Virtual reality learning: A randomized controlled trial assessing medical student knowledge of fetal development

To investigate whether a virtual reality learning environment (VRLE) enhanced student understanding and knowledge compared with a traditional tutorial.

as well as software to deliver an immersive experience. 2 One such immersive experience is a VR learning environment (VRLE) in which users are completely immersed in a virtual setting using HMDs. 3 Several studies have already demonstrated the benefits of VRLEs in comparison with or in addition to traditional teaching modalities in undergraduate medical education. [4][5][6][7] VRLEs are believed to provide a more enhanced learning experience when compared with partially immersive VR technologies. 8 However, they are educational tools and do not by themselves teach. Learning through VR is based on the constructivists theory whereby an environment is created enabling learning by experimentation. 9 In medical education, this can be applied to the subjects of anatomy and embryology where students are required to translate two-dimensional images into three-dimensional (3D) concepts, which can be a cognitive challenge for those who have difficulty in visualizing this transformation of images. 10 The introduction of VRLEs as an educational tool could automatically standardize this process for students and enhance understanding.
In obstetrics and gynecology education, few studies have been performed investigating the educational effect of VR technologies to enhance embryology teaching. Two recent studies both developed VRLEs to teach embryology; however, in both studies, no evaluation was performed to assess the educational effectiveness of these tools. 11,12 Therefore, the aim of this study was to investigate whether a VRLE enhanced student understanding and knowledge retention on the topic of "stages of fetal development in pregnancy" compared with a traditional PowerPoint tutorial.

| ME THODS
A randomized controlled trial (RCT) was conducted of students from all academic years of the undergraduate (6-year program) and postgraduate (4-year program)  Medical students were invited to take part in the study via announcements on Brightspace (the university's e-learning platform), class announcements, and medical student societies. Interested students contacted the study team via the email address provided and were emailed an information leaflet and consent form to review.
Consent forms were signed electronically to reduce contact, in line with coronavirus disease 2019 (COVID-19) guidance as the study took place during the pandemic. All medical students except those younger than 18 years or with a medical condition including cardiac (e.g., pacemakers) and binocular vision abnormalities, psychiatric disorders, or epilepsy were eligible to take part in the study.
The sample size was calculated in conjunction with advice from the university statistical support group (CSTAR), based on previous similar studies in the literature. Assuming a normal distribution, with a standard deviation (SD) of 1.75 taken from the literature, 13 the sample required to demonstrate a difference of a score of two between the intervention and the control groups at a type I error rate of 0.05 (adjusted for multiple comparisons) at 90% power with an allocation ratio of 1:1. After an adjustment to allow for 20% dropout, the total sample size required was 40 for 90% power.  In addition, students' experiences were evaluated using the 13-item Student Satisfaction and Self-Confidence in Learning Scale (SCLS) measuring student satisfaction (five items) and selfconfidence in learning (eight items). The SCLS was developed and validated by the National League for Nursing and is reported to have a Cronbach α of 0.94 and 0.87 for satisfaction and self-confidence, respectively. 16 The 20-item Simulation Design Scale (SDS), renamed and adapted for the purpose of this study as the Virtual Reality Design Scale (VRDS), also developed by the National League for Nursing, is a Likert-style scale and divided into five sections, which are rated by the student. The reported Cronbach α for the SDS is 0.92, 16 and adaptation for use within our VRLE was reasonable as parameters of evaluation were applicable. 17 Reliability analysis was performed for both scales in the context of our study for further validation with Cronbach α scores of 0.87 and 0.89 for the SCLS and VRDS, respectively.
The primary outcome was knowledge (measured by MCQ score) postintervention. Prespecified secondary outcomes included attitudes on the learning experience assessed using the SCLS and the VRDS. Side effect profiles of the VRLE were also evaluated to determine the usability of VRLEs as an educational tool.
In the SCLS questionnaire, participants were also asked, "Do you have any other comments to add to your learning experience MCQ scores were compared between groups immediately postintervention (MCQ 2) and after 1 week (MCQ 3) using one-way analysis of covariance (ANCOVA). Both models were adjusted for baseline score (MCQ 1) and also MCQ 2 in the latter test. Individual one-way analysis of variance (ANOVA) and post hoc Tukey's honestly significant difference (HSD) tests were undertaken to explore the impact of time on knowledge scores for each study group independently. ANCOVA was used to assess between group differences for total SCLS scores, correcting for previous VR use.
Data were tested for normality prior to assessment using Shapiro-Wilk tests and QQ plot assessment. Homogeneity of variances was F I G U R E 1 CONSORT (Consolidated Standards of Reporting Trials) diagram representing the randomization process. *Discontinued the study denotes those that did not attend on the day of the trial.

| RE SULTS
Fifty-six medical students responded with completed and signed consent forms, and 32 students did not return the consent form. Of the 56 medical students, 41 (73%) completed the study with 21 and 20 participants in the intervention and control groups, respectively ( Figure 1). Baseline characteristics of study participants are outlined in Table 1 and reported in accordance with the CONSORT guidelines. 19 The majority of participants (61%) were aged 25 to 34 years, with the remaining 39% patients 18 to 24 years. Thirty (73%) participants were women and 11 (26%) were men, and 14 (34%) were from the undergraduate medical degree program, while 27 (66%) were from the postgraduate degree program.
With regard to the primary outcome testing the effect of intervention on MCQ knowledge scores, there were no significant differences in the MCQ 2 and MCQ 3 outcomes between the intervention and control groups (   Table 7. A total of 38% of participants reported no symptoms during the intervention, whereas 19% experienced one or two symptoms, 24% experienced three or four symptoms, and 19% experienced five or more symptoms.

F I G U R E 2 (a) Image of participant wearing the Oculus Quest VR headset undertaking the VRLE intervention (taken with permission), (b) Image of fetus at 8 weeks gestation demonstrating a 2D ultrasound image for clinical correlation, (c) Image of 3D fetus at 14-16 weeks gestation (d) Image of fetus at 20-24 weeks gestation with a 2D ultrasound image for clinical correlation.
Students in the control group were mostly appreciative of the lecture format, reporting that the "pace of the lecture was good," the lecture was "… very informative," and it was a "good learning experience overall of a topic that I personally don't find very accessible." Three themes were identified in the intervention group: experience, visualization, and lesson design. For experience, students praised the novelty and innovation of VR, as a "fun new way to interact with information." "A nice change from the traditional lecture format!", where they reported that VR was "very cool" and that "I LOVED IT". Having experienced VR for teaching, their experience mirrored the postulations of their colleagues where visualization was useful "VR … seems to allow for greater appreciation of complex 3D structures" that was "very helpful for visualizing embryology" which some qualifiers "would take some getting used to." In relation to lesson design of the VRDS, the majority of students thought it would be a useful learning tool in the classroom, suggesting that it is "… a great addition," "a valuable asset," and a "novel learning tool." However, some students acknowledged the potential benefits of VR while having reservations attributable to the side effects they experienced during the VRLE: "It makes me a bit dizzy but other than that it is very fun and interesting and would help me to learn better than usual lectures, or at least would enhance my learning along with lectures." Secondary outcomes of our study involved exploring students' level of satisfaction with learning and self-confidence in learning.

| DISCUSS ION
In our study, results of the SCLS questionnaire were rated higher among the VRLE group when compared with the control group.
Similar results are found in the literature, with most studies reporting high levels of satisfaction with VR technologies. 23 Our study reflects these findings, adding to the evidence that VR increases students' satisfaction and self-confidence in learning.
The main strength of the study was the novel application of a VRLE to effectively enhance the understanding and learning of less accessible concepts, such as those found in the topic of fetal de-

AUTH O R CO NTR I B UTI O N S
The study was part of a thesis for Grace Ryan involved with the study design, interpretation of data analysis, writing, and review of the study protocol and manuscript.

ACK N OWLED G M ENTS
The authors would like to sincerely thank all of the medical students for their participation in the study, the research center, and the research team for their support. Open access funding provided by IReL.

FU N D I N G I N FO R M ATI O N
The study was supported by funding from University College Dublin, Ireland, and the National Maternity Hospital, Dublin, Ireland.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare that they have no conflicting interests.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.