Nursing education plays a crucial role in preparing skil-led nurses by combining theoretical foundations in the classroom with clinical practice opportunities, where students apply their knowledge in real-world settings [1]. However, the rapid increase in nursing programs and students has outpaced the availability of clinical sites, leading to a widening gap between theory and practice [2]. This gap is compounded by an overreliance on observation rather than hands-on experience due to limited clinical sites and opportunities, which restricts students’ ability to effectively translate theoretical knowledge into clinical practice [3].

In obstetric nursing, this gap is even more profound. South Korea's historically low birth rate, with a fertility rate of 1.05 in 2017, has significantly impacted nursing education by limiting students’ exposure to diverse childbirth experiences [4]. This scarcity, coupled with pregnant women's reluctance to involve students in their birthing processes, has further constrained clinical training opportunities [5]. As a result, traditional teaching methods, reli-ant on didactic and clinical experiences no longer suffice to equip nursing students with the necessary skills and problem-solving abilities required for childbirth care [4,6]. Furthermore, the rise in high-risk pregnancies has increased delivery room nurses’ responsibilities, emphasizing the need for advanced competencies and specialized education in labor nursing [7]. However, limited clinical sites further restrict nursing students’ opportunities to experience the full childbirth process, leading to fragmented learning. Therefore, alternate and effective educational approaches are essential to bridge these gaps and promote the development of clinical skills and critical thinking in labor nursing care.

Simulation-based education (SBE) has become a vital supplement to traditional clinical practice, by using realistic scenarios to improve technical skills, communication, nursing performance, critical thinking, patient safety, and confidence [8]. In obstetrics, simulation has demonstrated positive outcomes by introducing students to rare clinical scenarios, such as cesarean sections, vacuum extractions, dystocia management, and high-risk deliveries, which are difficult to experience in real-life settings [9]. However, the shift to remote learning during the COVID-19 pan-demic highlighted challenges associated with traditional SBE, including high initial costs, space limitations, and the need for small group participation, which limited its scalability for larger groups [10]. These logistical demands have reduced the SBE's benefits during the pandemic, emphasizing the need for innovative educational strategies in nursing education.

In response, virtual reality (VR) simulations have emerged as a complementary method, addressing re-source constraints of traditional simulation and enabling diverse, interactive, and realistic scenarios [9]. VR simulation offers several advantages over traditional simulation, such as reduced time and cost, scalability, and accessibility. Unlike traditional simulation, VR does not require extensive physical space, equipment, or direct fac-ulty supervision, allowing students to participate anytime and anywhere, aligning with current nursing education trends. VR creates highly immersive scenarios that range from common to rare conditions, providing students with low-risk, realistic settings that foster learning and build confidence in a safe environment [8]. Moreover, VR sup-ports self-directed learning, which is increasingly im-portant in modern nursing education, and prepares students for complex clinical environments by integrating innovative technologies. VR proved invaluable during the COVID-19 pandemic by maintaining students’ clinical competencies without in-person training. Immersive virtual reality applied in this study is a form of implementation that allows users to experience a three-dimensional virtual space synthesized by a computer while wearing a three-dimensional head-mounted display (HMD) device on their heads [11]. Immersive virtual reality maximizes immersion in that it allows users to see only the virtual world by blocking the external environment and is applied according to individual capabilities and needs, so that it can overcome the limitations of repetitive learning and time limits. However, as noted by Blizzard et al. [9], VR simulation alone may not fully enhance technical skills, highlighting the need for a more comprehensive approach.

To address these limitations, a new educational approach combining VR with high-fidelity simulation (HFS) has been developed, offering immersive clinical practice that enhances skill development while fostering critical thinking and problem-solving abilities. This integrated method is particularly promising for labor nursing care, where limited clinical sites and restricted exposure to complex scenarios present significant barriers to acquiring essential skills. In addition, with the recent expansion of virtual reality simulation, virtual reality simulation and offline learning methods such as HFS (SimJunior, Laerdal Medical, Stavanger, Norway) are being integrated to confirm their effectiveness [12].

Despite its potential, research on integrating VR with traditional simulation in labor nursing education remains limited. To address this gap, the present study developed an educational program using VR and HFS to evaluate its effectiveness in educating students on complex childbirth care. Findings from this study will provide nurse educa-tors with valuable insights into how an integrated approach can enhance competencies in labor nursing, ulti-mately enabling them to develop targeted intervention strategies to address challenges in obstetric nursing education.

The general characteristics of the participants and the homogeneity of the dependent variables are summarized in Table 2. The research findings on the effects of education on nursing knowledge, problem-solving abilities, and nursing performance are presented in Table 3. The experimental group showed a significant difference in nursing knowledge, with scores rising from 10.71±1.62 points before education to 14.05±1.98 points after education, while the control group showed no significant change (F=6.14, p=.018). However, there was no significant difference in the interaction between the group and time regarding nursing knowledge (F=2.46, p =.125). The experimental group showed increases in problem-solving abilities (from 3.64±0.70 to 4.19±0.30) and nursing performance (from 33.62±7.92 to 42.90±4.83) after education. The control group had a slight increase in problem-solving abilities (from 3.78±0.34 to 3.87±0.47) and nursing performance (from 35.70±5.16 to 38.95±5.04) after education. No significant differences were found between the groups (F=0.72, p=.403; F=0.34, p=.561), but there were significant improvements within both groups before and after education in problem-solving abilities (F=39.00, p=.003) and nursing performance (F=46.99, p<.001). There was a significant interaction between group and time for prob-lem-solving abilities (F=5.26, p=.027) and nursing performance (F=10.89, p=.002).

The research findings regarding the learning satisfaction after education are presented in Table 4. The experimental group showed significantly higher satisfaction, with a mean of 4.71±0.36, compared to the control group's mean of 3.71±0.32 (t=9.38, p<.001).

This study aimed to develop and validate a VR-based childbirth nursing education program to enhance nursing knowledge, problem-solving abilities, and performance. Findings showed that the experimental group, which received combined VR and HFS education, scored significantly higher in nursing knowledge, problem-solving abil-ities, and nursing performance than the control group, which received only HFS. This indicates that integrating VR with HFS offers significant advantages in childbirth nursing education over traditional simulation alone.

In this study, nursing knowledge improved in both groups, and there were significant improvements within both groups before and after education. However, there was no significant difference in the interaction between the group and time. The findings of this study align with prior research in maternal and neonatal nursing education that demonstrates significant improvements in pregnancy nursing knowledge [18] and neonatal nursing assessment [3] with the VR integration. Some studies on neonatal infection control knowledge and preeclampsia did not show significant differences [19]. This discrepancy may be due to variations in educational delivery methods, such as the use of YouTube in Weideman and Culleiton's study [18] and the extended intervention period lasting one semester in Kang et al.'s research [20], which allowed for repeated education and prolonged exposure. In addition, a meta-analysis by Chen et al.[8] confirmed the VR's efficacy in enhancing knowledge across various nursing specialties. In this study, both the experimental and control groups improved their problem-solving abilities. This result is consistent with the findings of Song and Kim [4], who reported that nursing students participating in VR-based labor nursing simulation education demonstrated higher problem-solving abilities. Similarly, Kim et al.[12] reported that VR simulation focused on asthmatic childcare substantially increased problem-solving ability scores. In addition, this study's findings resonate with prior research where VR-based nursing education improved neonatal nursing skills [21]. Similarly, in a study on VR-based pre-natal education, pregnant women demonstrated significantly higher scores in pregnancy health management practice behaviors [22], aligning with the outcomes ob-served in this study. These results further validated that VR simulation is a valuable educational tool for improving problem-solving skills through repeated practice in labor nursing education. Integrating VR and HFS simulation offers a more effective educational approach than relying solely on a single method. Even though the nursing performance in both experimental and control groups improved after the training, the group with integrated VR and HFS achieved higher nursing performance outcomes. In a comparative study, Kim et al. [12] showed that blended simulations substantially improve nursing performance in groups receiving HFS. Kim et al. [12] argued that using VR simulations before engaging in HFS enhances positive outcomes by building foundational knowledge and self-confidence. Moreover, engaging in immersive simulation allows students to acquire information through individual experiences, enabling them to prioritize nursing actions based on the specific knowledge gained. This further enhances self-confidence and practical application of skills in nursing practice [22]. A blended educational approach also promotes higher student satisfaction. Son and Choe [23] reported that nursing students learning in-travenous injection and indwelling catheterization techni-ques via VR and HFS expressed higher learning satisfaction levels than those receiving simulation or traditional lecture-based education. Chae [24] similarly found that in-corporating VR in psychiatric nursing classes increased students’ learning satisfaction. A study by Kim and Kim [25] employed VR with actual hospital environment foot-age that gave nursing students a sense of presence in clinical settings. This innovative approach allowed students to select their observation points and experiences, leading to higher engagement and significantly increased learning satisfaction [25]. By applying the immersive virtual reality program in this study, it was possible to improve the educational satisfaction of nursing students by conducting practical training according to individual competencies and needs [11].

However, some argue that the impact of blended approaches may vary based on a study sample's demographics. Bryant et al.[26] reported no significant difference in satisfaction level among graduate nursing students using VR simulation. This discrepancy could be due to differences in student demographics, as over 64% of participants in their study were over 36 years old. In contrast, this study's sample average was 21 years, representing ‘ digital natives’ [27] who are accustomed to and proficient in digital technology, likely contributing to enhanced learning outcomes and satisfaction.

Traditional simulation classes require large physical space for simulators, storage, and technologies. In contrast, VR simulation education is not constrained by location, does not require large physical spaces or extensive equipment, and can be accessed in a small educational setting with only an HMD device. The flexibility of VR also allows students to access their training anytime and anywhere, offering convenience and self-paced learning, which aligns with the modern nursing education trend. Song and Kim [4] argued that simulation-based nursing education provides students with invaluable opportunities to experience realistic scenarios to improve their prob-lem-solving skills. However, critical gaps remain, as current VR education programs do not sufficiently address knowledge and skills on preterm labor, dystocia, and high-risk pregnancies. Thus, educational programs are ur-gently needed to allow students to gain knowledge and develop hands-on skills to fill these gaps. VR content is an attractive learning medium for nursing students, allowing them to experience clinical environments safely, without the risk of patient safety incidents, and to engage in repeated learning anytime, anywhere, depending on the platform [11,12,25]. Continuous research and support are needed to enhance VR simulation education with advanced technology, fostering nursing students’ interest and engagement in their educational programs.

This study faced several limitations. The study sample, nursing students from a single university in a specific met-ropolitan area, posed challenges in generalizing the study results. In addition, this study measured outcomes only before and immediately after the intervention, limiting the ability to assess long-term effects. Future research should include follow-up evaluations to confirm the program's sustained impact.

This study demonstrated that a childbirth nursing education program using VR and HFS effectively enhanced students’ knowledge, problem-solving abilities, nursing performance, and learning satisfaction. Combining VR and HFS is a powerful and efficient strategy for advancing nursing education by providing immersive and hands-on learning experiences. To maximize the benefits of integrated simulation methodologies, developing systematic op-erational plans and guidelines is imperative to further enhance students’ knowledge, skills, and attitudes. Additionally, there is a growing need for diverse VR-based practical training programs in childbirth nursing, espe-cially given the shortage of clinical sites and limited opportunities for real-life exposure to complex scenarios. Ongoing long-term research focusing on the effectiveness of the blended approach to simulation education is required to validate and assess the sustainability of impacts over time.

The authors declared no conflict of interest.

Study conception and design acquisition - Hong SJ and Bang HL; Data collection - Hong SJ; Data analysis & Interpretation - Hong SJ, Bang HL and Ferencsik L; Drafting & Revision of the manu-script - Hong SJ, Bang HL and Ferencsik L.

Please contact the corresponding author for data availability.