A, Pervez N. The study of mindfulness as an intervening factor for enhanced psychological well-being in building the level of resilience. Front Psychol. 2022;13:1056834. Kiani J, Khan HM. Coping styles in patients with anxiety and depression. ISRN Psychiatry. 2012;2012: 128672. Freire C, Ferradás MDM, Regueiro B, Rodríguez S, Valle A, Núñez JC. Coping strategies and self-efcacy in university students: a person-centered approach. Front Psychol. 2020;11:841. Bosun A, Kalinovic R, Munteanu C, Pascariu AC, Vlad G, Enatescu VR. Stress sources and coping strategies in medicine students. Eur Psychiatry. 2023;66:895=899. Asif I, Thornton JS, Carek S, et al. Exercise medicine and physical activity promotion: core curricula for US medical schools, residencies and sports medicine fellowships: developed by the American Medical Society for Sports Medicine and endorsed by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med. 2022;56:369–75. Lubans D，Richards J，Hillman C，et al. Physical activity for cognitive and mental health in youth: a systematic review of mechanisms. Pediatrics,2016,138(3):l-13. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 29 Jul, 2025 Editor invited by journal 02 Jul, 2025 Editor assigned by journal 01 Jul, 2025 Submission checks completed at journal 01 Jul, 2025 First submitted to journal 22 Jun, 2025 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-6948814","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":493119080,"identity":"1a7f1208-35e3-423f-823b-4656405504a2","order_by":0,"name":"Chao Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIie3LMQrCMBTG8ReEuES7Pim0Vwh0VDxLRWhXJ3ESSyGTByg4eAWPkBLoJHUVdGhxcNXNRTEgDg6SujnkD2948P0AbLY/jLaThbrNBu+3AekylZxgG+Fr3YR4GKcBEeoHQmEk3Andzf11WsFlqsBZLUwkF27GDsgLyklWKsCjNBCSCGSoCWXQ6ggFHEMDaRFNeIm+0OTeiFCSBiyUCIUmpBFhJKkzOe5tiojnyzJmuDcQf32u5PUxdPxU1dVt2veczEA+kvrYD3ubzWazfesJCA8+UkCQvFsAAAAASUVORK5CYII=","orcid":"","institution":"Tangshan Normal University","correspondingAuthor":true,"prefix":"","firstName":"Chao","middleName":"","lastName":"Chen","suffix":""},{"id":493119081,"identity":"cabf41a3-cc6e-4c46-863b-58db8118d80d","order_by":1,"name":"Chuang Yan","email":"","orcid":"","institution":"Tangshan Normal University","correspondingAuthor":false,"prefix":"","firstName":"Chuang","middleName":"","lastName":"Yan","suffix":""},{"id":493119082,"identity":"86b09224-f4b8-4f25-a86a-2d53175e515f","order_by":2,"name":"Hailong Chang","email":"","orcid":"","institution":"Tangshan Normal University","correspondingAuthor":false,"prefix":"","firstName":"Hailong","middleName":"","lastName":"Chang","suffix":""},{"id":493119083,"identity":"b612a049-cdd4-4f7e-bb4b-e57affda5c8e","order_by":3,"name":"Jie Ma","email":"","orcid":"","institution":"Capital University of Physical Education and Sports","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Ma","suffix":""},{"id":493119084,"identity":"adbb8d03-e7ee-4388-9461-27b54323aea3","order_by":4,"name":"Feng Bao","email":"","orcid":"","institution":"Hebei Software Institute","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Bao","suffix":""}],"badges":[],"createdAt":"2025-06-22 09:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6948814/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6948814/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88011294,"identity":"9b5a940b-0b02-4653-bf1a-9534d4fcef3c","added_by":"auto","created_at":"2025-07-31 12:08:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50891,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the \u003cstrong\u003eMaterials and methods \u003c/strong\u003esection.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6948814/v1/99076699beaf18935aa1051a.png"},{"id":88013242,"identity":"62d319f8-76b1-4241-993f-5ed58932d6d0","added_by":"auto","created_at":"2025-07-31 12:24:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1076175,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6948814/v1/6f59542a-c56e-47e0-848e-efdbdcb6f417.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of Virtual Reality Integrated Exercise on the Subjective Exercise Experience, Resilience, and Coping Style for clinical medical students","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical work is widely recognized as a demanding profession, both physically and mentally, often characterized by staffing shortages and numerous clinical challenges. Developing good exercise habits and maintaining positive psychology during university education significantly impacts their professional growth[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It was found that when face external pressures and unpredictable events, positive psychological state can help clinical medical students to establish a mindset to overcome difficulties, as well as motivate them to continuously pursue high-quality healthcare competencies[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Students with negative psychological traits often have problems in academics, interpersonal interactions and emotional adjustment, with extreme thoughts and problematic behaviors that are detrimental to their long-term development. Universities should prioritize assessing medical students\u0026rsquo; coping styles and health literacy, gain a comprehensive understanding of their psychological well-being, leverage institutional educational resources effectively, and implement targeted health education programs to enhance their mental health[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. University health education initiatives should not only enhance medical students' health literacy but also emphasize effective strategies for managing negative emotions. By fostering adaptive coping mechanisms, these efforts can promote the adoption of healthy lifestyles and support sustained physical and psychological well-being among medical students[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe study of resilience originated in the 1970s, with researchers initially focusing on investigating both intrinsic trait factors and external protective environmental factors. Current definitions in resilience research predominantly center on two core elements negative and positive adaptation. As the previous study showed that resilience is the result of the combination of innate individual characteristics and learned adaptations, representing a dynamic capacity to effectively cope with adverse life experiences including stress, adversity[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The variability of resilience validates the rationality of its process-based dynamic definition. Empirical studies have effectively utilized resilience as both an indicator of psychological intervention efficacy and a marker of mental health status. This approach has facilitated the development of targeted, health-promoting interventions aimed at enhancing resilience, with demonstrated effectiveness in practical applications[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. clinical medical students in China will encounter significant physical and psychological stressors in their professional practice. However, current medical education predominantly emphasizes technical skill acquisition while providing inadequate training in stress management. This imbalance has resulted in low resilience levels among this student population[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, the universities should implement targeted training programs to cultivate adaptive personality traits and foster positive psychological dispositions, thereby enhancing students' resilience capabilities.\u003c/p\u003e\u003cp\u003eCoping style refers to an individual's characteristic cognitive and behavioral strategies for managing adverse external stimuli, aimed at maintaining psychological equilibrium during stressful experiences[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The study findings demonstrated that individuals' selected coping strategies can effectively mitigate the adverse effects of stress-induced emotional responses. When confronting stressful events, behavioral and cognitive adjustments serve to attenuate negative psychological impacts, thereby reducing stress reactivity and promoting restoration of psychological equilibrium[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Owing to substantial variations in physiological characteristics, personality traits, cognitive styles, and developmental backgrounds, individuals demonstrate diverse coping styles, which can be either positive or negative[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. According to conservation of resources theory, individuals employing positive coping style acquire and preserve greater psychological resources. This resource accumulation enables active cognitive-behavioral adjustments to internal and external demands during stressful encounters, thereby alleviating stress responses and facilitating successful adaptation[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Prior to entering clinical work, students must have the robust psychological attributes and the capacity to maintain positive psychological states in professional settings. This necessitates developing high-level resilience and positive coping styles during their academic training, competencies that require targeted educational interventions[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe International Society for Sport Psychology published a position statement entitled \u0026ldquo;Physical Activity and Psychological Benefits\u0026rdquo; back in 1994, stating that physical activity has a positive effect on psychological activity[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Related studies indicate that exercise-induced positive happiness and reduced psychological distress have significantly effect on enhance emotional well-being by amplifying positive emotions while mitigating negative affective states, including anxiety and depression[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. As a mental health intervention program, exercise not only help people stay fit and shape beautiful bodies, but more importantly, it can potentially guide people to form positive, optimistic psychological cognition and thoughts. Especially from a methodological perspective, exercise demonstrates substantial practical value and exerts statistically significant positive effects on mental health promotion, which the effects are both empirically and clinically relevant[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the field of psychology, there is growing demand for interdisciplinary innovation and integration in order to shift traditional psychological regulation methods from two-dimensional visual auditory single sensory simulation training to practical multi-channel sensory simulation scenario training. Consequently, virtual reality technology has emerged as a creative methodology in psychological research[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The integration of virtual reality with exercise represents a growing trend that not only enhances the intrinsic value of athletic activities but also drives advancements in the field of exercise for health[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Relevant studies has shown that exercise holds significant value in promoting psychological well-being, including the alleviation of depression, anxiety, and other negative emotional states. However, existing research has paid few attention to investigating the psychological characteristics and future career needs of clinical medical students. While numerous studies have explored the relationship between exercise and isolated psychological factors, however, there fewer study have examined its association with multiple interrelated psychological dimensions. Therefore, the aim of this study was to investigate the effects of virtual reality integrated exercise intervention on clinical medical students' psychological outcomes. And to assess if there was a difference in students\u0026rsquo; subjective exercise experience, resilience, and coping styles between those who participated in virtual reality integrated exercise teaching intervention compared to those who participated in a traditional teaching strategy. Furthermore, based on experimental results, we will analyze the relationships between changes in subjective exercise experience, resilience, and coping styles to identify underlying mechanisms.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003e This is one of the interventional studies demonstrating the virtual reality integrated exercise program for clinical medical students in university physical education, after obtaining approval from the ethics committee of North China University of Science and Technology (NSTCU2024-8-19), and registered in NSTCU(NSTC20248191103C5). This 4-month pre-post intervention study quantitatively assessed changes in subjective exercise experience, resilience, and coping styles among participants before and after a physical education program. clinical medical students from North China University of Science and Technology served as experimental subjects in this study, which aimed to evaluate the differential effects of various university exercise teaching strategy on promoting mental health. Firstly, we examines the effects of virtual reality integrated exercise on the subjective exercise experience, resilience, and coping style of clinical medical students. Secondly, to examine the interrelationships between subjective exercise experience, resilience, and coping styles. All students registered for the elective exercise course were included in the study, which were divided into intervention group and control group. The control group maintained their regular traditional exercise teaching strategy, while the intervention group participated in an innovative teaching strategy of virtual reality combined with power cycling. The different exercise intensities and virtual reality scenarios were set up for the intervention group, which they were systematically involved in a 16 week exercise program.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eIn this study, two classes of clinical major students from North China University of Science and Technology were selected as participants. Prior to the experiment, individuals with pre-existing physical injuries or mobility impairments were excluded from participation. Following the exclusion criteria, a total of 81 eligible students were enrolled in the study, with 40 assigned to the intervention group and 41 to the control group. The experiment was conducted from September to December 2024, with both the intervention and control groups participating in a 16-week exercise teaching program. The control group participated in traditional exercise teaching progarm (table tennis), while the intervention group participated in a virtual reality integrated exercise program. Both the intervention and control groups followed identical warm-up and relaxation protocols during each session. While the exercise sessions were equal in length, their content differed between groups.\u003c/p\u003e\u003cp\u003eThe intervention group's program required participants to wear virtual reality glasses during power cycling exercises. Each session comprised three structured components: Low-intensity cycling in an enjoyable virtual scenarios; Moderate-to-high-intensity cycling in a challenging virtual scenarios; Low-intensity cycling in a nature-themed virtual scenarios. Participants were required to adapt to varying exercise intensities and virtual scenarios until completing the prescribed exercise tasks.\u003c/p\u003e\u003cp\u003eDuring the experiment period, participants completed psychological assessments at two time points: resilience, coping style, subjective exercise experience questionnaires were administered one week before the intervention; all questionnaires (resilience, coping style, and subjective exercise experience) were readministered one week post-intervention. Ultimately, data from all 81 participants (40 in the intervention group and 41 in the control group) were compiled and analyzed using statistical methods.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eResilience questionnaires\u003c/h2\u003e\u003cp\u003eThe resilience questionnaires was designed by Conner and Davidson, and it was revised by Chinese researcher Yu Xiaonan and Zhang Jianxin. It includes three dimensions: fortitude, self-improvement, and optimism. The questionnaires included 25 questions which responses were recorded on a Likert scale with 1 indicating \u0026ldquo;strongly disagree\u0026rdquo; and 5 indicating \u0026ldquo;strongly agree\u0026rdquo;[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The procedures for assessing reliability and validity in resilience tests were employed. The results revealed acceptable reliability and content validity (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.80 and Scale-CVI\u0026thinsp;=\u0026thinsp;0.83).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCoping style questionnaires\u003c/h3\u003e\n\u003cp\u003eThe coping style questionnaires was simplified and modified by Xie Yaning based on china's actual condition. It is used to evaluate the coping styles that individuals are accustomed to when facing difficulties. This questionnaires consists of positive coping style and negative coping style, with a total of 20 items. The responses were recorded on a Likert scale from 0 to 3, and the higher the average score, the more stronger tendency toward this coping style[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The same procedures for assessing reliability and validity in coping style tests were employed, which the results revealed acceptable reliability and content validity (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.89 and Scale-CVI\u0026thinsp;=\u0026thinsp;0.82), confirming its robustness for empirical use.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSubjective exercise experience questionnaires\u003c/h2\u003e\u003cp\u003eThis study employed the Subjective Exercise Experiences Scale, a well-validated instrument originally developed by McAuley and subsequently culturally adapted and psychometrically refined by Wang Mengyang, to evaluate participants' exercise-induced psychological states[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The subjective exercise experience questionnaires included three aspects: positive happiness, psychological distress, fatigue, which consists of 12 questions ranged from 1 to 7, with higher scores in the positive happiness dimension indicating more favorable exercise experiences. Conversely, higher scores in psychological distress and fatigue reflect poorer emotional and physical states, respectively. Cronbach\u0026rsquo;s reliability coefficient and test-retest reliability of the scale were 0.75 and 0.79, which indicated that it had good reliability and validity.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe collected data were systematically entered into a computerized database and subsequently analyzed using IBM SPSS Statistics software (version 26.0, IBM Corp., Armonk, NY, USA) for statistical processing. Descriptive statistics were presented as frequencies and percentages for categorical variables. Continuous variables were compared between groups using independent t-tests, while within-group comparisons (pre-test vs. post-test) were assessed using paired t-tests. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed). Additionally, Pearson\u0026rsquo;s correlation analysis was conducted to examine the relationships among subjective exercise experience, resilience, and coping style.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e Eighty-one clinical medical students from North China University of Science and Technology participated in the experiments. All participants were sophomore, with 78% of students under 21 years old and 22% between 22 and 23 years old. Among the participants, 63% were male and 37% female. None of the students had participated in the virtual reality integrated exercise teaching program prior to this study.\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\u003edemographic characteristics of the participants(n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003emale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003efemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026le;\u0026thinsp;21\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e22\u0026ndash;23\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;24\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhether experienced virtual reality integrated exercise\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eyes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eno\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcademic year (n)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2rd\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3th\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe primary objective of this study was to evaluate the efficacy of a virtual reality integrated exercise in enhancing subjective exercise experience among clinical medical students. Independent sample t tests and paired samples t-test were used to analyze the differences in subjective exercise experience between the the groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Positive happiness scores were significantly higher in the intervention group (20.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77) than in the control group (16.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06) at post-test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Post-test results revealed significantly higher positive happiness scores in the intervention group (20.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77) compared to the control group (16.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06), with this difference reaching statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The intervention group demonstrated significantly reduced psychological distress scores relative to control group in post-testing. However, unlike the positive happiness and psychological distress scores, there was no significant difference in students' fatigue scores in the pre-test and post-test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively. In summary, while neither form of exercise alleviated subjective fatigue, the virtual reality integrated exercise intervention demonstrated significant benefits in enhancing positive happiness and reducing psychological distress.\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\u003e\u003cb\u003eComparison of subjective exercise experience before and after the intervention\u003c/b\u003e\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive happiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.39\u0026thinsp;\u0026plusmn;\u0026thinsp;3.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.731\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.87\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological distress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.391\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.16\u0026thinsp;\u0026plusmn;\u0026thinsp;3.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.673\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFatigue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.811\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.05\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.62\u0026thinsp;\u0026plusmn;\u0026thinsp;3.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.533\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.675\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.385\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe results showed that the virtual reality integrated exercise program produced significantly better outcomes in almost all aspects of clinical medical students\u0026rsquo; resilience, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Post-test fortitude scores were significantly higher in the intervention group (45.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.91) compared to the control group (39.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13), p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The average self-improvement scores of the intervention group and control group were increased in the post-test, but the intervention group obtained significantly better test results 29.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.93 and 25.79\u0026thinsp;\u0026plusmn;\u0026thinsp;4.01, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively. The intervention group showed significantly higher post-test optimism scores (13.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51) compared to the control group (11.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In a word, all three indicators related to resilience have significantly improved after participated in virtual reality integrated exercise.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison of resilience before and after the intervention\u003c/b\u003e\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFortitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.12\u0026thinsp;\u0026plusmn;\u0026thinsp;7.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.52\u0026thinsp;\u0026plusmn;\u0026thinsp;6.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.358\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.85\u0026thinsp;\u0026plusmn;\u0026thinsp;6.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.512\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-improvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.81\u0026thinsp;\u0026plusmn;\u0026thinsp;4.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.752\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.79\u0026thinsp;\u0026plusmn;\u0026thinsp;4.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.603\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.040\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOptimistic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.796\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.89\u0026thinsp;\u0026plusmn;\u0026thinsp;2.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.682\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis study aimed to evaluate the effects of virtual reality integrated exercise on coping styles among clinical medical students. Between-group differences were assessed using independent samples t-tests, while within-group changes were examined through paired samples t-tests. Paired t-tests indicated no significant change in positive coping scores for the control group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), while the intervention group showed significant improvement from pre-test to post-test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Independent samples t-tests revealed significantly higher positive coping scores in the intervention group (2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71) compared to the control group (2.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50), p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Independent samples t-tests revealed a significantly greater reduction in negative coping scores for the intervention group (1.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28) compared to the control group (1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35), p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison of coping style and after the intervention\u003c/b\u003e\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=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.751\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.047\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.385\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNegative coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epre-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.826\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003cb\u003e-value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.296\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis study demonstrated the effectiveness of virtual reality-integrated exercise in enhancing subjective exercise experience, psychological resilience, and coping strategies. Base on these findings we further examined the relationship between the subjective exercise experience, and the resilience and coping style. As shown in Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, the students' positive happiness scores were significantly positively correlated with fortitude scores, optimistic scores, and positive coping scores in the post-test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The student's positive happiness scores demonstrated a significant negative correlation with negative coping scores in the post-test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The results indicated that the student\u0026rsquo;s fatigue scores were not significantly correlated with most indicators, except for fortitude. A significant positive correlation was observed between psychological distress scores and both optimism and positive coping scores in the pre-test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, students' psychological distress scores remained significantly positively correlated with optimism in the post-test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The experimental results revealed a significant negative correlation between psychological distress and students' coping styles in the pre-test. In contrast, post-test results demonstrated an attenuation of this association, indicating a weakening of the initial relationship.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between \u003cb\u003esubjective exercise experience\u003c/b\u003e and \u003cb\u003eresilience and coping style\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003ePositive happiness\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eFatigue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003ePsychological distress\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFortitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.326*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.238\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.315*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;0.165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;0.118\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-improvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;0.102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;0.059\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOptimistic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.397*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;0.337*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;0.290*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.195\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.431*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.181\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;0.316*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;0.187\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNegative coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;0.187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;0.386*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;0.108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;0.136\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.171\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e*: Statistically significant at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eThe effect of virtual reality integrated exercise on subjective exercise experience\u003c/h2\u003e\u003cp\u003eSubjective exercise experience refers to an individual's self-evaluated affective and cognitive responses following physical activity participation. These personally mediated perceptions serve as critical psychological feedback mechanisms influencing future exercise engagement. The results of the study showed that positive happiness in subjective exercise experience of the intervention group was elevated, and psychological distress were reduced after the experiment, which indicated that virtual reality integrated exercise had the effect on promote subjective exercise experience of clinical medical students. Consistent with existing evidence, empirical studies have demonstrated that structured exercise interventions can facilitate positive psychological states, enhance self-efficacy beliefs and promote overall mental health. Positive affective states generated during physical activity can disrupt negative emotional cycles characteristic of depression[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Students in the intervention group completed different intensities of exercise in a virtual scene, which could help students to manage their anxiety and obtain more successful experiences. virtual reality integrated exercise helped to clinical medical students experience the joy of exercise, avoiding the frequency of psychological troubles and promoting mental health. The results of a systematic review indicated that physical education extends beyond knowledge acquisition, encompassing the development of motivation, skill competencies, and self-efficacy all essential components for health improvement through exercise[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The results of our experiment showed that the fatigue did not change before and after the experiment in both groups, and the fatigue feeling caused by exercise did not change due to the form of exercise. Previous studies have also confirmed that exercise fatigue is a normal physiological phenomenon, and has no significant effect on the promotion of human physical and mental health[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In summary, while virtual reality integrated exercise has been shown to boost happiness and alleviate psychological distress, it appears to have no significant effect on exercise-induced fatigue.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eThe effect of virtual reality integrated exercise on resilience\u003c/h2\u003e\u003cp\u003eResilience reflects an individual's positive psychological capacity, which are the ability of individuals to maintain stable emotions and behavioral responses through self regulation, self control, and positive coping when facing challenges and stressors[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Related studies have shown that sports can help improve individuals' resilience, enabling them to cope with stress and difficulties in a positive way, thereby maintaining a good level of mental health[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our study demonstrated that both tennis and virtual reality integrated with cycling effectively improved students' resilience, confirming the positive impact of exercise on resilience development. Notably, virtual reality integrated with cycling required participants to regulate their emotions in immersive virtual environments while simultaneously maintaining physical endurance through progressively increasing exercise intensity. This dual stimulation combining emotional control and physical challenge significantly enhanced students' resilience compared to traditional exercise.\u003c/p\u003e\u003cp\u003eThe results of a systematic review indicated that medical students with higher resilience levels could effectively mobilize psychological resources to cope with adversity negative events. This adaptive capacity helped mitigate adverse emotional responses and minimized disruptions to their academic engagement[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e][\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Adversity coping theory suggests that individuals who develop resilience through painful experiences can more effectively cope with challenges in future life[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In this study, we employed virtual reality technology to simulate adverse scenarios coupled with high-intensity exercise, simultaneously exposing clinical medical students to controlled physiological and psychological stressors[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Through repeated challenge-exposure and successful adversity overcoming, this intervention demonstrated measurable improvements in participants' resilience levels[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Enhancing resilience levels in clinical medical students fosters their ability to maintain a persistent, positive mindset when facing academic and professional challenges.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eThe effect of virtual reality integrated exercise on coping style\u003c/h2\u003e\u003cp\u003eCoping styles represent individuals' characteristic of cognitive, emotional, and behavioral responses to stressful situations or challenges, which encompass both positive and negative coping strategies[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Our study revealed that clinical medical students who engaged in virtual reality integrated exercise interventions demonstrated significant improvements in positive coping styles, concurrently showing a reduction in negative coping styles. The study demonstrated that the virtual reality integrated with cycling approach is a cognitive behavioral intervention method, which encourages individuals to reassess their criteria for coping with challenges, promoting self criticism reduction and the exploration of new solutions to problems.\u003c/p\u003e\u003cp\u003eThe training approach set by our research requires clinical medical students to complete tasks while progressively increasing levels of exercise intensity and psychological stress, which necessitates that students adopt appropriate strategies to manage both psychological pressure and high intensity physical demands[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The results demonstrate that the virtual reality integrated with cycling intervention facilitated the development of adaptive cognition, enhancing participants' stress coping capacity through the cultivation of positive psychological capital. This psychological reinforcement subsequently promoted the acquisition of effective stress management strategies. Furthermore, through effective coping, and confrontation techniques, students can enhance their problem-solving cognitive abilities and diminish feelings of helplessness, ultimately enabling more effective response capability of academic and clinical challenges[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eRelationship between subjective exercise experience with coping style and resilience\u003c/h2\u003e\u003cp\u003eRelated studies have shown that positive affective experiences during exercise are significantly associated with improved physiological outcomes, thereby facilitating the attainment of health promotion objectives through physical activity interventions[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Our study demonstrated that exercise is interconnected with three key psychological constructs, which the subjective exercise experience is the affective and perceptual outcomes of physical activity engagement, the coping styles is the cognitive-behavioral tendencies in response to exercise associated challenges, the resilience is the adaptive capacity to recover from and adjust to exercise-related stressors. These elements collectively shape an individual\u0026rsquo;s exercise behavior. A significantly correlation existed between positive happiness and resilience, self-improvement, and positive coping styles for clinical medical students who participate in virtual reality integrated with cycling. This suggests that exercise experiences supported by virtual reality technology can help improve clinical medical students' resilience and coping styles. Consistent with our findings, prior research demonstrates that creating personalized virtual scenarios through virtual reality technology can enhance students' positive psychological experiences, improve emotional perception and adaptability.\u003c/p\u003e\u003cp\u003eExercise experience serves as a critical determinant of cognitive-behavioral orientation, significantly influencing subsequent decision making processes and behavioral choices[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Compared to pre-test levels, clinical medical students showed a significantly decrease in psychological distress, accompanied by a weakened negative correlation between psychological distress and optimism as well as positive coping styles. The findings indicate that integrating virtual reality with cycling can effectively mitigate psychological distress among students while fostering greater optimism and promoting the adoption of more constructive coping strategies. The study proposes that virtual reality integrated with cycling may not only alter clinical medical students' subjective exercise experiences, but also transform their perspectives and approaches to stress management. The findings suggest this intervention cultivates resilience, equipping students with enhanced coping capacities to withstand the rigors of clinical training while building the emotional stamina essential for sustained professional success. Virtual reality technology creates immersive psychological engagement, while exercise provides authentic kinesthetic perception. The synergistic integration of virtual reality and physical exercise amplifies the depth of psychological engagement while reinforcing implicit memory formation. In conclusion, virtual reality integrated exercise can provide students with a positive exercise experience, which in turn contributes to enhanced resilience and optimized coping styles.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and strengths\u003c/h2\u003e\u003cp\u003eSeveral limitations should be acknowledged in this study. Although the results indicated that participants were enthusiastic about engaging in studies, however, the psychological characteristics and personality traits of individuals may potentially impacting the validity of the findings. This study requested participants to refrain from extracurricular exercise activities to prevent potential confounding effects from varying exercise participation levels. However, as independent individuals, students' after-school activities could not be strictly controlled. Future research could address these limitations by employing more controlled environments, selecting a broader array of participants, enhancing technological support. This study specifically focuses on integrating virtual reality technology with cycling. Future research could explore its application to other exercise modalities. Furthermore, future study could explore virtual reality-enhanced exercise interventions targeting comorbid psychological distress in medical students, potentially yielding multidimensional mental health benefits.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study demonstrate that virtual reality integrated exercise approach have effect on clinical medical students' subjective exercise experience, resilience, and coping styles. This form of exercise not only allows students to gain a positive exercise experience but also enhances their resilience and improves coping style. Additionally, the subjective exercise experience serves as a critical determinant of both resilience and coping styles, contributes to the improvement of these ability. Given these positive outcomes, it is recommended that this integrated method can be as the course for clinical medical students\u0026rsquo; university learning.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors of this study would like to appreciate all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChao Chen contributed to the conception of the study and wrote the manuscript.\u003c/p\u003e\n\u003cp\u003eChuang Yan performed the data analyses.\u003c/p\u003e\n\u003cp\u003eFeng Bao contributed to analysis and manuscript preparation.\u003c/p\u003e\n\u003cp\u003eJie Ma helped perform the analysis with constructive discussions.\u003c/p\u003e\n\u003cp\u003eHailong Chang contributed to the data collection and conception of the study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the 2023-2024 Hebei Province Higher Education Teaching Reform Research and Practice Project (2023GJJG563), Tangshan Normal University Scientific Research (Discipline Construction) Project (20252121052).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are included within the article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of North China University of Science and Technology (NSTCU2024-8-19), and the clinical trial number is (NSTC20248191103C5). Participants signed a written informed consent form before taking part in the study, in accordance with the guidelines of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePedrelli P, Nyer M, Yeung A, Zulauf C, Wilens T. College students: Mental Health problems and treatment considerations. Acad Psychiatry. 2015;39:503\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eDessauvagie AS, Dang HM, Nguyen TAT, Groen G. Mental Health of University Students in Southeastern Asia: a systematic review. 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Journal of Nursing. 2020, 35 :76-78.\u003c/li\u003e\n\u003cli\u003ePechmann C, Petermann F, Br\u0026auml;hler E, et al. Does low resilience causes to greater psychological impairment?[J]. Psychiatr Prax, 2015, 42(4): 197-201.\u003c/li\u003e\n\u003cli\u003eZhang Chonghui, Hu Hong, Wang Qun. Theory and Practice of Adversity Coping Psychological Training Paradigm - Taking the Psychological Training Case of Fencing Team as an Example . Journal of Xi\u0026apos;an Sport University, 2013; 30:3 88- 395. \u003c/li\u003e\n\u003cli\u003eCassidy S. Resilience building in students: the role of academic self-efficacy. Front Psychol. 2015;6:1781.\u003c/li\u003e\n\u003cli\u003eOh VKS, Sarwar A, Pervez N. The study of mindfulness as an intervening factor for enhanced psychological well-being in building the level of resilience. Front Psychol. 2022;13:1056834.\u003c/li\u003e\n\u003cli\u003eKiani J, Khan HM. Coping styles in patients with anxiety and depression. ISRN Psychiatry. 2012;2012: 128672.\u003c/li\u003e\n\u003cli\u003eFreire C, Ferrad\u0026aacute;s MDM, Regueiro B, Rodr\u0026iacute;guez S, Valle A, N\u0026uacute;\u0026ntilde;ez JC. Coping strategies and self-efcacy in university students: a person-centered approach. Front Psychol. 2020;11:841.\u003c/li\u003e\n\u003cli\u003eBosun A, Kalinovic R, Munteanu C, Pascariu AC, Vlad G, Enatescu VR. Stress sources and coping strategies in medicine students. Eur Psychiatry. 2023;66:895=899. \u003c/li\u003e\n\u003cli\u003eAsif I, Thornton JS, Carek S, et al. Exercise medicine and physical activity promotion: core curricula for US medical schools, residencies and sports medicine fellowships: developed by the American Medical Society for Sports Medicine and endorsed by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med. 2022;56:369\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eLubans D，Richards J，Hillman C，et al. Physical activity for cognitive and mental health in youth: a systematic review of mechanisms. Pediatrics,2016,138(3):l-13.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Virtual Reality, Exercise. Subjective Exercise Experience, Resilience, Coping Style","lastPublishedDoi":"10.21203/rs.3.rs-6948814/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6948814/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Exercise demonstrates substantial practical value and exerts statistically significant positive effects on mental health promotion. Meanwhile, virtual reality technology has emerged as the creative methodology in psychological research. The integration of virtual reality with exercise represents a growing trend that drives advancements in the field of students’ development. The aim of this study was to investigate the effects of virtual reality integrated exercise intervention on clinical medical students' psychological outcomes. And to assess if there was a difference in students’ subjective exercise experience, resilience, and coping styles between those who participated in virtual reality integrated exercise teaching intervention compared to those who participated in a traditional teaching strategy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e The study enrolled 81 clinical medical students from North China University of Science and Technology, randomly allocated to either the intervention group (n=40) or control group (n=41). The control group participated in traditional physical education (table tennis), while the intervention group participated in a virtual reality integrated exercise program. Data collection tools included the Resilience questionnaires, Coping style questionnaires, Subjective exercise experience questionnaires, which were completed one week before and after the intervention by each clinical student. The data were analyzed through independent t-tests, paired t-tests, and pearson’s correlation. The significance level was set at P\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e The average positive happiness scores were significantly higher in the intervention group compared to the control group in the post-test, p\u0026lt;0.05. The intervention group demonstrated significantly reduced psychological distress scores relative to control group in post-testing. All three indicators related to resilience have significantly improved after participated in virtual reality integrated exercise. The positive coping scores of intervention group were higher than the control group, p\u0026lt;0.05. The student’s positive happiness scores was significantly positively correlated with fortitude scores and optimistic scores and positive coping scores in the post-test, p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e The findings of this study demonstrate that virtual reality integrated exercise approach effectively enhanced clinical medical students' subjective exercise experience, resilience, and coping styles. Furthermore, the subjective exercise experience serves as a critical determinant of both resilience and coping styles. Given these positive outcomes, it is recommended that this integrated method can be as the course for clinical medical students’ university learning.\u003c/p\u003e","manuscriptTitle":"The effect of Virtual Reality Integrated Exercise on the Subjective Exercise Experience, Resilience, and Coping Style for clinical medical students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 12:08:05","doi":"10.21203/rs.3.rs-6948814/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-07-29T16:43:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-02T10:03:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-01T07:00:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-01T06:59:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-06-22T09:37:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"caacf3f1-9334-4a8a-a787-d8393b93d0ad","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-31T12:08:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 12:08:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6948814","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6948814","identity":"rs-6948814","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}