Introduction

Simulation-based education is a widely used teaching method in medical education [1]. It offers a controlled environment that replicates authentic clinical scenarios, yielding positive outcomes in knowledge acquisition and communication skill development [2]. Furthermore, it enables students to practice medical procedures without the stress and pressure associated with real-life situations [3]. Among the available methods, high-fidelity (HF) simulation, which uses mannequins as virtual patients to recreate a realistic medical setting, is widely integrated into the regular curriculum of medical education, yielding ample evidence that simulation aids healthcare students’ learning process. HF simulation enhances clinical competencies, including knowledge, skills, and decision-making [1,4–6], as well as nonclinical competencies, such as communication and collaboration skills, leadership, and critical thinking [1,4,7,8]. In addition, it fosters self-satisfaction and self-confidence [1,4,6,9,10]. However, HF simulations are not always feasible or accessible to schools and students because they require substantial financial, spatial, and human resources. To implement an HF simulation, a high-cost mannequin with an accommodating room is a prerequisite, along with an extra control room and trained personnel who can control the mannequins and provide feedback to students.

Meanwhile, virtual reality (VR) simulation has emerged as a transformative simulation method in medical education. VR simulations enable learners to experience environments typically inaccessible in real life [11,12] by transporting them into interactive virtual environments, which positively influence student learning [13]. VR simulation requires a head-mounted display (HMD), handheld controllers, a high-functioning computer or laptop, and a small physical space of approximately 4m² [13]. Compared to the characteristics of HF simulation (see [3]), VR simulation offers comparable or even greater advantages in terms of low cost, realistic healthcare experience, the ability to pause and repeat practice, and support for both individual and group evaluations, all without patient safety concerns [13].

As VR simulations have begun to appear in medical education curricula, research on their effectiveness is expanding. However, a limited number of studies have compared VR simulations with other types of simulations and reported inconsistent results (for a review, see [14]). Some studies have reported that VR simulations outperform traditional simulations in terms of enhancing diagnostic accuracy and facilitating knowledge acquisition [15,16]. In contrast, other studies have found no significant difference in skill performance between VR and other simulation methods [17,18].

A handful of prior studies suggest that VR simulation is at least non-inferior to HF simulation in terms of knowledge acquisition and skill attainment. However, affective domains such as anxiety, confidence, engagement, and perceived learning remain largely unexplored despite that simulation-based learning can be effective in helping learners manage emotional responses [19]. One of the key challenges students face during internships is high anxiety and a lack of confidence in practicing their skills and meeting clinical demands [20]. High levels of anxiety can impair decision-making and negatively impact skill performance [21,22]. Similarly, a lack of confidence may lead to hesitation, impacting decision-making and clinical performance [23]. Minter et al. [20] proposed that preparatory programs, such as simulation-based training can address medical students’ lack of confidence and high anxiety, making them better prepared for clinical practice.

A growing body of evidence shows that HF simulation significantly reduces medical students’ anxiety and increases their confidence in clinical practice [24–26]. Likewise, VR simulation provides a psychologically safe environment in which students can practice and refine their skills without fear of judgment or error [27]; thus, it can be an alternative method for effectively handling affective variables [28]. In this context, whether HF or VR can better prepare students for emotional and attitudinal demands needs to be investigated.

Additionally, prior studies on the subjective experience of VR and HF simulations primarily focused on surface-level factors, such as student preferences or satisfaction (e.g., [29,30]) or the usability of VR simulators (e.g., [15,17]), showing that VR simulation is a relatively new educational method utilizing advanced technology. Although these approaches capture subjective learning experiences, they fail to address such experiences comprehensively. Although HF and VR simulations are known to induce high levels of student engagement by providing immersive settings and realistic clinical scenarios, no empirical studies have directly compared the engagement levels between these modalities. Furthermore, beyond assessing learner preferences or satisfaction with VR simulations, it is important to explore how learners perceive their learning within the simulation. Therefore, to comprehensively investigate and understand the educational effects of the two simulation methods in terms of subjective experience, levels of engagement and perceived learning must be systematically compared.

Materials and methods

Results

Table 1 presents the levels of anxiety, confidence, engagement, and perceived learning reported by participants after each simulation. The findings suggest no statistically significant differences between the VR and HF simulations across the measured variables, on average.

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Table 1. Comparison of anxiety, confidence, engagement, and perceived learning in VR and HF simulations between VR and HF simulations.

https://doi.org/10.1371/journal.pone.0323150.t001

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Table 2. Items showing statistically significant differences in anxiety, engagement, and perceived learning between VR and HF simulations.

https://doi.org/10.1371/journal.pone.0323150.t002

Discussion

This study compared the anxiety, confidence, engagement, and perceived learning outcomes for VR and HF simulations. The results showed that the two simulations did not produce significantly different levels of anxiety, confidence, engagement, or perceived learning. The absence of differences does not directly support that VR simulation is equally effective as HF simulation in maintaining students’ affective factors. This study may have failed to capture these differences due to various factors, such as an insufficient sample size to detect the impacts, inadequate measurement tools for assessing both VR and HF simulation experiences. Although our final sample size (n = 41) exceeded the threshold suggested by a conventional power analysis (α = .05, power = .80, medium effect size d = 0.5; [37]), it is possible that the true effect size between the two modalities was much smaller than anticipated, making it difficult to detect significant differences. Nevertheless, considering previous studies that compared VR and HF simulations, the lack of differences between the two simulations can be regarded as a consistent finding.

Prior studies in nursing education found non-inferiority of VR simulation to HF simulation in building self-confidence (for a review, see [38]), which supports the finding of this study. However, the findings in medical education are not consistent. Abulfaraj et al. [17] reported no significant difference in confidence levels between VR and HF simulations for managing patients with status epilepticus. But Macnamara et al. [39] found higher confidence in a HF simulation than in a VR simulation when performing airway, breathing, circulation, disability, and exposure (ABCDE) assessments. Both study applied a single item scale with 5-point likert scale to measure confidence. This study was the first to use a multi-item scale to measure psychological variables in comparing impacts of two simulation methods, further research is required to replicate the effects of the simulations on both anxiety and confidence.

An item-level comparison of the anxiety scale revealed that the students reported higher levels of discomfort during the VR simulation than during the HF simulation. Despite prior experience and familiarity with VR instruction, students could not always control their movements as intended in the VR environment, which may have contributed to their feeling upset. This finding aligns with that of a prior study suggesting that increased anxiety in VR simulations may stem from technological challenges rather than the simulation [40]. In the prior studies, participants reported that HF simulation is not easy to control as well [17,39]. Insufficient experience with VR simulators may contribute to discomfort, considering the finding of Palmisano and Constable [41] that cybersickness is reduced with repeated use of a head-mounted display.

This study also found no significant differences in engagement and perceived learning between HF and VR simulations. To our knowledge, this is the first study to compare student engagement and perceived learning across these two simulation modalities. A prior study similarly reported no significant difference in immersion between VR and HF simulations [39]. Given that ‘immersion and time transformation’ is a subscale of engagement, this finding suggests that engagement levels may not differ significantly between the two modalities. Moreover, as previous research has shown that confidence levels correlate with perceived learning in VR simulations [41,42], the lack of differences in confidence levels between the two modalities may explain the absence of perceived learning differences.

However, the sequential design raises the possibility of a confounding effect, in which prior experience with the VR simulation may have influenced students’ confidence or anxiety during the subsequent HF simulation. Because the order of simulations was determined by the fixed clerkship schedule, we could not manipulate or counterbalance it. Considering that repeated simulation can positively influence affective outcomes [21], future research needs to counterbalance or randomize the order of simulation modalities to clarify the distinct effects of each on students’ emotional and subjective outcomes.

While the overall scores revealed no significant differences between the two simulation methods, the analysis of individual items showed significant differences. The items belonging to Cognitive Control in the “Flow in Education Scale” and Cognitive Domain in the “Perceived Learning Scale” showed a higher score in the VR simulation than in the HF simulation. These results raise the intriguing possibility that VR simulations may be more effective for cognitive learning than HF simulations.

VR simulation is known to be more effective for gaining knowledge than for developing skills [43], with particular strength in enhancing procedural knowledge and skills [44,45]. For example, medical students who trained using a VR simulator demonstrated better procedural knowledge acquisition and retention than those who trained using computerized virtual patient simulations, particularly in managing clinical scenarios such as diabetic ketoacidosis and sepsis [46]. Similarly, VR simulation resulted in greater surgical procedural skills in subdermal drain placement and surgical dissection than video lectures with a VR recording [47]. Integrating the findings of this study with prior research, VR simulation appears to have a great impact on cognitive learning. Prior findings have demonstrated the superiority of VR simulations over conventional teaching methods, such as didactic lectures or videos [47–49]. This study further suggests that VR simulations may have a greater impact than HF simulations on acquiring procedural knowledge and skills.

In summary, this study found that VR simulation did not produce significantly different educational outcomes compared to HF simulation in terms of emotional and subjective experience. Even if the absence of differences is not attributed to sample size or measurement, this study has limitations in generalizability. First, the study was conducted with a single NRP scenario in a pediatric clerkship; further investigation with different topics and other specialties is needed. Second, because it was the second VR simulation in the students’ clerkship, they may not have had sufficient experience with the simulators. The results of the study could be confounded by their lack of skill or the novelty of the VR simulation. In addition, given that the expertise of the learner impacts learning in VR simulations [42,50], a study with various learners, such as junior students or residents, is needed. Finally, as the study focused solely on students’ subjective variables, it did not confirm whether they truly affected their clinical performance. A follow-up study is needed to explore the relationship between subjective variables and objective outcomes such as test scores and clinical skills. Nevertheless, this study is meaningful as it compared VR and HF simulations using standardized scales to investigate their impact on subjective outcomes and highlighted VR’s effect on students’ responses and perceptions during simulation. Simulation-based learning activates both positive and negative emotions [19,51]. As sensory and emotional responses can stimulate cognitive learning (e.g., [52]), understanding emotional responses during simulation is essential for optimizing simulation-based education

VR simulation offers distinct advantages over HF simulation in terms of practical implementation. A prior study found that VR simulation costs less per single-learner session than HF simulation [30]. Zendejas et al. [53] pointed out that HF simulations incur significant costs from the initial purchase of mannequins to the management of infrastructure and simulators. In addition, HF simulation requires a spacious room to set up and control simulators. Compared to this, VR simulation is a more space-efficient alternative. The cost and space efficiency of VR simulation present a significant opportunity for its adoption in schools, making it a highly applicable educational model.

Moreover, VR simulation enables independent and self-directed learning because it operates autonomously, adapts to the student’s performance in real time, and records the entire process for review and feedback [54]. As it does not require the assistance of an operator, students can run and repeat the simulation independently, offering highly accessible and flexible simulation training [55]. Students can effectively enhance their clinical competence, including procedural knowledge and skill proficiency, through repeated self-directed training (e.g., [42]). Iterative simulations boost confidence and reduce anxiety [26,42], and the feedback further improves their learning [56]. Moreover, by using recorded performance data and feedback from the system, students can reflect on their actions and regulate their learning, thus fostering metacognitive skills [55]. Ultimately, VR simulations can facilitate student-centered learning and enable individualized education. Given its cost and space efficiency, and the potential for self-directed repeated practice, VR simulation holds significant promise for widespread application in medical education. Although this study found no significant differences between VR and HF simulations, VR’s cost- and space-efficiency and its support for autonomous learning highlight the need for further research, particularly on affective response and cognitive learning.

Supporting information

Acknowledgments

No acknowledgments are applicable for this study.