Nurse's RoleNCT06536361
Effect of Virtual Reality Simulation on Nursing Students' Knowledge and Skill Performance in Respiratory Physical Examination
A study testing Virtual Reality-Based Learning Tool and Traditional Small Group Training in people with Nurse's Role and Nurse-Patient Relations, run by Gazi University at 1 site in Turkey (Türkiye).
Trial summary
Aim To compare the effects of immersive virtual reality (I-VR) and peer-assisted small-group practice on nursing students' knowledge, skill performance, and performance time in respiratory system physical examination. Read more about this study
- Who is it for?
- Any ageHealthy volunteers can take part
- Conditions the study is for
- Nurse's Role, Nurse-Patient Relations, Exanimation
- What is being tested?
- Virtual Reality-Based Learning Tool and Traditional Small Group Training
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 76 participants
- Where
- 1 siteTurkey (Türkiye)
- Study dates
- 20 May 2024to 14 Jul 2024
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages Any age
- All sexes
- Healthy volunteers accepted
- Child, Adult, Older adult
Who may be able to join
- The student must:
- Voluntarily participate in the study,
- Not have difficulty understanding and speaking Turkish,
- Not have refractive errors that can affect depth perception, such as amblyopia (lazy eye), anisometropia (different refractive errors of the two eyes), and strabismus (crossed eyes) (Chan et al., 2023). (The individual's self-declaration was used to determine refractive errors. Individuals with these refractive errors were not included in the study because focal eye adjustment was required, but this adjustment was not supported on the Oculus 2 device. Individuals with other refractive errors were able to use the application with their glasses).
- Have a general academic achievement score between 2.00 and 4.00,
- Have taken the Health Assessment course for the first time in the 2023-2024 academic year and passed this course with at least a CC grade (CC indicates minimum success; grades below indicate conditional passing).
Who cannot join
- The student must:
- Have a high school, associate's degree, or bachelor's degree in a health-related field,
- Be retaking the Health Assessment course (code HEM 205).
- Criteria for removal from the study:
- The student must:
- Want to withdraw from the study,
Show all 12Show fewer
- Not attend the theoretical thoracic and pulmonary physical examination course,
- Not watch the thoracic and pulmonary physical examination demonstration videos,
- Not attend the practical lessons,
- Not fill out and/or incompletely fill out the data collection forms,
- Not use the virtual reality-based learning tool,
- Not participate in any stage of the skills assessment.
Trial locations and contacts
1 site in 1 country.
Turkey (Türkiye)1 site
Gazi University Nursing Faculty
Ankara, Ankara, 06500
About this study
Official title: Effect of Virtual Reality Simulation on Nursing Students' Knowledge and Skill Performance in Respiratory Physical Examination: A Randomized Controlled Trial
Aim To compare the effects of immersive virtual reality (I-VR) and peer-assisted small-group practice on nursing students' knowledge, skill performance, and performance time in respiratory system physical examination.
Background Respiratory system physical examination is a fundamental yet difficult-to-teach clinical skill in nursing education. Although I-VR has increasingly been used in physical examination teaching, existing studies have largely focused on limited examination components, most commonly inspection or auscultation. Evidence remains limited on how respiratory system physical examination can be taught as a holistic and structured clinical process within an I-VR environment.
Read more
Design A single-blind, parallel-group, randomized controlled trial with a pre-test/post-test design.
Methods Second-year nursing students from a university participated in the study. Participants were randomized to either the I-VR group or the peer-assisted small-group practice group. Data were collected using a knowledge test, a skill checklist, performance time measurement, and a technology acceptance questionnaire. Analyses included t-tests, chi-square tests, Pearson correlation analyses, and frequency analyses.
Results Knowledge and skill scores improved in both groups, but the increase was significantly greater in the I-VR group (p <0.001). Performance time was longer in the I-VR group (p =0.01). Students also rated the I-VR simulation highly in terms of feasibility and usability.
Conclusions A systematically designed I-VR approach may be a useful instructional option for teaching respiratory system physical examination as a holistic, multi-step clinical skill in undergraduate nursing education.
Read the detailed description
1.1. Objectives
The primary objective of this study was to compare the effects of immersive virtual reality (I-VR) and peer-assisted small-group practice on nursing students' respiratory system physical examination training in terms of knowledge, skill performance, and completion time. The secondary objective was to explore students' perceptions of the feasibility and usability of the I-VR simulation.
1.2. Hypotheses
H1: Post-intervention knowledge scores differ between the I-VR group and the peer-assisted small-group practice group.
H2: Post-intervention skill performance scores differ between the two groups. H3: Knowledge scores are positively associated with skill performance in both groups.
H4: Performance time differs between students trained with I-VR and those trained with peer-assisted small-group practice.
- Methods 2.1. Design
This assessor-blinded, parallel-group, pre-test/post-test randomized controlled trial was reported in line with the CONSORT 2025 statement.
2.2. Population and Sample
The study was conducted with nursing students enrolled at a university during the 2023-2024 academic year. Eligible participants were second-year students aged 18 years or older who had completed the Health Assessment course and agreed to participate voluntarily. Students with prior graduation from a health-related program, repeat course enrollment, or visual conditions affecting depth perception were excluded.
Sample size was estimated using G*Power 3.1.9.7, indicating a minimum of 68 participants. Allowing for possible attrition, the final target sample was set at 80 students, with 40 participants in each group.
2.3. Randomization
Among 83 eligible students, all were assigned identification numbers and anonymized by an independent statistician. Three students were randomly excluded to reach the target sample size. The remaining 80 participants were stratified by academic achievement and gender, then allocated to either the I-VR group or the peer-assisted small-group practice group using Random.org. Baseline testing confirmed group homogeneity for academic achievement and gender (p > 0.05).
2.4. Blinding
Randomization was conducted independently by computer. Participant blinding was maintained throughout the study. In addition, skill performance was evaluated by an independent blinded assessor, and statistical analyses were performed using coded group data. To reduce contamination, the two groups were trained separately and at different times, and participants were asked not to discuss the interventions until the study was completed.
2.5. Development of the I-VR Simulation
The I-VR scenario for respiratory system physical examination was developed in accordance with the INACSL Simulation Design Standards and Jeffries' Simulation Theory. The scenario focused on the preoperative assessment of a patient capable of basic self-care and was aligned with course objectives and the relevant literature.
Content validity was evaluated by 13 field experts, yielding item-level content validity index (I-CVI) values between 0.92 and 1.00 (Kendall's W = 0.40, p = 0.01). The simulation was created with an external software team experienced in Unity-based VR/XR systems (ClinVR). It functioned as a multi-user, controller-free system using hand tracking. Students entered a virtual examination room, completed preparatory steps, performed respiratory examination procedures, interpreted findings, communicated with the patient, and documented results.
Technical adequacy and content suitability were reviewed in multiple stages by technical experts and researchers, followed by pilot testing with 10 nursing students. Revisions were made based on feedback, and the final version required approximately 30-40 minutes per user, depending on familiarity with VR technology.
2.6. Data Collection Instruments 2.6.1. Descriptive Characteristics Form
This researcher-developed form included nine items covering demographic, academic, and technology-related characteristics. Expert review showed I-CVI values ranging from 0.92 to 1.00 (Kendall's W = 0.72, p = 0.00).
2.6.2. Knowledge Test
The knowledge test was developed by the researchers based on course objectives and the literature. Expert evaluation indicated I-CVI values between 0.92 and 1.00 (Kendall's W = 0.72, p = 0.00). A pilot study with 80 third-year nursing students was used for item analysis. One weak item was removed, and the final test contained 20 questions with varying difficulty levels. Scores ranged from 0 to 100, and the test duration was 30 minutes.
2.6.3. Skill Checklist
The skill checklist was developed from the literature to assess respiratory system physical examination performance within a standardized scenario. Expert review demonstrated I-CVI values between 0.92 and 1.00 (Kendall's W = 0.72, p = 0.00). Following pilot testing with 10 students, the final checklist included 48 steps and yielded scores from 0 to 96.
2.6.4. Technology Acceptance Questionnaire
The technology acceptance questionnaire was developed by the researchers based on the Technology Acceptance Model and related studies. It consisted of 27 items assessing feasibility (perceived ease of use) and usability (perceived usefulness) of the I-VR simulation using a five-point Likert scale. Expert evaluation showed I-CVI values between 0.84 and 1.00 (Kendall's W = 0.68, p = 0.00). Cronbach's alpha coefficients were 0.86 for feasibility and 0.84 for usability.
2.7. Procedures 2.7.1. Standardized Pre-Intervention Training
Before group allocation, all students received the same preliminary training, including two class hours of theoretical instruction on respiratory system anatomy, physiology, examination steps, and normal/abnormal findings, supported by demonstration videos.
2.7.2. Laboratory-Based Skills Training
One week later, all students participated in laboratory practice using high-fidelity simulators and training manikins. This ensured that all participants had the same baseline practical preparation before the interventions.
2.7.3. Pre-Test
One week before the intervention, participants completed the knowledge test and underwent a skill performance assessment with a standardized patient. Performance time was recorded by the independent evaluator. Students were informed that the assessment would not affect their course grades.
2.7.4. Pre-Briefing
Before the intervention, the peer-assisted small-group practice group received a 10-minute briefing on the session and procedures. The I-VR group received a 5-minute scenario briefing and a 5-minute VR orientation.
2.7.5. Implementation Phase 2.7.5.1. Immersive Virtual Reality Group
Each participant in the I-VR group was given one hour to complete the simulation individually. Students progressed at their own pace, repeated steps when necessary, and performed the respiratory system examination in a virtual environment. The simulation included preparation, patient interaction, inspection, palpation, percussion, auscultation, interpretation of findings, and documentation. Participants also completed self-checklists during the process and were allowed to take breaks if needed.
2.7.5.2. Peer-Assisted Small-Group Practice Group
Participants in this group were organized into groups of eight and worked in peer pairs. Based on peer-assisted learning principles, each student alternated between patient and nurse roles within standardized scenarios. Each pair had one hour to practice, repeat procedures, and reinforce learning through peer observation and structured feedback. Researchers only observed the process to maintain safety, privacy, and time control. Written informed consent was obtained, and physical contact boundaries were clarified beforehand.
2.8. Debriefing
After the interventions, separate debriefing sessions were conducted by simulation-trained researchers using the PEARLS framework. Students reflected on their feelings, described the scenario, evaluated their performance, and identified key points. Each session lasted approximately 25-30 minutes. After debriefing, students in the I-VR group completed the technology acceptance questionnaire.
2.9. Post-Test
One week after the intervention, all participants repeated the knowledge test and underwent a second skill performance assessment with a standardized patient. Performance time was again recorded by the evaluator.
2.10. Data Analysis
Data were analyzed using IBM SPSS Statistics 23. Descriptive statistics included frequency, percentage, mean, and standard deviation. Normality was assessed using skewness, kurtosis, and histogram distributions. Independent samples t-tests were used for between-group comparisons, paired samples t-tests for within-group comparisons, chi-square tests for categorical variables, and Pearson correlation analysis to examine relationships between continuous variables. Statistical significance was set at p < 0.05 with a 95% confidence interval.
2.11. Ethical Approval Statement
Ethical approval was obtained from the relevant university ethics committee (02 August 2023; E-77082166-302.08.01-711267).
- Conditions
- Nurse's Role, Nurse-Patient Relations, Exanimation
- Being tested
- Virtual Reality-Based Learning Tool, Traditional Small Group Training
- Keywords
- Clinical Skills, Educational Technology, Immersive Virtual Reality, Respiratory System, Physical Examination, Nursing Education
- Medical subject headings
- Coma
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Virtual Reality-Based Learning ToolOther
The intervention involves the use of a virtual reality-based learning tool to teach thorax and lung physical examination skills. The tool uses Oculus Meta Quest 2 VR headset to provide immersive simulation experiences. The VR tool includes high-quality graphics and interactive scenarios to facilitate skill development.
Traditional Small Group TrainingOther
The intervention involves traditional small group training conducted in the Nursing Principles Skills Laboratory. This training includes hands-on practice with physical examination techniques using simulation mannequins and feedback from instructors. The approach is designed to provide practical experience without the use of virtual reality technology.
| Study group | Role | What they receive |
|---|---|---|
| Immersive Virtual Reality Group | Experimental | Following the orientation, each participant was allocated a fixed one-hour period to complete the I-VR simulation. During this session, participants progressed through the application at their own pace, could repeat steps as needed, and performed the respiratory system physical examination holistically in the virtual environment. Within the simulation, participants prepared the necessary materials, communicated with the virtual patient, performed inspection, carried out superficial palpation, chest expansion, and thoracic vibration assessments, conducted indirect percussion, and performed auscultation. They also evaluated normal and abnormal respiratory and percussion sounds, informed the patient about the examination findings, and recorded the assessment data in the system. In addition, they completed self-checklist forms after each examination step. Participants were allowed to remove the headset and take breaks whenever needed throughout the training session. Receives: Other: Virtual Reality-Based Learning Tool |
| Peer-Assisted Small-Group Practice Group | Active comparator | After the pre-briefing, participants were divided into groups of eight, with four peer pairs formed within each group. The implementation was conducted according to peer-assisted learning principles and aligned with the peer practice approach (Lam et al., 2024). During the session, each participant assumed two roles: (i) a patient admitted to the surgical ward for an operation and capable of independent self-care, and (ii) a clinical nurse responsible for performing a preoperative respiratory system examination and managing postoperative follow-up. These roles were alternated within standardized scenarios. Each pair was given a total of one hour for the activity, allowing students to proceed at their own pace and repeat the examination as needed. Throughout the sessions, participants reinforced their learning through mutual observation, structured peer feedback, and role switching. Researchers remained in an observational role without direct intervention in order to ensure safety, pri Receives: Other: Traditional Small Group Training |
What is being measured
The primary outcome is the main question the study is designed to answer.
Knowledge Test
The knowledge test was created by the researchers to evaluate participants' theoretical understanding of the physical examination of the respiratory system, aligned with the course content and learning objectives (Choi et al., 2021; Des Jardins \& Burton, 2023; Fennessey \& Wittmann-Price, 2011; Jarvis, 2023; Narula et al., 2018; Reyes et al., 2024; Tybjerg, 2023). According to expert assessments, the I-CVI scores for each item ranged from 0.92 to 1.00, with an inter-rater agreement of Kendall's W =0.72 and p =0.00 (Davis, 1989).
To assess the suitability of the knowledge test items, a pilot study was conducted with a group of 80 third-year undergraduate nursing students who had previously completed the Health Assessment course. After the pilot, the Item Difficulty Index (IDI) and Item Discrimination Index (IDIsc) were calculated for each question. One question with an IDI of 0.11 and an IDIsc of 0.15 was removed from the test. The final version of the knowledge test was designed to ens
Measured: Skill levels will be assessed seven days before the intervention (pre-test) and seven days after the intervention (post-test).
Skill Checklist
The skill checklist was created by the researchers, based on relevant literature, to assess participants' respiratory system physical examination skills (Choi et al., 2021; Des Jardins \& Burton, 2023; Fennessey \& Wittmann-Price, 2011; Jarvis, 2023; Narula et al., 2018; Reyes et al., 2024; Tybjerg, 2023). The form was organized around a scenario where the student performs a respiratory system physical exam on a conscious patient who can meet basic needs independently in a single-patient examination room. According to expert evaluations, the I-CVI scores for individual items ranged from 0.92 to 1.00, with inter-rater agreement of Kendall's W =0.72 and p =0.00 (Davis, 1989).
The pilot version of the form was tested with a group of ten third-year nursing students who had previously completed the Health Assessment course. Based on their feedback, the final version of the checklist included 48 procedural steps, with a total possible score ranging from 0 to 96.
Measured: Knowledge levels will be evaluated seven days prior to the intervention (pre-test) and seven days following the intervention (post-test)
Secondary outcomes (1)
Technology Acceptance Questionnaire
The researchers created the technology acceptance questionnaire based on the Technology Acceptance Model (TAM) and relevant literature (Bıyık Bayram \& Çalışkan, 2019; Farra et al., 2015; Nilashi \& Abumalloh, 2025). The survey included 27 items assessing the feasibility (Items 1-12; perceived ease of use) and usability (Items 13-27; perceived usefulness) of the I-VR simulation tool. Participants indicated their opinions on the I-VR simulation using a five-point Likert scale. According to expert evaluations, the I-CVI values for individual items ranged from 0.84 to 1.00, with inter-rater agreement of Kendall's W =0.68 and p =0.00 (Davis, 1989). Internal consistency reliability analysis produced a Cronbach's α of 0.86 for the feasibility subdimension and a Cronbach's α of 0.84 for the usability subdimension.
Measured: Seven days after the intervention
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted2 Aug 2024
- Study start20 May 2024
- Primary completion14 Jun 2024
- Study completion14 Jul 2024
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (18)Papers the sponsor has linked to this study.
- Other trials for Nurse's RoleStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Other
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Model description
- An assessor-blinded, parallel-group, pre-test/post-test randomized controlled trial.
- Masking
- Single blind
- Who is masked
- Outcomes assessor
- Enrolment
- 76 participants (actual)
Sponsor and investigators
- Lead sponsor
- Gazi University
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Nurcan Çalışkan, Gazi University
- Investigators
- Dr. Aslı A YILMAZ, PhD, Study director, Gazi University Nursing Faculty
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT06536361
- Sponsor's protocol ID
- 2023-915
- Other IDs
- 2024-9040, TDK-2024-9040
- Status last verified
- Sep 2026
- First submitted
- 23 Jul 2024
- Last updated
- 10 Sep 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Chan AW, Tetzlaff JM, Gotzsche PC, Altman DG, Mann H, Berlin JA, Dickersin K, Hrobjartsson A, Schulz KF, Parulekar WR, Krleza-Jeric K, Laupacis A, Moher D. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ. 2013 Jan 8;346:e7586. doi: 10.1136/bmj.e7586.
PubMed 23303884Padilha JM, Machado PP, Ribeiro A, Ramos J, Costa P. Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial. J Med Internet Res. 2019 Mar 18;21(3):e11529. doi: 10.2196/11529.
PubMed 30882355Bayram SB, Caliskan N. Effect of a game-based virtual reality phone application on tracheostomy care education for nursing students: A randomized controlled trial. Nurse Educ Today. 2019 Aug;79:25-31. doi: 10.1016/j.nedt.2019.05.010. Epub 2019 May 9.
PubMed 31102793Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P; CONSORT NPT Group. CONSORT Statement for Randomized Trials of Nonpharmacologic Treatments: A 2017 Update and a CONSORT Extension for Nonpharmacologic Trial Abstracts. Ann Intern Med. 2017 Jul 4;167(1):40-47. doi: 10.7326/M17-0046. Epub 2017 Jun 20.
PubMed 28630973Akın, B. ve Koçoğlu, D. Randomize Kontrollü Deneyler. Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi. 2017 4(1): 73-92.
Han SG, Kim YD, Kong TY, Cho J. Virtual reality-based neurological examination teaching tool(VRNET) versus standardized patient in teaching neurological examinations for the medical students: a randomized, single-blind study. BMC Med Educ. 2021 Sep 15;21(1):493. doi: 10.1186/s12909-021-02920-4.
PubMed 34526004Yang TY, Huang CH, An C, Weng LC. Construction and evaluation of a 360 degrees panoramic video on the physical examination of nursing students. Nurse Educ Pract. 2022 Aug;63:103372. doi: 10.1016/j.nepr.2022.103372. Epub 2022 May 24.
PubMed 35644047Cheung VYT, Tang YM, Chan KKL. Medical students' perception of the application of a virtual reality training model to acquire vaginal examination skills. Int J Gynaecol Obstet. 2023 Jun;161(3):827-832. doi: 10.1002/ijgo.14670. Epub 2023 Jan 31.
PubMed 36637241Hogan-Quigley, B., Palm, M. L., Bickley, L. S. 2012. Bates' nursing guide to physical examination and history taking. Philadelphia, PA: Lippincott Williams & Wilkins.
Hogan-Quigley, B., Palm, M. L., Bickley, L. S. 2017. ''Bates' Nursing Guide to Physical Examination and History Taking. 2nd edtion'', Philadelphia: Wolters Kluwer, pp 292-299.
Weber, J. R., Kelley, J. H. 2014. ''Assessing Thorax and Lung in Health Assessment in Nursing''. 5th edition Lippincott Williams & Wilkins. pp 369-390
Chaplen, R. 2019. ''Thorax and Lung Assessment içinde Nursing health assessment: A best practice approach''. Editör Jensen, S. 3rd Edition, Lippincott Williams & Wilkins. pp 668-682
Görgülü, R. S. 2014. Hemşireler için fiziksel muayene yöntemleri. 1. Baskı (pp. 79-94). İstanbul Medikal Yayıncılık.
Benzaghta, M. A., Elwalda, A., Mousa, M., Erkan, I., & Rahman, M. (2021). SWOT analysis applications: An integrative literature review. Journal of Global Business Insights, 6(1), 55-73. https://doi.org/10.5038/2640-6489.6.1.1148
May, R., Tyndall, I., McTiernan, A., Roderique-Davies, G., & McLoughlin, S. (2022). The impact of the SMART program on cognitive and academic skills: a systematic review and meta-analysis. British Journal of Educational Technology, 53(5), 1244-1261. Advance online publication. https://doi.org/10.1111/bjet.13192
Study at a glance
From the registry record, last updated by the sponsor on 10 Sep 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Effect of Virtual Reality Simulation on Nursing Students' Knowledge and Skill Performance in Respiratory Physical Examination: A Randomized Controlled Trial
- ClinicalTrials.gov ID
- NCT06536361
- Acronym / sponsor ID
- 2023-915
- Conditions
- Nurse's Role, Nurse-Patient Relations, Exanimation
- Keywords
- Clinical Skills, Educational Technology, Immersive Virtual Reality, Respiratory System, Physical Examination, Nursing Education
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 76 participants (actual)
- Lead sponsor
- Gazi UniversityUniversity, hospital or other
- Study start
- 20 May 2024 (actual)
- Primary completion
- 14 Jun 2024 (actual)
- Study completion
- 14 Jul 2024 (actual)
- First posted
- 2 Aug 2024 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Aim To compare the effects of immersive virtual reality (I-VR) and peer-assisted small-group practice on nursing students' knowledge, skill performance, and performance time in respiratory system physical examination.
Background Respiratory system physical examination is a fundamental yet difficult-to-teach clinical skill in nursing education. Although I-VR has increasingly been used in physical examination teaching, existing studies have largely focused on limited examination components, most commonly inspection or auscultation. Evidence remains limited on how respiratory system physical examination can be taught as a holistic and structured clinical process within an I-VR environment.
Design A single-blind, parallel-group, randomized controlled trial with a pre-test/post-test design.
Methods Second-year nursing students from a university participated in the study. Participants were randomized to either the I-VR group or the peer-assisted small-group practice group. Data were collected using a knowledge test, a skill checklist, performance time measurement, and a technology acceptance questionnaire. Analyses included t-tests, chi-square tests, Pearson correlation analyses, and frequency analyses.
Results Knowledge and skill scores improved in both groups, but the increase was significantly greater in the I-VR group (p <0.001). Performance time was longer in the I-VR group (p =0.01). Students also rated the I-VR simulation highly in terms of feasibility and usability.
Conclusions A systematically designed I-VR approach may be a useful instructional option for teaching respiratory system physical examination as a holistic, multi-step clinical skill in undergraduate nursing education.
Detailed description
1.1. Objectives
The primary objective of this study was to compare the effects of immersive virtual reality (I-VR) and peer-assisted small-group practice on nursing students' respiratory system physical examination training in terms of knowledge, skill performance, and completion time. The secondary objective was to explore students' perceptions of the feasibility and usability of the I-VR simulation.
1.2. Hypotheses
H1: Post-intervention knowledge scores differ between the I-VR group and the peer-assisted small-group practice group.
H2: Post-intervention skill performance scores differ between the two groups. H3: Knowledge scores are positively associated with skill performance in both groups.
H4: Performance time differs between students trained with I-VR and those trained with peer-assisted small-group practice.
- Methods 2.1. Design
This assessor-blinded, parallel-group, pre-test/post-test randomized controlled trial was reported in line with the CONSORT 2025 statement.
2.2. Population and Sample
The study was conducted with nursing students enrolled at a university during the 2023-2024 academic year. Eligible participants were second-year students aged 18 years or older who had completed the Health Assessment course and agreed to participate voluntarily. Students with prior graduation from a health-related program, repeat course enrollment, or visual conditions affecting depth perception were excluded.
Sample size was estimated using G*Power 3.1.9.7, indicating a minimum of 68 participants. Allowing for possible attrition, the final target sample was set at 80 students, with 40 participants in each group.
2.3. Randomization
Among 83 eligible students, all were assigned identification numbers and anonymized by an independent statistician. Three students were randomly excluded to reach the target sample size. The remaining 80 participants were stratified by academic achievement and gender, then allocated to either the I-VR group or the peer-assisted small-group practice group using Random.org. Baseline testing confirmed group homogeneity for academic achievement and gender (p > 0.05).
2.4. Blinding
Randomization was conducted independently by computer. Participant blinding was maintained throughout the study. In addition, skill performance was evaluated by an independent blinded assessor, and statistical analyses were performed using coded group data. To reduce contamination, the two groups were trained separately and at different times, and participants were asked not to discuss the interventions until the study was completed.
2.5. Development of the I-VR Simulation
The I-VR scenario for respiratory system physical examination was developed in accordance with the INACSL Simulation Design Standards and Jeffries' Simulation Theory. The scenario focused on the preoperative assessment of a patient capable of basic self-care and was aligned with course objectives and the relevant literature.
Content validity was evaluated by 13 field experts, yielding item-level content validity index (I-CVI) values between 0.92 and 1.00 (Kendall's W = 0.40, p = 0.01). The simulation was created with an external software team experienced in Unity-based VR/XR systems (ClinVR). It functioned as a multi-user, controller-free system using hand tracking. Students entered a virtual examination room, completed preparatory steps, performed respiratory examination procedures, interpreted findings, communicated with the patient, and documented results.
Technical adequacy and content suitability were reviewed in multiple stages by technical experts and researchers, followed by pilot testing with 10 nursing students. Revisions were made based on feedback, and the final version required approximately 30-40 minutes per user, depending on familiarity with VR technology.
2.6. Data Collection Instruments 2.6.1. Descriptive Characteristics Form
This researcher-developed form included nine items covering demographic, academic, and technology-related characteristics. Expert review showed I-CVI values ranging from 0.92 to 1.00 (Kendall's W = 0.72, p = 0.00).
2.6.2. Knowledge Test
The knowledge test was developed by the researchers based on course objectives and the literature. Expert evaluation indicated I-CVI values between 0.92 and 1.00 (Kendall's W = 0.72, p = 0.00). A pilot study with 80 third-year nursing students was used for item analysis. One weak item was removed, and the final test contained 20 questions with varying difficulty levels. Scores ranged from 0 to 100, and the test duration was 30 minutes.
2.6.3. Skill Checklist
The skill checklist was developed from the literature to assess respiratory system physical examination performance within a standardized scenario. Expert review demonstrated I-CVI values between 0.92 and 1.00 (Kendall's W = 0.72, p = 0.00). Following pilot testing with 10 students, the final checklist included 48 steps and yielded scores from 0 to 96.
2.6.4. Technology Acceptance Questionnaire
The technology acceptance questionnaire was developed by the researchers based on the Technology Acceptance Model and related studies. It consisted of 27 items assessing feasibility (perceived ease of use) and usability (perceived usefulness) of the I-VR simulation using a five-point Likert scale. Expert evaluation showed I-CVI values between 0.84 and 1.00 (Kendall's W = 0.68, p = 0.00). Cronbach's alpha coefficients were 0.86 for feasibility and 0.84 for usability.
2.7. Procedures 2.7.1. Standardized Pre-Intervention Training
Before group allocation, all students received the same preliminary training, including two class hours of theoretical instruction on respiratory system anatomy, physiology, examination steps, and normal/abnormal findings, supported by demonstration videos.
2.7.2. Laboratory-Based Skills Training
One week later, all students participated in laboratory practice using high-fidelity simulators and training manikins. This ensured that all participants had the same baseline practical preparation before the interventions.
2.7.3. Pre-Test
One week before the intervention, participants completed the knowledge test and underwent a skill performance assessment with a standardized patient. Performance time was recorded by the independent evaluator. Students were informed that the assessment would not affect their course grades.
2.7.4. Pre-Briefing
Before the intervention, the peer-assisted small-group practice group received a 10-minute briefing on the session and procedures. The I-VR group received a 5-minute scenario briefing and a 5-minute VR orientation.
2.7.5. Implementation Phase 2.7.5.1. Immersive Virtual Reality Group
Each participant in the I-VR group was given one hour to complete the simulation individually. Students progressed at their own pace, repeated steps when necessary, and performed the respiratory system examination in a virtual environment. The simulation included preparation, patient interaction, inspection, palpation, percussion, auscultation, interpretation of findings, and documentation. Participants also completed self-checklists during the process and were allowed to take breaks if needed.
2.7.5.2. Peer-Assisted Small-Group Practice Group
Participants in this group were organized into groups of eight and worked in peer pairs. Based on peer-assisted learning principles, each student alternated between patient and nurse roles within standardized scenarios. Each pair had one hour to practice, repeat procedures, and reinforce learning through peer observation and structured feedback. Researchers only observed the process to maintain safety, privacy, and time control. Written informed consent was obtained, and physical contact boundaries were clarified beforehand.
2.8. Debriefing
After the interventions, separate debriefing sessions were conducted by simulation-trained researchers using the PEARLS framework. Students reflected on their feelings, described the scenario, evaluated their performance, and identified key points. Each session lasted approximately 25-30 minutes. After debriefing, students in the I-VR group completed the technology acceptance questionnaire.
2.9. Post-Test
One week after the intervention, all participants repeated the knowledge test and underwent a second skill performance assessment with a standardized patient. Performance time was again recorded by the evaluator.
2.10. Data Analysis
Data were analyzed using IBM SPSS Statistics 23. Descriptive statistics included frequency, percentage, mean, and standard deviation. Normality was assessed using skewness, kurtosis, and histogram distributions. Independent samples t-tests were used for between-group comparisons, paired samples t-tests for within-group comparisons, chi-square tests for categorical variables, and Pearson correlation analysis to examine relationships between continuous variables. Statistical significance was set at p < 0.05 with a 95% confidence interval.
2.11. Ethical Approval Statement
Ethical approval was obtained from the relevant university ethics committee (02 August 2023; E-77082166-302.08.01-711267).
Study design
- Primary purpose
- Other
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind (outcomes assessor)
- Number of arms
- 2
- Model description
- An assessor-blinded, parallel-group, pre-test/post-test randomized controlled trial.
| Arm | Type | Receives |
|---|---|---|
| Immersive Virtual Reality Group | Experimental | Other: Virtual Reality-Based Learning ToolFollowing the orientation, each participant was allocated a fixed one-hour period to complete the I-VR simulation. During this session, participants progressed through the application at their own pace, could repeat steps as needed, and performed the respiratory system physical examination holistically in the virtual environment. Within the simulation, participants prepared the necessary materials, communicated with the virtual patient, performed inspection, carried out superficial palpation, chest expansion, and thoracic vibration assessments, conducted indirect percussion, and performed auscultation. They also evaluated normal and abnormal respiratory and percussion sounds, informed the patient about the examination findings, and recorded the assessment data in the system. In addition, they completed self-checklist forms after each examination step. Participants were allowed to remove the headset and take breaks whenever needed throughout the training session. |
| Peer-Assisted Small-Group Practice Group | Active comparator | Other: Traditional Small Group TrainingAfter the pre-briefing, participants were divided into groups of eight, with four peer pairs formed within each group. The implementation was conducted according to peer-assisted learning principles and aligned with the peer practice approach (Lam et al., 2024). During the session, each participant assumed two roles: (i) a patient admitted to the surgical ward for an operation and capable of independent self-care, and (ii) a clinical nurse responsible for performing a preoperative respiratory system examination and managing postoperative follow-up. These roles were alternated within standardized scenarios. Each pair was given a total of one hour for the activity, allowing students to proceed at their own pace and repeat the examination as needed. Throughout the sessions, participants reinforced their learning through mutual observation, structured peer feedback, and role switching. Researchers remained in an observational role without direct intervention in order to ensure safety, pri |
Who may qualify
- Sex
- All
- Healthy volunteers
- Accepted
- Age groups
- Child, Adult, Older adult
Key inclusion criteria (6 listed)
- Voluntarily participate in the study,
- Not have difficulty understanding and speaking Turkish,
- Not have refractive errors that can affect depth perception, such as amblyopia (lazy eye), anisometropia (different refractive errors of the two eyes), and strabismus (crossed eyes) (Chan et al., 2023). (The individual's self-declaration was used to determine refractive errors. Individuals with these refractive errors were not included in the study because focal eye adjustment was required, but this adjustment was not supported on the Oculus 2 device. Individuals with other refractive errors were able to use the application with their glasses).
- Have a general academic achievement score between 2.00 and 4.00,
- Have taken the Health Assessment course for the first time in the 2023-2024 academic year and passed this course with at least a CC grade (CC indicates minimum success; grades below indicate conditional passing).
Key exclusion criteria (12 listed)
- Have a high school, associate's degree, or bachelor's degree in a health-related field,
- Be retaking the Health Assessment course (code HEM 205).
- Want to withdraw from the study,
- Not attend the theoretical thoracic and pulmonary physical examination course,
- Not watch the thoracic and pulmonary physical examination demonstration videos,
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Virtual Reality-Based Learning ToolThe intervention involves the use of a virtual reality-based learning tool to teach thorax and lung physical examination skills. The tool uses Oculus Meta Quest 2 VR headset to provide immersive simulation experiences. The VR tool includes high-quality graphics and interactive scenarios to facilitate skill development. | Other | Immersive Virtual Reality Group |
| Traditional Small Group TrainingThe intervention involves traditional small group training conducted in the Nursing Principles Skills Laboratory. This training includes hands-on practice with physical examination techniques using simulation mannequins and feedback from instructors. The approach is designed to provide practical experience without the use of virtual reality technology. | Other | Peer-Assisted Small-Group Practice Group |
Primary outcome
Knowledge Test
Time frame: Skill levels will be assessed seven days before the intervention (pre-test) and seven days after the intervention (post-test).
The knowledge test was created by the researchers to evaluate participants' theoretical understanding of the physical examination of the respiratory system, aligned with the course content and learning objectives (Choi et al., 2021; Des Jardins \& Burton, 2023; Fennessey \& Wittmann-Price, 2011; Jarvis, 2023; Narula et al., 2018; Reyes et al., 2024; Tybjerg, 2023). According to expert assessments, the I-CVI scores for each item ranged from 0.92 to 1.00, with an inter-rater agreement of Kendall's W =0.72 and p =0.00 (Davis, 1989). To assess the suitability of the knowledge test items, a pilot study was conducted with a group of 80 third-year undergraduate nursing students who had previously completed the Health Assessment course. After the pilot, the Item Difficulty Index (IDI) and Item Discrimination Index (IDIsc) were calculated for each question. One question with an IDI of 0.11 and an IDIsc of 0.15 was removed from the test. The final version of the knowledge test was designed to ens
Skill Checklist
Time frame: Knowledge levels will be evaluated seven days prior to the intervention (pre-test) and seven days following the intervention (post-test)
The skill checklist was created by the researchers, based on relevant literature, to assess participants' respiratory system physical examination skills (Choi et al., 2021; Des Jardins \& Burton, 2023; Fennessey \& Wittmann-Price, 2011; Jarvis, 2023; Narula et al., 2018; Reyes et al., 2024; Tybjerg, 2023). The form was organized around a scenario where the student performs a respiratory system physical exam on a conscious patient who can meet basic needs independently in a single-patient examination room. According to expert evaluations, the I-CVI scores for individual items ranged from 0.92 to 1.00, with inter-rater agreement of Kendall's W =0.72 and p =0.00 (Davis, 1989). The pilot version of the form was tested with a group of ten third-year nursing students who had previously completed the Health Assessment course. Based on their feedback, the final version of the checklist included 48 procedural steps, with a total possible score ranging from 0 to 96.
1 secondary outcome
Technology Acceptance Questionnaire
Time frame: Seven days after the intervention
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 10 Sep 2026.
- Background: PubMed 23303884Chan AW, Tetzlaff JM, Gotzsche PC, Altman DG, Mann H, Berlin JA, Dickersin K, Hrobjartsson A, Schulz KF, Parulekar WR, Krleza-Jeric K, Laupacis A, Moher D. SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials. BMJ. 2013 Jan 8;346:e7586. doi: 10.1136/bmj.e7586.
- Background: PubMed 30882355Padilha JM, Machado PP, Ribeiro A, Ramos J, Costa P. Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial. J Med Internet Res. 2019 Mar 18;21(3):e11529. doi: 10.2196/11529.
- Background: PubMed 31102793Bayram SB, Caliskan N. Effect of a game-based virtual reality phone application on tracheostomy care education for nursing students: A randomized controlled trial. Nurse Educ Today. 2019 Aug;79:25-31. doi: 10.1016/j.nedt.2019.05.010. Epub 2019 May 9.
- Background: PubMed 28630973Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P; CONSORT NPT Group. CONSORT Statement for Randomized Trials of Nonpharmacologic Treatments: A 2017 Update and a CONSORT Extension for Nonpharmacologic Trial Abstracts. Ann Intern Med. 2017 Jul 4;167(1):40-47. doi: 10.7326/M17-0046. Epub 2017 Jun 20.
- BackgroundAkın, B. ve Koçoğlu, D. Randomize Kontrollü Deneyler. Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi. 2017 4(1): 73-92.
- Background: PubMed 34526004Han SG, Kim YD, Kong TY, Cho J. Virtual reality-based neurological examination teaching tool(VRNET) versus standardized patient in teaching neurological examinations for the medical students: a randomized, single-blind study. BMC Med Educ. 2021 Sep 15;21(1):493. doi: 10.1186/s12909-021-02920-4.
- Background: PubMed 35644047Yang TY, Huang CH, An C, Weng LC. Construction and evaluation of a 360 degrees panoramic video on the physical examination of nursing students. Nurse Educ Pract. 2022 Aug;63:103372. doi: 10.1016/j.nepr.2022.103372. Epub 2022 May 24.
- Background: PubMed 36637241Cheung VYT, Tang YM, Chan KKL. Medical students' perception of the application of a virtual reality training model to acquire vaginal examination skills. Int J Gynaecol Obstet. 2023 Jun;161(3):827-832. doi: 10.1002/ijgo.14670. Epub 2023 Jan 31.
- BackgroundHogan-Quigley, B., Palm, M. L., Bickley, L. S. 2012. Bates' nursing guide to physical examination and history taking. Philadelphia, PA: Lippincott Williams & Wilkins.
- BackgroundHogan-Quigley, B., Palm, M. L., Bickley, L. S. 2017. ''Bates' Nursing Guide to Physical Examination and History Taking. 2nd edtion'', Philadelphia: Wolters Kluwer, pp 292-299.
- BackgroundWeber, J. R., Kelley, J. H. 2014. ''Assessing Thorax and Lung in Health Assessment in Nursing''. 5th edition Lippincott Williams & Wilkins. pp 369-390
- BackgroundChaplen, R. 2019. ''Thorax and Lung Assessment içinde Nursing health assessment: A best practice approach''. Editör Jensen, S. 3rd Edition, Lippincott Williams & Wilkins. pp 668-682
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Dr. Aslı A YILMAZ, PhD study director
Gazi University Nursing Faculty
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Virtual Reality-Based Learning Tool and Traditional Small Group Training in people with Nurse's Role and Nurse-Patient Relations, run by Gazi University at 1 site in Turkey (Türkiye).
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 6 inclusion and 12 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 10 Sep 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Turkey (Türkiye). Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Knowledge Test (time frame: Skill levels will be assessed seven days before the intervention (pre-test) and seven days after the intervention (post-test).). The study lists 2 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT06536361, which also lists 18 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 10 Sep 2026.