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.

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.

2. 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 (α = 0.05, power = 0.90, Cohen's d = 0.80), 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).

Inclusion Criteria for the Study

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).

Exclusion criteria from the study:

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,
• 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.

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.