Immersive Virtual Reality for Respiratory System Physical Examination Training Compared With Peer-Assisted Small-Group Practice: 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.

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.

Study Overview

• Status: Completed
• Conditions: Nurse-Patient Relations; Nurse's Role; Exanimation
• Intervention / Treatment: Other: Virtual Reality-Based Learning Tool; Other: Traditional Small Group Training

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.

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).

• Study Type: Interventional
• Enrollment (Actual): 76
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Ankara
    • Ankara, Ankara, Turkey (Türkiye), 06500
      • Gazi University Nursing Faculty

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Immersive Virtual Reality Group; 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.	Other: Virtual Reality-Based Learning Tool; 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 3 VR headset to provide immersive simulation experiences. The VR tool includes high-quality graphics and interactive scenarios to facilitate skill development.
Active Comparator: Peer-Assisted Small-Group Practice Group; 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	Other: Traditional Small Group Training; 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.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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	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.	Knowledge levels will be evaluated seven days prior to the intervention (pre-test) and seven days following the intervention (post-test)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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.	Seven days after the intervention

Collaborators and Investigators

• Sponsor: Gazi University
• Investigators: Study Director: Dr. Aslı A YILMAZ, PhD, Gazi University Nursing Faculty

Publications and helpful links

General 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.
• Boutron 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.
• Bayram 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.
• Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015 Apr;10(2):106-15. doi: 10.1097/SIH.0000000000000072.
• Akın, 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.
• Yang 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.
• Cheung 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.
• Hogan-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
• INACSL Standards Committee. (2021). Healthcare Simulation Standards of Best PracticeTM Simulation Design. Clinical Simulation in Nursing, 58, 14-21
• Pereira D, Gomes P, Faria S, Cruz-Correia R, Coimbra M. Teaching cardiopulmonary auscultation in workshops using a virtual patient simulation technology - A pilot study. Annu Int Conf IEEE Eng Med Biol Soc. 2016 Aug;2016:3019-3022. doi: 10.1109/EMBC.2016.7591365.
• Padilha 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.

Study record dates

Study Major Dates

• Study Start (Actual): May 20, 2024
• Primary Completion (Actual): June 14, 2024
• Study Completion (Actual): July 14, 2024

Study Registration Dates

• First Submitted: July 23, 2024
• First Submitted That Met QC Criteria: July 30, 2024
• First Posted (Actual): August 2, 2024

Study Record Updates

• Last Update Posted (Actual): March 19, 2026
• Last Update Submitted That Met QC Criteria: March 16, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: Physical Examination; Educational Technology; Nursing Education; Immersive Virtual Reality; Respiratory System; Clinical Skills
• Additional Relevant MeSH Terms: Neurologic Manifestations; Nervous System Diseases; Neurobehavioral Manifestations; Consciousness Disorders; Unconsciousness; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Coma
• Other Study ID Numbers: 2023-915; 2024-9040 (Other Grant/Funding Number: GAZI UNIVERSITY RESEARCH PROJECTS UNIT (BAP)); TDK-2024-9040 (Other Grant/Funding Number: Scientific Research Projects Coordination Unit of Gazi University)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No