Effects of interactivity, immersion, and physical discomfort on learning in VR nursing education

BACKGROUND: Although VR provides innovative opportunities for nursing education, little is known about how its core features immersion and interactivity shape learners' self-efficacy, motivation, and cognitive processes. Furthermore, the impact of physical discomfort during VR use remains underexplored. This study investigates the effects of immersion and interactivity on affective and cognitive constructs in nursing education using virtual reality (VR), while examining the influence of physical discomfort and the moderating roles of age and gender. METHODS: A cross-sectional study was conducted with 209 students (aged ≥20 years) recruited from three nurse aide training centers in Taiwan. The research team developed a VR training system using Unity 3D and Autodesk 3DS Max, incorporating three essential nursing skills: Heimlich maneuver, meal preparation/feeding/medication assistance, and vital sign measurement. After completing the VR training, participants filled out structured questionnaires. Data were analyzed using partial least squares structural equation modeling (PLS-SEM). RESULTS: Interactivity showed stronger positive associations than immersion with self-efficacy, intrinsic motivation, situational interest, and embodied learning, and was associated with lower levels of extraneous cognitive load. Visual discomfort was negatively associated with both immersion and interactivity, whereas neck, shoulder, and back (NSB) pain was positively associated with immersion. Multi-group analysis revealed that female participants reported greater visual discomfort, which reduced immersion and interactivity. Additionally, participants under 35 years old exhibited greater sensitivity to visual discomfort in relation to immersion compared with older participants. CONCLUSIONS: Interactivity is more crucial than immersion for enhancing affective and cognitive learning outcomes in VR-based nursing education. Visual discomfort significantly impairs learning experiences, with stronger negative effects among female and younger users, suggesting the need for further attention to user characteristics and physical comfort in VR-supported nursing education.