In this study, we observed that virtual reality sickness (VRS) affected 57.3% of the 75 participants (Fig. 4). This number aligns with findings from previous studies, which reported an incidence rate between 60 and 70% [13, 18,19,20,21]. The mean SSQ score in our study was 9 with a range of 0 to 29, indicating lower score than previous study by Saredakis et al. which reported a pooled mean of 28 with a range of 14.30 to 35.27 [19]. Among the SSQ components, disorientation scored the highest at 125.6, followed by oculomotor at 6.36, and nausea at 5.97 (Fig. 5). These results are consistent with previous research reporting pooled mean SSQ scores of 16.72, 17.09, and 23.5 for nausea, oculomotor, and disorientation, respectively [19]. According to Kenendy et al., total SSQ score of 9 indicates minimal symptoms [17, 18]. Although majority of the participants in our study experienced negligible to significant symptoms, there were 16% of them that experienced severe symptoms, and further mitigation plan should be prompted.

In the context of emergency setting simulations, healthcare professionals are mandated to possess not just the knowledge base, but a comprehensive technical skill set. This proficiency encompasses the continuous monitoring of hemodynamic changes subsequent to specific medical procedures like looking at the monitor over and over after performing a medical procedure. This well involved repetitive rotational movement of the neck. Other technical skill healthcare professionals need to understand are the assembly and operation of medical equipment, effective communication, and a diverse array of medical competencies, such as airway management, resuscitation, and the precise administration of pharmaceuticals. In an emergency scenario, temporal considerations are of paramount importance, as any delays in response time or decision-making may yield profound and potentially life-altering consequences. Moreover, the demanding nature of emergency setting simulations, characterized by intricate and occasionally repetitive actions, can engender VRS.

The disorientation component of the SSQ, encompassing symptoms such as difficulty focusing, nausea, fullness of the head, blurred vision, dizziness with eyes open or closed, and vertigo, exhibited a high occurrence of bad scores (>20) in 43 participants (57.3%) as seen in Fig. 5. Our research findings have illuminated that VRS, particularly of a severe degree, predominantly falls within the disorientation category. This observation implies that the performance of users engaged in simulation exercises may be disrupted and hindered, preventing them from effectively showcasing their genuine competencies during training simulations. This can further impact learning process. Kelly et al. discovered that virtual reality users are particularly susceptible to disorientation, especially when using locomotion interfaces lacking self-motion cues. To address this issue, incorporating environmental cues, such as boundaries, into the design of locomotion interfaces is crucial to reduce disorientation-related effects [22].

Our study found that hardware-related issues, specifically the VR mode, were associated with VRS. Participants using the stationary mode were five times more likely to experience VRS. This is in line with previous research indicating that nonstationary VR modes, especially physically walking mode, can help reduce the incidence of VR sickness [23]. Chang et al. classified VRS factors into three domains: hardware, content, and human factors. Hardware factors encompassed various VR device manipulations, including display type, display mode, time delay, and device weight. Content factors involved altering VR scenes or scenarios, such as graphics, task-related features, duration, and controllability. Human factors considered individual differences, such as age, gender, BMI, postural sway, previous VR experience, and eye-related measures like interpupillary distance, refractive error, and eye-hand coordination [1]. In Saredakis et al.’s study, the mean SSQ scores for nausea, oculomotor, and disorientation were 22.6, 22.4, and 28.5, respectively, in the stationary group, whereas in the walking group, they were 13.2, 15.3, and 18.5, respectively [19, 24].

Our findings revealed that male are more prone to VRS. This is the opposite of previous studies. Schmitz et al. found gender as an essential variable associated with motion sickness in VR systems [25]. Males were 2.8 times more likely to experience VRS than females. However, a large-scale meta-analysis reported no significant gender difference in VRS [19]. Former VR experience was believed to increase the likelihood of VRS [26]. Surprisingly, our study did not find any significant effect of previous VR experience on VRS. Further research is needed to fully comprehend the underlying pathophysiology of this phenomenon [27]. Young et al. discovered that ocular refraction disorders influenced motion sickness during head-mounted display experiences. Myopic and astigmatic participants showed significantly higher SSQ scores for nausea and disorientation. Our findings are aligned with these results, as we observed a higher incidence of VRS in participants with myopia and astigmatism.

This study has several limitations. Firstly, its cross-sectional design makes it difficult to establish causal relationships between factors. It would be better if further research could address the dose-response relationship between the amount of time spent in VR-based learning and development of fatigue. Conducting further research using cohort or randomized trials would be more suitable for addressing this issue. Secondly, the consecutive sampling method used may introduce bias as it is a nonprobability sampling technique. Thirdly, the lack of pre-treatment SSQ scores before participants engaged in the VR experience could lead to additional biases in interpreting the results.

We interviewed participants with simple preference questions, asking their opinion whether VR is potential for learning method in the near future and whether the VRS that they experienced hinder them for trying VR for educational purposes in the near future. All of the 75 people answered that VR has the potential for learning method, and only one of 75 people has chosen to avoid using VR in the near future due to the side effect that he experienced.

Based on the current report, we recommend using the room-scale mode as the locomotion interface for VR to minimize VRS. Additionally, participants with refractive disorders should receive proper treatment by wearing glasses for refractive correction before engaging in VR activities. These strategies are essential to ensure all participants have the best possible environment to enhance learning outcomes in VR-based simulation training for traumatic brain injury management.