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Interactive Learning Environments
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/nile20
Effects of integrating maternity VR-based situated
learning into professional training on students’
learning performances
Ching-Yi Chang, Patcharin Panjaburee & Shao-Chen Chang
To cite this article: Ching-Yi Chang, Patcharin Panjaburee & Shao-Chen Chang (2022): Effects
of integrating maternity VR-based situated learning into professional training on students’ learning
performances, Interactive Learning Environments, DOI: 10.1080/10494820.2022.2141263
To link to this article: https://doi.org/10.1080/10494820.2022.2141263
Published online: 07 Nov 2022.
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Effects of integrating maternity VR-based situated learning into
professional training on students’learning performances
Ching-Yi Chang
a,b
, Patcharin Panjaburee
c
and Shao-Chen Chang
d
a
School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan;
b
Department of Nursing, Shuang
Ho Hospital, Taipei Medical University, Taipei, Taiwan;
c
Institute for Innovative Learning, Mahidol University,
Nakhon Pathom, Thailand;
d
International bachelor program in informatics and the department of information
communication, Yuan Ze University, Taoyuan, Taiwan
ABSTRACT
Educators have recognized the importance of providing a realistic
learning environment which helps learners to not only comprehend
learning content, but also to link the content to practical problems.
Such an environment can hence foster problem-solving skills in nursing
training. However, when learners interact in a virtual environment with
rich learning resources, they might encounter difficulties if there is a
lack of proper guidance, clinical sense, or a well thought-out
instructional design process. Hence, this work developed a maternity
VR-based situated learning system (MVR-SLS) based on the experiential
learning theory to support professional courses in obstetrics. A quasi-
experiment was conducted to verify the impacts of this method on
learners’learning achievement, OSCE (Objective Structured Clinical
Examination) competency, problem solving skills, learning engagement,
and teaching effectiveness. The experimental results indicate that the
new method improved learners’learning achievement, OSCE
competency, problem-solving ability, and recognition of learning
engagement. Moreover, the learners who learned with the new method
showed more active learning behaviors compared to the learners in the
control group. Findings of the present study offer concrete suggestions
for implementing effective virtual reality (VR)-based learning strategies
for medical and nursing textbooks.
ARTICLE HISTORY
Received 3 August 2021
Accepted 20 October 2022
KEYWORDS
Mobile learning; situated
learning; nurse education;
higher education
Introduction
The key objectives of nursing training are to train nursing students to have core literacy regarding
the profession, and to impart the required knowledge along with professional, clinical, and critical
thinking competences (Chang et al., 2020). However, in traditional nursing training programs,
instructors mainly deliver knowledge and experience of handling clinical cases via the lecture-
oriented approach (Lee et al., 2010). Moreover, in most nursing training contexts, it could be
highly risky to situate novice learners in practical problem contexts since improper treatments are
likely to danger the patients. This implies that trainees generally do not have sufficient opportunities
to experience the clinical procedure before facing real cases, and hence they are likely to encounter
difficulties in internship or practical applications (Keshk et al., 2018). Thus, there is a need to find
alternative ways to provide practicing opportunities (Huang et al., 2021; Juan et al., 2019;O’Brien,
2022). Such a training mode could slow down the process of fostering quality nursing staff; in par-
ticular, when facing a serious epidemic, such as the COVID-19 pandemic, it is important to train those
© 2022 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Shao-Chen Chang shao.chen76@gmail.com
INTERACTIVE LEARNING ENVIRONMENTS
https://doi.org/10.1080/10494820.2022.2141263
nursing staffin the knowledge and skills of dealing with the epidemic in a short time (Marks et al.,
2021). In response to the learning needs of learners in the present epidemic situation, educators
around the world have indicated the need to adopt suitable teaching strategies without delay
(Wang et al., 2020) so as to mitigate the influence of the epidemic on training and learning. Educators
in many fields regard interactive platforms for digital learning as an alternative solution for addres-
sing learner needs (Novikov, 2020), as teachers are forced to transform their teaching strategies in
response to the epidemic. Beech and Anseel (2020) suggested that more interactive courses
could be offered through digital platforms. Scholars have also pointed out three distinct advantages
of establishing a digital learning interactive platform: the ability to meet students’learning needs
without the constraints of time and location (Fang et al., 2019), the ease of addressing students’
needs for cross-domain learning (Chen, 2020), and provisions to help students create opportunities
for interaction and to foster a sense of learning achievement (Valencia-Vallejo et al., 2018).
Modern digital textbooks should be fully diversified and include technological choices, inter-
action, and high-quality content that can showcase the specific value of digital textbooks to special-
ist fields (Demirkan, 2019). Enabling nursing students to learn in a safe environment using digitized
teaching materials can enhance their professionalism, knowledge, and skills, along with core infor-
mation literacy that will help ensure the quality of medical care, which is the current teaching goal
(Chang et al., 2020). From the perspective of guiding students to ensure both patient safety and
learner safety, students can learn and practice repeatedly in a safe environment, thereby improving
the learning effectiveness when a suitable digital learning platform is used (Chang et al., 2020). In
addition, in response to the epidemic situation and the demand for digital teaching materials, it
was discovered that the main drawback of traditional nursing education sites was that students
lacked effective interactive teaching materials which could provide them with authentic experience
of facing practical cases (Pears et al., 2020; Zhao et al., 2020). In addition, owing to the COVID-19 pan-
demic, traditional face-to-face instruction has been widely suspended around the globe; as a conse-
quence, instructors have tried to deliver professional knowledge via digital learning platforms
(Ainsworth & McKenzie, 2020). Through a digital learning platform, students are taught to practice
basic nursing skills repeatedly, participate in interactive learning strategies, improve their motiv-
ation, and gain inspiration. Enhancing students’problem-solving ability is a topic worthy of educa-
tors’continuous research and attention (Irmak & Erdogan, 2019).
However, earlier studies on assisted nursing learning featured few attempts to provide interactive
and authentic learning contexts in nursing training. To address this problem, this study proposed a
learning approach that employs a digital learning platform combined with a virtual reality (VR) learn-
ing mode by referring to the situated learning theory (Chang et al., 2020; Fredricks et al., 2018). To
estimate the efficiency of the projected method, a VR learning system was established and
implemented in obstetrics courses. Students’learning achievements, OSCE competency, problem-
solving skills, learning engagement, and learning satisfaction are also discussed. On this basis, the
following research questions were proposed to verify and evaluate the effectiveness of this method:
1. Does the Maternity VR-based situated learning approach (MVR-SLS) intensify learners’learning
achievements compared with the traditional maternity education method?
2. Does the MVR-SLS approach intensify learners’OSCE competency compared with the traditional
maternity education method?
3. Does the MVR-SLS approach enhance learners’problem-solving skills more than the traditional
maternity education approach?
4. Does the MVR-SLS approach enhance learners’learning engagement more than the traditional
maternity education method?
5. Does the MVR-SLS approach intensify learners’learning satisfaction more than the traditional
maternity education method?
2C.-Y. CHANG ET AL.
Literature review
Situated learning
Brown et al. (1989) anticipated the situational learning concept (situated learning) based on cogni-
tive psychology, and elucidated the relationship between education and situational learning. Situ-
ated learning is a globally recognized learning method emphasizing the importance of situating
learners in contexts related to the learning objectives to acquire knowledge and skills (Al Hakim
et al., 2022). From the perspective of professional training in nursing education, situated learning
allows learners to have a sense of clinical reality and learn in depth from the contexts in which
they are situated (Choi & Ahn, 2021; Yu & Mann, 2021). However, in many nursing or medical training
programs, instructors generally deliver knowledge in a lecture-based instruction mode; moreover,
teaching institutions generally have difficulties providing real learning environments, implying the
need to use digital technologies to provide situational learning contexts to enable trainees to
have concrete experience of facing practical cases (Choi & Ahn, 2021). Several previous studies
have made attempts in this direction. For example, Chen et al. (2017) proposed interactive situational
simulation teaching to improve new nurses’clinical ability and self-confidence, and to reduce their
workplace pressure. Additionally, in professional education fields, researchers have recognized the
value of situated learning. For instance, Chang et al. (2019) highlighted the usefulness of situated
learning while emphasizing the safety of patients and students during the nursing training
process. They emphasized that, with the help of technologies, students remain safe in the learning
environment and can still acquire nursing expertise and skills as well as learning the attitude to care
for patients. Therefore, the use of teaching materials based on actual contexts in the educational
environment and the integration of the situated learning theory are particularly important for
effective learning. For example, Rim and Shin (2020) integrated virtual simulation textbooks for situ-
ated learning into nursing education to help learners obtain professional knowledge and skills.
Meanwhile, some scholars have attempted to use digital games to situate learners in situational con-
texts to improve learners’learning achievement in various subjects, including in medical education
environments (Berkhout et al., 2018), museum education courses (Chen & Chen, 2018), and language
learning (Ünal & Yelken, 2020).
Researchers have indicated that the provision of situational learning contexts not only provides
learners with opportunities to experience the authentic procedure, but also enables them to practice
making decisions on relevant practicing cases, which in turn helps them to perceive the meaningful-
ness of the learning content (Chiou, 2020; Özüdogru & Özüdogru, 2017; Zhang, 2020). Therefore,
scholars have suggested practical decision-making methods to enhance learners’learning knowl-
edge and to direct learners to build their personal information base (Song, 2019; Wise & Jung,
2019), so as to help them practice and reflect while exposing them to more content. Amendum
and Liebfreund (2019) also proposed that appropriate technological assistance systems have the
potential to improve learners’problem-solving skills. Tapingkae et al. (2020) also found that learning
methods based on situational digital games can effectively enhance students’problem-solving skills.
Other scholars have also noted that placing learners in realistic game situations can assist them in
extending the information they have gained from textbooks or classroom activities to their everyday
lives (Hayes, 2018). These competences and skills are the aims of nursing education (Hwang & Chang,
2020). Whistance (2018) further emphasized that in situational learning contexts, teachers must use
materials that allow students to learn interactively, and provide them with opportunities to expand
their prior knowledge.
Although situated learning has been adopted in several previous studies, researchers have indi-
cated the need to develop digital learning systems that can better simulate real contexts, in particu-
lar, for nursing training which aims to foster learners’ability to deal with real cases by taking every
detail into account (Choi & Ahn, 2021;Dubovi et al., 2018). Pears et al. (2020) stated that providing
experiential and interactive learning contexts to simulate the details of the procedure for handling
INTERACTIVE LEARNING ENVIRONMENTS 3
real cases is crucial to facilitate students’learning performance, and virtual reality is such a potential
context. Chang et al. (2018) and Yu and Mann (2021) further indicated that more empirical studies
examining the effectiveness of using virtual reality in professional training are needed, particularly in
the field of nursing education. Therefore, this study aimed to employ a virtual reality-based approach
by referring to the situated learning theory in order to improve nursing students’learning
performance.
VR-based technology learning
In this era of information technology, applying mobile technology at teaching sites has become the
mainstream (Chang & Hwang, 2018; Tang et al., 2021), while earlier studies have publicized the
importance of conducting nursing training activities in a realistic environment so that learners
can identify and tackle the kinds of clinical problems they need to learn to solve in real clinical
environments (Chang et al., 2019). Therefore, combining real and digital learning content in learning
scenarios will prepare students for their entry into the workplace. With the speedy growth of tech-
nologies, mobile devices have become indispensable in our day-to-day lives. Using mobile devices,
students can learn anywhere through digital learning scenarios (Chang & Hwang, 2018; Hwang &
Chang, 2021).
In the past few decades, scholars have developed many technologies that support situated learn-
ing for various types of courses. For example, Chang et al. (2020) developed game-based learning in
nursing EKG activities to improve trainees’learning performance. Chen et al. (2020) also stated the
benefits of using technologies in professional training in terms of skills, knowledge, learning satisfac-
tion, and self-confidence via conducting a meta-analysis. Researchers have also proposed appropri-
ately connecting clinical questions and virtual situational learning resources, and have combined
them into learning systems to reduce the learning load of students while simultaneously enhancing
their learning in the learning process and allowing them to interact with virtual situations in a safe
environment (Hwang et al., 2018). When students are presented with learning tasks involving real
clinical problems, these virtual situations can combine professional know-how with their learning
goals, and mobile applications allow learners to practice repeatedly (Chang et al., 2019). VR has
the potential for use in educational applications, and students can interact directly with virtual
objects in the real world (Araiza-Alba et al., 2020; Baker et al., 2020). Weiner et al. (2019) used VR
to teach nursing students ultrasound skills. Chang et al. (2019)effectively applied spherical, video-
based VR to train students in childbirth education.
In addition, Liaw et al. (2020) further clarified that the application of VR in educational environ-
ments has unlimited potential. In contrast with control group teaching, learning in virtual environ-
ments is usually more challenging for learners. Yang et al. (2020) claimed that using VR technology
can help learners focus on key tasks through relevant digital interventions, thereby reducing their
learning burden while at the same time developing a VR learning system. It was found that, com-
pared with traditional action learning methods, this mode of learning is more beneficial to learners.
Other researchers have combined teaching activities. Guan et al. (2021) proposed a VR-based
pottery-making approach to promote student creativity and learning engagement. Liaw et al.
(2020) used VR rather than live simulations to develop the communication skills and attitudes of
doctors and nurses. Subsequent research shows that in this kind of VR-based realistic learning
activity, students are generally revealed to be highly motivated (Chen et al., 2021; Cheng & Tsai,
2020). Moreover, VR allows students to repeatedly practice. Therefore, VR-immersive learning has
become an important research topic of technology-enhanced learning.
Although some previous studies have shown the potential of VR-based learning for improving
students’learning performance, several researchers have raised significant concerns, such as the
technological affordances of VR, the challenges in pedagogical design, and the cost-effectiveness
(Luo et al., 2021; Merchant et al., 2014; Mikropoulos & Natsis, 2011). The advancement and popularity
of computer technologies have provided an answer to the concerns of technological affordances
4C.-Y. CHANG ET AL.
and cost-effectiveness; however, the pedagogical design of VR-based learning remains a challenge
to researchers and school teachers. As indicated by O’Brien and Battista (2020) and Kim et al. (2018),
engaging students in competition activities could involve them more in comprehending the learn-
ing content. Zenios (2020) further proposed the technology-enhanced professional learning model
based on social constructivism, in which they emphasized the importance of promoting students’
learning engagement and performance in technology-supported learning contexts by guiding
them to respond to questions, making reflections and debriefing in professional learning tasks.
Accordingly, in the present study, we proposed a Maternity VR-based Situated Learning approach
with an effective learning design consisting of several elements, namely recognizing key concepts,
responding to questions, making reflections, and debriefing what they had learned.
The maternity VR-based situated learning system (MVR-SLS)
This study used the CoSpaces software to develop the MVR-SLS based on the situated learning
theory that enables students to participate in nursing courses in context-based learning scenarios.
The system puts learning materials into context, provides suggestions to remind students of the con-
cepts that they learned earlier, and encourages them to make decisions based on system questions
that encourage students to learn actively. The developed materials include a VR scene, VR camera, VR
project title, Blockly coding area, 3D objects, learning materials, pictorial materials, and Coding/Play,
as shown in Figure 1.
The structure of the MVR-SLS system consists of a learning material database, student infor-
mation, a question database, and a learning log database, as shown in Figure 2. The learning material
database includes all of the learning content, such as videos, photos, and texts. There is also a test
content database. When students are situated in the VR contexts, they are guided to experience the
maternity process by recognizing key concepts, responding to questions, making reflections, and
debriefing what they had learned. During the learning process, the system will ask relevant questions
to guide learners to learn from the contexts they are situated in. The learning behavior database is
used to store the logs of individual students’learning progression, such as their browsing, reading
information, and question answering. After completing the study, a summary evaluation is given.
During the learning process, every question raised by the system relates to some contexts of the
learning tasks. Learners need to make observations in accordance with the prompts (i.e. questions)
provided by the MVR-SLS. Learners can also tick the “More Information”icon displayed on the VR
Figure 1. The system development interface of MVR-SLS.
INTERACTIVE LEARNING ENVIRONMENTS 5
interface to obtain related material or to search for supplementary materials related to the learning
objective; furthermore, they can click the “Start Test”icon to start the interactive formative assess-
ment process, making reflections and debriefing what they have learned; following that, they can
choose to experience the contexts again, as shown in Figure 3.
Method
This course provides training in obstetrics through the MVR-SLS. To verify the method’seffective-
ness, quasi-experiments were designed to verify students’learning achievements, OSCE compe-
tency, problem-solving skills, learning engagement, and learning satisfaction.
Participants
The learners in this experiment were 42 students from two classes of a nursing university. The
average age of the students was 21. The two classes were assigned to an experimental group and
a control group. The experimental group learned with the MVR-SLS, while the control group
Figure 2. The system structure of MVR-SLS.
Figure 3. The system interface for the experimental group.
6C.-Y. CHANG ET AL.
learned with the conventional lecture-based approach via instructional videos. All of the students
were taught by the same teacher who had 20 years of clinical practice and teaching experience in
obstetrics. To prevent the learners from the two classes influencing each other, the classes were
taught at different times. During the activities, the instructor provided learning tasks, supplementary
learning materials, and examination items. Moreover, the instructor answered questions pertaining
to the learning tasks that were raised by the students at the teaching site.
Experimental process
The experiment lasted for 3 weeks. The learners attended a lecture on the basics of maternity in the
first week. Following that, they were administered a pre-test and pre-questionnaire. In the second
week, both groups were instructed on childbirth skills. The experimental group received guidance
using the MVR-SLS. That is, during the learning process, the MVR-SLS learning system guided
them to observe and interact with authentic learning objects. In this study, a total of four tasks
were prepared in the MVR-SLS contexts. Instead of giving answers, the MVR-SLS provided students
with prompts or supplementary materials after receiving the answers submitted by the students. If
they failed to make correct decisions on a learning task, they were guided to observe the learning
task in detail for making reflections through the MVR-SLS formative assessment; following that,
they were allowed to experience the learning contexts again to try to make correct decisions. On
the other hand, the control group learned with the conventional approach, that is, watching instruc-
tional videos that presented the same learning content and completed learning sheets with the
same learning tasks. In the third week, both groups were scheduled to take a half-hour OSCE (Objec-
tive Structured Clinical Examination), a standard test for nursing skills, by interacting with a standard
patient (SP). They were also scheduled to complete the post-test and post-questionnaires on
problem-solving skills, learning engagement, and learning satisfaction to verify their learning effec-
tiveness, as shown in Figure 4.
Measuring tools
The measurement tools included pre- and post-tests as well as the OSCE competency examination
and a set of questionnaires on learning perceptions.
The tests were designed by the course instructor, and were verified by two obstetric education
experts. The pre-test assessed students’prior knowledge of obstetric delivery and their expectations
before undertaking the learning activities, while the post-test aimed to evaluate the students’learn-
ing achievement after the activities. Both the pre- and post-test included 20 multiple-choice ques-
tions, with a perfect score of 100.
The OSCE competency examination, designed by two experienced teachers to assess maternity
nursing skills, consisted of 10 dimensions, and two experienced teachers were recruited to evaluate
the students’case-handling performances using the rubrics. The Kappa coefficient of OSCE compe-
tency scorer reliability between the two teachers was 0.73.
The problem-solving questionnaire proposed by Hwang and Chen (2017) included five items,
such as “Other than the problem itself, the cause related to the problem should also be clarified”
and “When solving a problem, I would think about the strategy and the process for solving the
problem.”A 5-point Likert scoring scale was adopted, and its Cronbach’sαvalue was .78.
The engagement scale proposed by Dixson (2015) included 19 items, such as “Finding ways to
make the course interesting to me”and “Really desiring to learn the material.”A 5-point Likert
scoring scale was adopted, and its Cronbach’sαvalue was .86.
The learning satisfaction scale proposed by Chu et al. (2010) was composed of nine items, such as
“When using this system, I learned how to observe the target learning objects from new perspec-
tives”and “The mission of this learning activity was not easy to complete, but it was easy to under-
stand the way of learning.”It was adopted with a 5-point Likert scoring scale. Its Cronbach’sαvalue
was .91.
INTERACTIVE LEARNING ENVIRONMENTS 7
Experimental results
Learning achievement
ANCOVA was used to compare the two groups’post-test scores by excluding the impacts of their
pre-test scores (i.e. the pre-test scores were adopted as the co-variant). The Levene’s test of deter-
mining homogeneity of variance was not violated (F= 3.42, p> 0.05), indicating that the null hypoth-
esis was tenable and the variance was equal across groups. In addition, the homogeneity of
regression slopes was confirmed, indicating that it was appropriate to employ the analysis of covari-
ance with F= 0.01 (p= 0.57 > .05). This indicates that the covariance and the independent variable
did not have interaction effects. Therefore, ANCOVA could be performed for the analysis.
A significant difference was evident between the two groups’post-test results (F= 4.67, p< 0.05).
The experimental group’s average score was 88.38 (standard error = 0.96), which was higher than
the control group’s score of 81.81 (standard error = 0.96). This indicates that, compared with the tra-
ditional learning method, the MVR-SLS was better able to improve the students’learning achieve-
ment (Table 1).
Figure 4. Experimental procedure.
8C.-Y. CHANG ET AL.
OSCE competency
This section explores the OSCE competency of the students in the experimental group and the
control group. An independent sample ttest examined the pre-OSCE scores of the two groups,
and there was no significant difference between the two groups’pre-OSCE scores (t= 0.507, p>
0.05), inferring that the two groups had an equivalent tendency regarding OSCE scores before learn-
ing. As shown in Table 2, the results showed that the experimental group’s ratings were higher than
those of the control group (t= 2.32, p< 0.5). It can be concluded that the MVR-SLS learning approach
can promote students’OSCE competency.
Problem solving
ANCOVA was used to compare the two groups’post-questionnaire ratings of problem solving by
excluding the impacts of their pre-questionnaire ratings (i.e. the pre-questionnaire ratings were
adopted as the co-variant). To verify the rationality of the ANCOVA analysis of the problem-
solving capability measurements of the study, the regression coefficients’homogeneity in each
group was verified. It was found that F= 1.25 did not violate the homogeneity assumption (p
> .05). Thereafter, the ANCOVA was used. As shown in Table 3, by excluding the influence of the
pre-questionnaire scores, the two groups’post-questionnaire scores were significantly different (F
= 27.94, p< 0.05). The experimental group adjusted average was 4.28 (standard error = 0.11),
which was higher than the average of 3.43 (standard error = 0.11) for the control group. The
results show that situational learning using the MVR-SLS can effectively improve students’
problem-solving skills.
Engagement
ANCOVA was used to compare the two groups’post-questionnaire ratings of engagement by
excluding the impacts of their pre-questionnaire ratings (i.e. the pre-questionnaire ratings were
adopted as the co-variant). The Levene’s test of determining homogeneity of variance was not vio-
lated (F= 0.55, p> 0.05), indicating that the null hypothesis was tenable and the variance was equal
across groups. In addition, the homogeneity of regression slopes was confirmed, indicating that it
was appropriate to employ the analysis of covariance with F= 0.58 (p= 0.63 > 0.05). Therefore,
ANCOVA could be used. Table 4 shows the ANCOVA results. By excluding the influence of the
pre-questionnaire scores, the two groups’post-questionnaire scores were significantly different (F
= 4.36, p< 0.05). The experimental group’s adjusted average was 4.79 (standard error = 0.70),
which was higher than the average of 4.56 (standard error = 0.70) for the control group. The
results show that situated learning based on the MVR-SLS can effectively improve student
engagement.
Learning satisfaction
Before evaluating the students’learning satisfaction, the two groups’ratings of the pre-question-
naire were compared using a ttest. The means and SDs of the experimental group and the
Table 1. ANCOVA of learning achievement.
Groups NMean S.D. Std. error Fvalue
Pre-test Experimental group 21 80.76 4.67 1.20 0.38
Control group 21 81.81 6.23 1.20
Post-test Experimental group 21 88.38 6.34 0.96 4.67*
Control group 21 81.81 6.23 0.96
*p< 0.05
INTERACTIVE LEARNING ENVIRONMENTS 9
control group were 4.74, 0.31, and 4.53, 0.36, respectively. There was no significant difference in the
two groups’scores (t= 1.03, p> 0.05). This implies that the two groups had equivalent experience.
After the experiment, a questionnaire was administered to investigate the two groups’learning
satisfaction.
As shown in Table 5, the t-test results of the post-questionnaire ratings show that the experimen-
tal group’s ratings were higher than those of the control group (t= 1.98, p< 0.05). It can be con-
cluded that the MVR-SLS learning approach can promote students’learning satisfaction.
Discussion and conclusions
To improve the obstetric care ability of nursing students, we proposed an action learning system
based on situated learning using the MVR-SLS, and conducted a quasi-experiment among university
students to estimate the efficiency of the method. The trial results show that, compared with tra-
ditional education, this method can improve students’learning achievement, their OSCE compe-
tency, problem-solving skills, learning engagement, and learning satisfaction.
We integrated the situations in a typical clinical learning environment for obstetric nursing into
the VR action learning system. The MVR-SLS reintroduces the focus on on-site learning activities.
Learners in the experimental group could use the VR system to practice learning tasks repeatedly
and to build the necessary knowledge and operating skills to prepare for the OSCE competency
test in advance. Therefore, learners in the experimental group could approach the teacher in the
classroom with more specific questions or problems. In contrast, learners in the control group
were unable to obtain specific contexts or operational skills when entering the classroom stage;
therefore, the study results showed that students who used the MVR-SLS showed better learning
achievement, OSCE competency, problem-solving skills, learning engagement, and learning satisfac-
tion. This could be ascribed to the VR-based learning tasks, in which the learners were required to use
different strategies to complete them (Choi & Ahn, 2021; Zhang, 2020). This result corresponds with
that of Chang et al. (2019). The study also pointed out that situational learning is a reality-based
learning method (O’Brien, 2022). Students acquire professional knowledge and skills through appro-
priate arrangements to improve their learning achievement, OSCE competency, and learning satis-
faction. This result shows that students are more likely to grasp specific concepts and knowledge
through realistic situations. This result can be explained by the theory of situated learning (Billett,
1996), which emphasizes that learners’acquisition of professional skills is highly affected by the con-
texts they are situated in. Previous research has also pointed out that the inclusion of interactive
learning strategies can enhance students’professional knowledge of the subject, make them
active participants in the learning process, help them solve learning tasks effectively, and enhance
their metacognition (Juan et al., 2019; Kucuk, 2018).
Situated learning is a globally recognized learning method that allows learners to have a sense of
clinical reality and learn in depth based on the context (Choi & Ahn, 2021; Hayes et al., 2019;Yu&
Table 2. T-test results of OSCE competency.
Groups NMean S.D. t d
Experimental group 21 8.60 0.88 2.31* 0.74
Control group 21 8.00 0.78
*p< 0.05
Table 3. ANCOVA results for problem solving.
Groups NMean S.D. Adjusted mean Std. error Fvalue η
2
Experimental group 21 4.40 0.62 4.28 0.11 27.94*** 0.417
Control group 21 3.32 0.41 3.43 0.11
***p< 0.001
10 C.-Y. CHANG ET AL.
Mann, 2021). The experimental results in the present study also provide evidence that situating stu-
dents in VR contexts could promote their positive attitudes towards using MVR-SLS to learn OSCE’s
maternity care operations. Numerous studies have highlighted that situated learning is a learner-
centered method in which learners can access materials outside the textbook and then discuss
them in depth with their classmates (Rosenberg & An, 2019). This method also helps learners
adapt to subjects that are difficult to understand (Tseng et al., 2013) and can improve their
problem-solving skills (Wang et al., 2017) and learning achievement (Chang et al., 2020). Based on
this study, we can conclude that situational learning using the likes of the MVR-SLS may be recog-
nized as an important avenue for research. As information technology and digital learning increase
in popularity, it is foreseeable that, in the future, more research and applications will be carried out in
combination with VR teaching theories or strategies.
However, this study has some limitations that should be noted. First, this study used situational
learning technology based on the MVR-SLS. The extensibility of the technology may be affected by
the characteristics of various training specialties. Second, the experiment was carried out in nomi-
nated schools for specific courses, and hence it might be improper to directly infer that the same
results will be obtained in other applications using the same approach. Third, the duration of the
experiment was only 3 weeks, which might have a short-term effect on learning. So, it is rec-
ommended to do a longer experiment. Fourth, the sample size of the present study was not
large, and hence the findings need to be interpreted in a conservative manner. In the future,
related research can be carried out, such as collecting and analyzing qualitative data via interviewing
and recording students’learning behaviors to better show the effectiveness of the proposed
approach by analyzing the logs recorded in the VR system using the sequential analysis method,
as suggested by Chang et al. (2019) and Chen et al. (2021). In addition, from the perspective of soft-
ware development, the feedback of students (i.e. students’perceptions) could be a valuable refer-
ence for improving the function and effectiveness of the VR-based learning system. Therefore, it
is important to conduct studies to collect feedback from students via open-ended questions or
interviews.
To sum up, this study proposed a new MVR-SLS method that applies a situational learning para-
digm to a VR action learning system, and innovatively subverts conventional instruction design prac-
tices in obstetrics. The experimental results show that the strategy of guiding students to address
situational problems and seek answers according to the situation is beneficial, and this method
may be used in other fields of medical and nursing education. Although VR has been applied to
several courses in school settings and professional training, to the best of our knowledge, it has
not been applied to maternity training. The applications and findings of the present study fill the
gaps in the field of VR in professional training and nursing education. The findings could be a
good reference for teachers and researchers who intend to apply this emerging technology for pro-
viding authentic experience of learning different clinical situations as well as developing contextual
teaching materials for different majors and departments in medical and nursing practice. Moreover,
Table 4. ANCOVA results for engagement.
Groups NMean S.D. Adjusted mean Std. error Fvalue η
2
Experimental group 21 4.78 0.25 4.79 0.70 4.36* 0.10
Control group 21 4.56 0.33 4.56 0.70
*p< .05
Table 5. T-test results of learning satisfaction.
Groups NMean S.D. t d
Experimental group 21 4.74 0.31 1.98* 0.63
Control group 21 4.53 0.36
*p< 0.05
INTERACTIVE LEARNING ENVIRONMENTS 11
the findings of the proposed approach can be generalized to other professional training appli-
cations, in which virtual learning contexts are needed to avoid causing dangers in workspace
while enabling novice learners to practice facing real cases and making decisions, such as accident
handling in factories and urgent problem solving in industries as well as medical and nursing case
resolving in hospitals.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work was supported by Ministry of Science and Technology of the Republic of China: [grant no MOST 111-2410-H-
038-029-MY2 , MOST 111-2628-H-155 -001 -MY2].
Statements on open data, ethics and conflict of interest
The participants were protected by hiding their personal information during the research process.
They knew that participation was voluntary and they could withdraw from the study at any time.
There is no potential conflict of interest in this study. The data can be obtained by sending a
request e-mail to the corresponding author.
Notes on contributors
Dr. Ching-Yi Chang is a PhD, RN, and Assistant Professor of the School of Nursing, College of Nursing, Taipei Medical
University. She is also a supervisor in the Department of Nursing, Shuang Ho Hospital, Taipei Medical University. Her
research interests include mobile learning, digital game-based learning, flipped classroom and medical education,
nursing education, and AI in education.
Dr. Patcharin Panjaburee is an Associate Professor of the Institute for Innovative Learning, Mahidol University, Thailand.
Her research interest focuses on technology-enhanced learning such as digital game-based learning, adaptive web-
based learning, expert systems, computer testing, and diagnostic systems.
Dr. Shao-Chen Chang is an assistant professor in the Department of the International Bachelor Program in Informatics
and the Department of Information Communication, Yuan Ze University. His research interests include mobile learning,
digital game-based learning, and AI education.
ORCID
Ching-Yi Chang http://orcid.org/0000-0002-3146-2270
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