This paper draws on a broader PhD-by-publication project that employed a qualitative descriptive design to explore nursing and midwifery educators’ perceptions of virtual reality (VR) integration in their teaching practice. Within this focus, the project examined educators’ views on perceived benefits, concerns, key implementation barriers, and suggested strategies for effective curricular integration. The overarching aim of the broader project was to develop best-practice guidelines for incorporating VR into nursing and midwifery education. However, this paper underpinned by Kirkpatrick’s Four-Level Training Evaluation Model, specifically focuses on educators’ perceptions, highlighting how they experience VR integration and identify practical strategies for its use in teaching.

This qualitative approach provided rich, detailed insights into educators’ experiences and perspectives, allowing for in-depth understanding of both benefits and challenges in VR integration.

The study was conducted at two purposively selected universities in South Africa to capture diverse contextual experiences in nursing education. The first site was an urban university in the Free State province with well-established virtual reality (VR) infrastructure and a strong technological environment. The second site was a rural university in Limpopo province, classified as a historically disadvantaged institution and characterised by limited exposure to VR due to infrastructural and resource constraints. Both universities are accredited by the Council on Higher Education (CHE), the South African Qualifications Authority (SAQA), the South African Nursing Council (SANC), and the Department of Higher Education and Training (DHET) to offer clinical training in the R174 general nursing and midwifery programme.

The study targeted nurse and midwifery educators who were registered with the South African Nursing Council (SANC) and actively involved in clinical teaching within the two selected universities. Eligible participants were required to have a minimum of three years’ experience in clinical nursing or midwifery education to ensure sufficient expertise in training students. A non-probability purposive sampling approach was used to recruit participants, focusing on educators directly engaged in clinical modules. Out of a total population of 22 eligible educators across both institutions. Educators who were not registered with SANC, not employed at the selected universities, or not involved in clinical teaching were excluded from the study.

Data were collected through three semi-structured focus group discussions (FGDs) guided by an interview guide. One open ended question was asked ‘ What are your perceptions/views regarding the use of VR in nursing and midwifery education? The FGDs aimed to explore nursing and midwifery educators’ perceptions, challenges, and recommendations regarding the integration of virtual reality (VR) into their teaching curricula. The central focus was on educators’ views of the benefits and potential applications of VR in nursing and midwifery education, with probing questions such as whether there were specific areas or topics where VR could be particularly effective.

Twenty-two nurse and midwifery educators, representing the full population of lecturers involved in clinical training within the two selected universities, participated in the discussions. All FGDs were conducted in English, the medium of instruction at both institutions, to facilitate natural dialogue and accurate expression of concepts. Sessions were held in pre-booked boardrooms at the respective universities to provide a familiar, comfortable, and distraction-free environment. The first FGD, conducted on 25 September 2025, included six participants and lasted 55 minutes. The second FGD, held on 21 October 2025, involved six participants and lasted one hour and 22 minutes. The third FGD took place on 7 November 2025 with five participants and lasted 41 minutes, whilst the fourth and final FGD took place on 13 ^th November with 5 participants, lasting for 45 minutes. All discussions were audio-recorded and transcribed verbatim.

The duration of the FGDs fell within the typical range for qualitative research, with 45–90 minutes generally considered sufficient to explore topics in depth without causing participant fatigue ( Rabiee, 2004). Shorter sessions (30–45 minutes) may limit the depth of discussion ( Smith, 2015), while longer sessions (90–120 minutes) are better suited to complex topics or larger participant groups ( Krueger & Casey, 2015). The 60-minute duration chosen for this study was appropriate given the moderate group size (5–6 participants) and the detailed, technical nature of the topic: VR integration in nursing and midwifery education. Aligned with best practice guidance, skilled facilitation and high participant engagement ensured that rich, detailed data were collected within these time frames ( Guest, Namey & McKenna, 2017).

Data collection continued until thematic saturation was achieved. After the second FGD, preliminary analysis indicated that participants were providing nuanced details, often supported with specific examples from their clinical teaching practice. Multiple perspectives emerged on the potential benefits and challenges of integrating VR, and participants engaged in an interactive discussion, clarifying and expanding on one another’s viewpoints. In the third focus group discussion, similar details from previous FGD were reemerging. The fourth FGD was conducted to confirm saturation, yielding no new themes. The combination of focused discussion, detailed examples, diverse perspectives, and dynamic interaction confirmed that the data were both comprehensive and sufficiently rich to address the study objectives. For reporting purposes, the discussions are referred to as FGD1, FGD2, FGD3 and FGD4, and each participant was assigned a unique alphanumeric code (e.g., FGD2-speaker 5).

Ethical approval was obtained from the University of KwaZulu-Natal Research Ethics Committee (BREC/00008434/2025), and institutional permission was secured from both universities. The study adhered to ethical principles of respect for persons, beneficence, non-maleficence, justice, and autonomy ( Beauchamp & Childress, 2019). Participants received a detailed information sheet explaining the study’s purpose, procedures, potential risks and benefits, the right to withdraw at any time, and measures to ensure confidentiality. Written informed consent was obtained prior to participation, ensuring autonomy. In compliance with the Protection of Personal Information Act (POPI-A, 2013), participants were fully informed about the purpose of collecting their personal information, and their data were handled with strict confidentiality ( University of South Africa, 2020).

To ensure privacy, all data, including audio recordings and transcripts, were anonymised and linked to unique participant codes (e.g., FGD01, speaker03). Identifying information was removed during transcription, and all files were securely stored on password-protected institutional servers, accessible only to the core research team. In reporting findings, direct quotes were attributed solely to these participant codes to safeguard the principle of non-maleficence ( Saunders et al., 2015). Furthermore, the focus group discussions were conducted in private, convenient, and comfortable locations to promote respect for persons and beneficence ( Manti & Licari, 2018). Participants were reminded of their shared responsibility for confidentiality, further supporting justice and allowing them to share experiences openly and safely.

Data was analyzed using reflexive thematic analysis ( Braun & Clarke, 2017). Audio recordings were transcribed verbatim by TM. The primary researcher (TM) worked closely with the main supervisor (OB), with both independently approaching each analytic step and meeting periodically to discuss and reach consensus. The transcripts and initial analysis were also shared with co-supervisors (ZG and WTB), who independently reviewed the data. All parties ultimately discussed and agreed on the final themes. The analysis process involved repeated reading of transcripts, line-by-line coding of relevant segments, grouping codes into candidate themes, and refining themes for coherence and distinctiveness. Selected quotes were used to illustrate each theme in the findings. Reflexive notes were maintained throughout to document analytic decisions and ensure transparency.

Trustworthiness was established through multiple strategies that employed the criteria of credibility, dependability, confirmability, and transferability ( Nowell et al., 2017). Credibility was enhanced by prolonged engagement with participants, member checking, and probing questions during focus groups to confirm accurate interpretation. Dependability was supported by detailed audit trails and peer debriefing with the main supervisor (OB) and co-supervisors (ZG and WTB). Confirmability was maintained by independent review of transcripts and codes by the researcher (TM) and supervisors, ensuring findings reflected participants’ perspectives rather than researcher bias. Transferability was facilitated by purposive sampling across urban and rural universities and detailed descriptions of context and participants, allowing readers to assess applicability to similar settings.

Of the 22 participants involved across four focus group discussions held at two universities, all were academic staff involved in the clinical training of nursing and midwifery students. The cohort comprised 12 nursing and midwifery educators, 6 doctoral-qualified nursing and midwifery educators, senior lecturers, and 4 full professors. The 12 lecturers all held master’s degrees in nursing or related fields, and each possessed between three to five years of experience (averaging four years) as nurse educators specifically engaged in clinical training. The 6 doctoral-level senior lecturers each held a PhD in Nursing Science and brought substantial experience, ranging from 10 to 15 years (averaging 12.5 years), in student education and clinical supervision. The 4 full professors represented the most senior cohort, each with a conservative estimated average of over 25 years of dedicated experience as nursing and midwifery educators actively involved in clinical training. Collectively, the participants brought a profound depth of perspective rooted in direct academic and clinical instructional practice, with an overall mean of approximately 10.1 years of experience in clinical nursing and midwifery education. In this study, four main themes were extracted; namely, immersive educational benefits with subthemes (1.1) increased engagement, excitement, and memory (1.2) safe, accessible practice for high-stakes scenarios (1.3) bridging theory-practice and building competence. Enhanced student learning, high-value applications and curricular integration with subthemes (2.1) priority applications in midwifery and nursing (2.2), a complementary tool, not a replacement. Essential facilitation. Strategies for sustainability with sub-themes (3.1) securing institutional buy-in and building support (3.2) investment in training and dedicated support (3.3) policy and structural integration and implementation challenges and barriers with sub-themes (4.1) resource constraints (4.2) educator readiness and resistance (4.3) pedagogical and health considerations (see Table 1).

The educators from both institutions perceived VR as transformative. According to them, VR provided students with an immediate and memorable encounter with clinical environments. Thus, creating a sense of “being there” that traditional teaching methods rarely achieve.

Sub-theme 1.1: Increased engagement, excitement, and memory

According to the data sources, educators reported that VR increased students’ engagement and excitement. This, according to them, ensured stronger and longer memory retention and lifelong recall. The students’ initial reactions were described by the educators as enthusiastic, with many recalling specific visual details and scenarios well beyond the VR session itself. As indicated by the educators, this sustained memory recall suggests that VR supports deeper cognitive processing, thereby making learning experiences more memorable than traditional classroom engagement. This is evident in the following extracts:

Sub-theme 1.2: Safe, accessible practice for high-stakes scenarios

The data sources further indicated that VR offers a safer, accessible platform by exposing students to clinical case studies and scenarios that are often not readily available in clinical settings. This VR experience offered students a safe space to practice critical clinical skills without fear of harming patients. It was during these VR practice sessions that the students were observed exercising their higher-order thinking skills (HOTS), practising clinical decision-making, problem-solving, and clinical reasoning in safer environments. As illustrated in the following quotes, this experience was beneficial in preparing students for emergencies they may encounter infrequently but must manage competently in practice:

Sub-theme: 1.3 Bridging theory-practice and building competence

In this study VR was perceived by the educators from both institutions as an effective way of bridging the theory-practice gap. According to them VR enables students to visualize and apply their theoretical knowledge into meaningful ways, through its ability of situating complex and complicated concepts into realistic clinical contexts. Below is what they had to say:

Furthermore, participants observed an increased level of confidence and better preparedness from the students, which, according to them indicated that VR supports the development of practical competence and clinical reasoning skills. The following extracts provide evidence to this statement:

Educators from both institutions described virtual reality as most impactful when strategically integrated into nursing and midwifery curricula, rather than used as a stand-alone innovation. Two sub-categories emerged under this category as indicated below.

The data sources highlighted specific areas within nursing and midwifery training curricula where VR was perceived a much-needed, impactful teaching and learning strategy. These specific areas were but not limited to complex and complicated clinical procedures, obstetric emergencies and areas where student exposure during clinical placements was perceived as inaccessible or inconsistent. The below narratives confirm this:

As much as VR was preferred by all the educators from both institutions, they persistently alluded that VR should be seen as a complementary teaching and learning tool and not necessarily a complete replacement for traditional teaching methods or clinical practice. In this study it emerged that VR is beneficial when integrated within lectures, simulation laboratories and clinical placement rather than when it is used as standalone. Evidence from the educators suggest that integration of VR into teaching and learning prepares the student for authentic real-world clinical practice. The following extracts attest to this:

Intentional facilitation at the institutional level was mentioned by the data sources as a key to long term sustainability of VR in nursing and midwifery education. Organisational support, adequate academic training, and alignment with policy were highlighted by the participants as pivotal in ensuring effective integration of VR into the current nursing and midwifery education and beyond. Without the above enablers VR remained at risk of remaining short-lived and fragmented within the institutions of higher learning.

The three sub-themes which emerged under this theme will be further elaborated below:

Institutional buy-in was mentioned by all the participants as a critical factor in ensuring successful implementation of VR. Data sources perceived institutional executive leadership as key gatekeepers to the successful roll-out of VR. According to the data sources, institutional executives have influence over access to resources, allowing the integration of VR into the curriculum as well as their final and overall acceptance of VR as a legitimate teaching and learning approach. The subsequent extracts provide evidence to this:

Educators highlighted the importance of ongoing training and technical support to enable effective use of VR. Confidence in the use of technology influences educators’ willingness to adopt and adapt it into teaching. Hence availability of dedicated support personnel would reduce their frustrations and disruptions as shown in the following extracts:

Although one of the institutions was using VR, educators from both institutions mentioned a dire need for VR to be formally acknowledged and integrated in institutional policies and curricular structures, both at undergraduate and postgraduate levels. According to them the absence of structural and institutional integration will render VR as inconsistent and vulnerable with the ultimate termination. These concerns are evident from the following quotes:

Theme 4: Implementation challenges and barriers

Several challenges that hindered the effective and efficient implementation of VR were identified by the educators. These will be elaborated in the following three sub-themes.

Finances, old and poorly maintained infrastructure and scarcity of equipment emerged as the key barriers for the successful implementation of VR. These constraints were perceived to hinder the scalability and routine use and integration of VR within the curricula. Some of the participants stated this:

The level of educator’s readiness and acceptance varied across the educators. Some of the educators verbalized excitement and readiness, while others were reluctant in integrating VR unto their day-day teaching and learning. The below statements attest to this:

Those who verbalized reluctance, mentioned their lack of trust and uncertainty from the institutions in ensuring sustainability. Furthermore, they mentioned their own limited technological confidence and workload challenges which often limit their kevel of creativity and trying new things. The below statement supports their level of reluctance and resistance:

Some of the participants raised health-related and pedagogical considerations which may negatively impact the integration of VR into nursing and midwifery education, teaching and learning. Some of the concerns raised included proper alignment of VR activities with the varied students’ needs. Educators also mentioned that VR may cause visual strain as well as dizziness, which may need extra careful facilitation. Below is how participants elaborated on this:

A key strength was the inclusion of participants across varying levels of academic seniority and experience, ensuring diverse yet informed perspectives. Conducting focus group discussions across two universities further enriched the data through interactive dialogue and cross-institutional comparison, enhancing contextual transferability.

However, the use of non-probability purposive sampling, the relatively small sample size (n = 22), and the inclusion of educators from only two universities limit generalisability. Additionally, focus group dynamics and the professional seniority of participants may have introduced social desirability bias. Future studies should include larger, multi-institutional samples and consider mixed methods approaches to enhance generalisability, reduce potential bias, and strengthen the evidence base for clinical nursing and midwifery education.