Effects of HMD-Based Virtual Reality Simulation on Enema Administration Skills in Nursing Students

Study Design and Setting

This study was designed as a two-arm, parallel-group randomized controlled trial to evaluate the effects of head-mounted display (HMD)-based immersive virtual reality (VR) simulation on enema administration skills, learning satisfaction, and self-confidence among undergraduate nursing students. The study was conducted at the Nursing Department of a public university in Türkiye during the spring semester of the 2025-2026 academic year.

Participants and Sample Size

The study population consisted of first-year nursing students enrolled in the Fundamentals of Nursing course. The required sample size was calculated using G*Power 3.1.9, with a significance level of 0.05, an effect size of 0.75, and a statistical power of 90%. The minimum required sample size was 62 participants. Considering potential attrition, the sample size was increased by approximately 10%, resulting in 68 participants.

Students were eligible if they were taking the Fundamentals of Nursing course for the first time and voluntarily agreed to participate. Students who had graduated from a health-related vocational high school or an associate or undergraduate health sciences program, or who had previously received training in enema administration, were excluded.

Randomization and Masking

A total of 68 eligible nursing students were randomly assigned to the intervention group (n=34) or control group (n=34) using a card-drawing method. Due to the nature of the educational interventions, participants, instructors, and the outcome assessor were not blinded to group allocation. For statistical analysis, the groups were coded as A and B.

Educational Interventions

All participants received standardized theoretical and practical training in cleansing enema administration. The theoretical session lasted approximately 30-40 minutes and included a PowerPoint presentation, questions and answers, and discussion of indications, procedural steps, and safety considerations. Participants subsequently watched a three-minute instructional video and observed an instructor-led demonstration using a low-fidelity patient mannequin.

Following the demonstration, all participants individually performed the enema administration procedure on the mannequin. Their performance was evaluated using a standardized skills checklist before the VR intervention.

In addition to standard training, participants in the intervention group completed one HMD-based immersive VR simulation session lasting approximately 10-15 minutes under the guidance of a researcher with expertise in information technology. The simulation provided an interactive virtual environment for practicing and reinforcing the procedural steps of enema administration.

Participants in the control group received standard theoretical and mannequin-based practical training without additional VR simulation during the study period.

Outcome Assessment and Follow-Up

The primary outcome was enema administration skill performance, assessed using a 30-item skills checklist developed from established nursing procedure references. Each item was scored as performed (2 points), partially performed (1 point), or not performed (0 points), yielding a total score ranging from 0 to 60. Higher scores indicated better skill performance.

Secondary outcomes included learning satisfaction and self-confidence, assessed using the Student Satisfaction and Self-Confidence in Learning Scale. The 12-item scale consists of two subscales: learning satisfaction (5 items) and self-confidence (7 items), rated on a five-point Likert scale.

Skill performance was initially assessed after standard training and before the VR intervention. Learning satisfaction and self-confidence were first assessed after completion of the assigned educational interventions.

One month after the educational interventions, participants in both groups performed the enema administration procedure again on a low-fidelity patient mannequin. Skill performance, learning satisfaction, and self-confidence were reassessed using the same instruments.

After all follow-up assessments and data collection procedures had been completed, participants in the control group were also offered the opportunity to experience the HMD-based VR simulation to ensure educational equity. This delayed VR training was not included in the comparative outcome analyses.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics version 25.0. Descriptive statistics were used to summarize participant characteristics and outcome measures. Distributional assumptions were assessed using the Shapiro-Wilk test and graphical methods. Depending on the characteristics of the data, chi-square tests, Fisher's exact tests, Mann-Whitney U tests, and paired-samples t-tests were used.

Analysis of covariance (ANCOVA) was performed to compare follow-up skill performance between the groups while adjusting for initial skill scores. Statistical significance was set at p<0.05.

Ethical Considerations

The study was approved by the Giresun University Medical Research Ethics Committee (April 15, 2026; Approval No. 04). Institutional permission was obtained, and written informed consent was provided by all participants before enrollment. The study was conducted in accordance with the principles of the Declaration of Helsinki.