The goal of this clinical trial is to compare the effects of immersive virtual reality (VR) simulation and computer-based simulation (CBS) with traditional laboratory practice on electrocardiogram (ECG) knowledge, practical skills, and motivation in first-year undergraduate nursing students. The main questions it aims to answer are:

Does VR simulation improve ECG knowledge scores more than CBS and traditional laboratory practice? Does VR simulation improve ECG practical skill scores more than CBS and traditional laboratory practice? Does VR simulation improve learner motivation more than CBS and traditional laboratory practice?

Researchers will compare three groups - VR simulation, computer-based simulation, and traditional laboratory practice - to see which method is most effective for ECG education outcomes.

Participants will:

Attend a standardized 90-minute ECG lecture before the intervention Be randomly assigned to one of three groups: VR simulation, computer-based simulation, or traditional laboratory practice Complete a 90-minute educational intervention according to their assigned group Complete knowledge, skills, and motivation assessments before and one week after the intervention

This three-arm randomized controlled trial was conducted at Beykent University, Istanbul, Turkey. The study population consisted of first-year undergraduate nursing students. Inclusion criteria were: voluntary participation, first-year enrollment, no prior ECG simulation training, and no visual impairment.

Sample size was calculated using G*Power 3.1.9.4 based on a medium effect size (f=0.40), α=0.05, and 80% power, yielding a minimum of 66 participants (22 per group). To account for potential attrition, 90 students were enrolled and randomly allocated to three groups: immersive virtual reality (VR) simulation (n=30), computer-based simulation (CBS) (n=30), and traditional laboratory practice (n=30).

All participants completed baseline assessments and attended a standardized 90-minute ECG lecture delivered by the same instructor. One week later, participants were randomly assigned to their intervention groups. The VR group performed three-dimensional ECG scenarios using Oculus Quest 2 (128GB) all-in-one headsets with integrated touch controllers, enabling full immersion and hand-tracking interactions simulating real ECG procedural movements. The CBS group completed interactive ECG modules developed with technical support from computer engineering specialists, covering ECG physiology, rhythm recognition scenarios, and nursing care protocols. The control group practiced on manikins with verbal instruction. All interventions lasted 90 minutes. Post-intervention assessments were conducted one week after the intervention.

Outcomes were assessed using three instruments. The ECG Knowledge Test is a researcher-developed multiple-choice test measuring ECG physiology, rhythm recognition, and interpretation, with content validity established by six medical-surgical nursing faculty. The ECG Skills Checklist is a researcher-developed checklist covering patient preparation, electrode placement, device operation, and strip interpretation, validated by five faculty experts; steps were scored as unsuccessful (0), requires improvement (2.5), or successful (5 points). The Instructional Materials Motivation Survey (IMMS) is a 33-item, 5-point Likert scale based on the ARCS model (Attention, Relevance, Confidence, Satisfaction), adapted to Turkish by Dinçer and Doğanay (2016); total scores range from 33 to 165, with higher scores indicating greater motivation. Cronbach's alpha in this study was 0.956.

Random allocation was conducted by an independent researcher not involved in data collection or intervention delivery, using a computer-generated random number sequence via www.random.org. Allocation concealment was maintained through sealed, sequentially numbered envelopes opened only after baseline assessments were recorded. Due to the nature of educational simulation interventions, blinding of participants and instructors was not feasible; however, the researcher responsible for baseline data collection was blinded to the randomization sequence before allocation.

Data were analyzed using IBM SPSS (v22.0). Normality was assessed via skewness, kurtosis, and the Shapiro-Wilk test. Between-group differences were examined using one-way ANOVA with post hoc Tukey tests. Within-group changes were assessed using repeated-measures ANOVA. ANCOVA was conducted with age and sex as covariates to account for baseline demographic imbalances. Partial eta-squared (η²) was used to index effect size. Significance was set at p<0.05.

Inclusion Criteria:

• First-year undergraduate nursing student enrollment
• Voluntary participation
• No prior ECG simulation training experience
• No visual impairment

Exclusion Criteria:

• Prior ECG simulation training experience
• Visual impairment
• Unwillingness to participate