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Comparative evidence between screen-based VS and headset virtual reality (VR) within the same VS scenario is especially limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>The primary goal of this study is to identify challenging\/bothersome events in a VS, compare how these events manifest in screen-based versus headset VR, and examine their impact on electrodermal activity (EDA; physiological arousal), performance, usability, and cognitive load.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A mixed-methods approach was applied to analyze audio-video and EDA data from 20 third-year nursing students during a VS. Objective performance scores were generated by the OMS software, while self-reported data on usability and cognitive load were collected through post-simulation surveys.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Six challenging\/bothersome event categories were identified: software-related restrictions and bugs, confusion\/lack of success, negative affect, technical errors, neglect of instruction, and other. Results revealed that encountering challenging\/bothersome events significantly increased students\u2019 EDA (an indicator of physiological arousal), possibly reflecting frustration\/confusion. Furthermore, while no single challenging\/bothersome event category predicted performance or usability relative to others, we found that software-related restrictions and bugs were particularly critical, significantly increasing extrinsic cognitive load compared to technical errors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Our findings highlight specific VS elements that hinder students\u2019 experience, directly pointing to areas for future improvements. We also provide valuable insights for educators and developers to enhance virtual learning environments in nursing education by addressing how to reduce cognitive load and improve performance and usability. Future research should develop VS-specific usability tools and replicate this study in diverse contexts to further refine virtual learning experiences.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/10468781251401059","type":"journal-article","created":{"date-parts":[[2025,11,26]],"date-time":"2025-11-26T05:37:40Z","timestamp":1764135460000},"page":"494-530","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Mixed Methods Examination of Challenging and Bothersome Events in Nursing Virtual Simulations: Comparing Screen-Based and Headset VR Modalities"],"prefix":"10.1177","volume":"57","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8840-1981","authenticated-orcid":false,"given":"Sayed","family":"Azher","sequence":"first","affiliation":[{"name":"McGill University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0130-6015","authenticated-orcid":false,"given":"Keerat","family":"Grewal","sequence":"additional","affiliation":[{"name":"McGill University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Negar","family":"Matin","sequence":"additional","affiliation":[{"name":"McGill University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amanda","family":"Cervantes","sequence":"additional","affiliation":[{"name":"McGill University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caroline","family":"Marchionni","sequence":"additional","affiliation":[{"name":"McGill University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hugo","family":"Marchand","sequence":"additional","affiliation":[{"name":"McGill University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2061-9519","authenticated-orcid":false,"given":"Jason M.","family":"Harley","sequence":"additional","affiliation":[{"name":"McGill University"},{"name":"Research Institute of the McGill University Health Centre"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2025,11,25]]},"reference":[{"key":"e_1_3_9_2_1","doi-asserted-by":"publisher","DOI":"10.3912\/OJIN.Vol23No02PPT39"},{"key":"e_1_3_9_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ecns.2017.09.008"},{"key":"e_1_3_9_4_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12912-025-03911-2"},{"key":"e_1_3_9_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.glmedi.2024.100051"},{"key":"e_1_3_9_6_1","doi-asserted-by":"publisher","DOI":"10.1111\/bjet.12989"},{"key":"e_1_3_9_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ssaho.2023.100532"},{"key":"e_1_3_9_8_1","doi-asserted-by":"publisher","DOI":"10.25304\/rlt.v26.2140"},{"key":"e_1_3_9_9_1","doi-asserted-by":"publisher","DOI":"10.1080\/01608061.2020.1746474"},{"key":"e_1_3_9_10_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11135-018-0700-2"},{"key":"e_1_3_9_11_1","doi-asserted-by":"publisher","DOI":"10.2196\/17823"},{"key":"e_1_3_9_12_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11133-019-9413-7"},{"key":"e_1_3_9_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ecns.2023.02.009"},{"key":"e_1_3_9_14_1","doi-asserted-by":"publisher","DOI":"10.1177\/15533506241238263"},{"issue":"3","key":"e_1_3_9_15_1","first-page":"114","article-title":"Determining what individual sus scores mean: Adding an adjective rating scale","volume":"4","author":"Bangor A.","year":"2009","unstructured":"Bangor A., Kortum P., Miller J. 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