Feasibility of virtual reality-based simulation for neonatal resuscitation training: a pilot study at an international site

This study demonstrates the feasibility and positive reception of a VR-based neonatal resuscitation training program in an international setting, specifically in Vietnam. Through systematic coding and theme development, this analysis identified patterns that highlight both the challenges and opportunities in VR-based training implementation. Building on prior research conducted in the U.S. [9], this pilot study confirms the adaptability of the VR platform across diverse healthcare environments and highlights its potential as an innovative training tool for neonatal resuscitation.

Comparison with traditional training methods

The Vietnamese participants reported high satisfaction with the VR training, with 86% rating it as more realistic than traditional training methods. This aligns with previous findings that VR offers an immersive learning environment, enabling repeated exposure to high-stakes clinical scenarios in ways that traditional manikin-based training may not, though some learners perceive limitations in realism and patient interaction [12]. The dynamic and interactive nature of the VR platform allowed participants to engage with a simulated 30-week neonate, providing valuable opportunities to practice critical interventions such as positive pressure ventilation and corrective steps. These features are particularly relevant in settings with limited access to high-fidelity manikins or formal neonatal resuscitation training.

A key distinction between this study and our previous VR-based neonatal resuscitation training study [9] was the shift from an individualized to a team-based training approach with enhanced nursing and allied health representation. As established in our methodology, this study was designed to better reflect real-world clinical team dynamics and align with the interdisciplinary structure of traditional NRP education. By allowing nurses, respiratory therapists, and other allied health providers to train alongside physicians, the VR sessions enhanced the realism of the simulation and underscored the essential role of coordinated teamwork in neonatal resuscitation. This approach may better prepare participants for clinical practice by promoting collaborative decision-making, clarifying team roles, and strengthening communication skills—all of which are critical for optimizing neonatal outcomes. These findings suggest that VR-based training can be effectively expanded beyond individual skill acquisition to enhance team dynamics, an aspect that warrants further exploration in future studies.

International adaptability and cultural considerations

This study highlights the international adaptability of VR-based training. Compared to the U.S. cohort, the Vietnamese participants expressed higher perceived realism and comfort with the VR platform, despite lower baseline familiarity with VR technology. This suggests that VR can potentially bridge gaps in training quality in resource-constrained settings. However, unique challenges were encountered, including language barriers and limited familiarity with the NRP algorithm. Future iterations of the program should incorporate bilingual instruction and region-specific clinical guidelines to further enhance accessibility and relevance.

Implementation challenges and potential improvements

Despite the overwhelmingly positive reception, several implementation challenges were noted. Language implementation required real-time human translation, as the VR system lacked built-in multilingual capabilities. While effective, this approach necessitated dedicated translator presence and added logistical complexity.

Technical infrastructure also presented challenges, particularly regarding internet connectivity. Unstable internet connections occasionally disrupted the immersive experience, as stable connectivity was required to enable real-time communication between local participants and the remote U.S.-based instructor (R.M.) who joined the virtual environment simultaneously. Initially, the hospital’s internal Wi-Fi network encountered significant latency issues, which were resolved by using individual mobile hotspots for each VR station and connecting headsets via physical cables to reduce wireless dependency.

Additionally, participants expressed a desire for increased scenario variability and more opportunities for practice to enhance skill mastery. Future implementations would benefit from VR systems with integrated language selection and localized content, improved technical infrastructure, and expanded scenario libraries to enhance scalability and effectiveness.

Virtual environment familiarity and adaptation

One important consideration when deploying VR-based neonatal resuscitation training is the potential adjustment period required for participants to familiarize themselves with a virtual environment that may differ from their actual clinical setting. The layout of virtual resuscitation rooms, positioning of equipment, and user interfaces may not precisely mirror participants’ real-world work environments. This discrepancy could lead to an initial learning curve, requiring additional time to orient participants to the virtual space before they can fully engage in resuscitation tasks. Future research should evaluate the extent to which this familiarization process impacts training efficiency, skill acquisition, and overall learning outcomes. Optimizing the design of virtual environments to reflect local clinical settings may help minimize disorientation and enhance the realism and relevance of the simulation experience.

Flexibility to accommodate multiple resuscitation algorithms

While the VR training platform in this study was designed according to the NRP 8th edition guidelines, there are several neonatal resuscitation algorithms currently in use across different regions and institutions. A key advantage of VR technology is its adaptability; virtual scenarios can be tailored to reflect various protocols and guidelines, thereby supporting widespread applicability. However, certain procedural elements—such as endotracheal intubation and chest compressions—may currently lack the tactile realism provided by advanced haptic feedback systems, which remain in early stages of development. Despite this limitation, VR offers an effective modality for practicing cognitive elements of neonatal resuscitation, including algorithm adherence, clinical decision-making, and team coordination.

Psychological impact of training in a virtual environment

Another important consideration is the psychological experience of participants during VR-based simulations. Ideally, these environments promote psychological safety so learners can engage fully, take risks, and learn from mistakes without fear of embarrassment or judgment. This sense of safety supports critical behaviors such as asking questions, reflecting on performance, and openly acknowledging uncertainty—behaviors that are foundational to simulation-based education [13]. Psychological safety is especially important in unfamiliar learning environments like VR, where the novelty of the interface can heighten anxiety. Effective strategies to foster this safety begin before the simulation itself. A structured pre-briefing that clarifies learning objectives, roles, expectations, and evaluation methods can help reduce ambiguity and support learner engagement. As described by Rudolph et al., the pre-briefing also establishes a “fiction contract,” a mutual agreement that acknowledges the simulation’s limitations while encouraging learners to interact with the scenario as if it were real [14]. This contract normalizes performance variability and invites participants to focus on learning rather than scenario appearance. In VR contexts, where the simulated experience may feel isolating or immersive in unfamiliar ways, facilitator support plays an important role in encouraging curiosity and demonstrating respect for the learner’s perspective. Future research should explore how psychological safety influences learning outcomes in VR-based training and identify effective, culturally adaptable strategies for creating safe learning environments across diverse settings.

Cybersickness and VR-related discomfort across cohorts

While VR can serve as a valuable adjunct to traditional manikin-based neonatal resuscitation simulations, challenges such as cybersickness warrant consideration. Cybersickness, which is characterized by symptoms like dizziness, nausea, and disorientation, is a frequently reported side effect of VR use [15, 16]. Previous studies have shown that a significant proportion of users experience these symptoms, with rates as high as 49% among midwifery students [17] and 23% among medical students receiving VR-based trauma education [18]. In our study, 28.6% of participants reported VR-related discomfort, a lower incidence compared to our U.S. cohort (40.5%) [9], yet still notable. This reduction may reflect differences in session structure, participant demographics, or prior VR exposure. Regardless, the overall occurrence of discomfort highlights the need for mitigation strategies, such as improved hardware, stable internet connectivity, and structured orientation. Strategies such as limiting session lengths to one hour, as recommended by Holla and Berg [18], and incorporating gradual acclimation to the VR environment could potentially mitigate these effects. In addition to motion sickness, prolonged VR use may lead to oculomotor strain, although both symptoms may diminish with repeated exposure [19]. Addressing these challenges through user preparation and technological refinements may help optimize the effectiveness and accessibility VR-based training programs. Further research is needed to understand the contributing factors to cybersickness and oculomotor strain, including how these issues vary across educational backgrounds and experience levels.

Strengths and limitations

A major strength of this study is its demonstration of VR training’s feasibility in a resource-limited international setting. The study design allowed for structured evaluation of participant attitudes and challenges, providing valuable insights for future adaptations. However, several limitations warrant discussion. The reliance on self-reported survey data introduces potential response bias, as participants may have been inclined to provide favorable feedback. In addition, the absence of a control group limits the ability to directly compare VR training outcomes with those of traditional methods. This pilot study also introduced multiple design variables simultaneously, including an international site, bilingual delivery, remote facilitation, and a team-based training model. While these features reflect the practical realities of global implementation, they limit our ability to isolate the individual contributions of each factor to the training outcomes. Future studies should consider more controlled designs to examine the specific effects of each component. Finally, the small sample size and limited representation of certain professional roles, such as nurses and allied health professionals, may affect the generalizability of the findings.

Future directions

Future research should focus on addressing identified challenges and expanding the scope of evaluation. Comparative studies with larger, more diverse samples are needed to rigorously assess the effectiveness of VR training relative to traditional methods. Objective outcome measures, such as skill retention and clinical performance, should complement participant feedback to provide a more comprehensive understanding of the program’s impact. Additionally, integration of emerging technologies, such as artificial intelligence, could enhance the adaptability and interactivity of VR-based training. Features such as real-time feedback, automated performance assessment, and multilingual support have the potential to address current limitations and further optimize training outcomes.