Effects of Nature-Based Virtual Reality and 2D Nature Videos on OSCE Exam Stress in Nursing Students

January 13, 2026 updated by: Güzin Ünlü Suvari, Acibadem University

Effect of Nature-Based Virtual Reality and Two-Dimensional Nature Videos on OSCE-Related Exam Stress in Nursing Students: A Randomized Controlled Trial

Objective Structured Clinical Examinations (OSCEs) are widely used in nursing education to assess clinical skills but are known to induce significant psychological and physiological stress due to performance anxiety, time pressure, and observation. Exam-related stress has been associated with changes in heart rate variability (HRV), particularly increased low-frequency/high-frequency (LF/HF) ratios, reflecting heightened sympathetic activity. Such stress may negatively affect cognitive performance, clinical competence, and professional readiness.

Nature-based virtual reality (VR) has emerged as a promising intervention for stress reduction by providing immersive, calming environments that promote relaxation and autonomic regulation. Previous studies suggest that short VR-based nature sessions can effectively reduce anxiety and may be more effective than two-dimensional (2D) nature videos, which represent a more accessible but less immersive alternative. However, evidence regarding the use of VR and 2D nature videos for managing stress during high-stakes clinical examinations such as OSCEs is limited.

This randomized controlled study aims to compare the effectiveness of nature-based VR and 2D nature videos in reducing OSCE-related stress among third-year nursing students using physiological (PPG-derived LF/HF ratio) and subjective (STAI and SUD) outcome measures.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Study Type

Interventional

Enrollment (Actual)

60

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Turkey (Türkiye)
    • Ataşehir
      • Istanbul, Ataşehir, Turkey (Türkiye)
        • Acıbadem University

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult

Accepts Healthy Volunteers

Yes

Description

Inclusion Criteria:

  • Undergraduate third-year nursing students scheduled to take the final OSCE examination.
  • Aged between 18 and 25 years.
  • Considered healthy, with no known cardiovascular disease or chronic stress-related disorders.
  • Willing to participate in the virtual reality or 2D nature video intervention.
  • Able to understand the study procedures and provide written informed consent.

Exclusion Criteria:

  • Known sensitivity or intolerance to virtual reality, including symptoms such as dizziness, nausea, headache, or visual discomfort.
  • Medical conditions that may affect photoplethysmography (PPG) measurements, such as cardiac arrhythmias or significant skin sensitivity at the measurement site.
  • Use of medications that may influence heart rate variability, including beta-blockers.
  • Inability to allocate sufficient time to participate in the pre-examination stress management intervention.
  • Pregnancy, acute illness, or current use of psychiatric medications.
  • Refusal to participate or failure to provide informed consent.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

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

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Nature-Based Virtual Reality
Participants receive a brief nature-based virtual reality relaxation session prior to the OSCE examination.
Other: Nature-Based Virtual Reality
Participants in the intervention group will receive a short nature-based virtual reality relaxation session prior to the OSCE examination. The VR content consists of calming natural environments with gentle visual transitions and ambient sounds designed to promote relaxation and reduce stress. The session is delivered using a head-mounted display and lasts approximately 5-10 minutes.
Experimental: 2D Nature Video
Participants watch a two-dimensional nature video for relaxation prior to the OSCE examination.
Other: 2D Nature Video
Participants in the control group will watch a two-dimensional nature video prior to the OSCE examination. The video presents relaxing natural scenes accompanied by ambient sounds and is displayed on a standard screen for approximately 5-10 minutes as a non-immersive relaxation intervention.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
State Anxiety (STAI-State Score)
Time Frame: Baseline (pre-intervention, before OSCE) and immediately after the OSCE examination (post-OSCE).
Change in state anxiety levels measured using the State-Trait Anxiety Inventory (STAI-State) to evaluate OSCE-related anxiety in nursing students.
Baseline (pre-intervention, before OSCE) and immediately after the OSCE examination (post-OSCE).
Subjective Distress (SUD Score)
Time Frame: Baseline (pre-intervention), immediately after the intervention (post-intervention), and immediately after the OSCE examination (post-OSCE).
Change in subjective stress levels assessed using the Subjective Units of Distress Scale (SUD).
Baseline (pre-intervention), immediately after the intervention (post-intervention), and immediately after the OSCE examination (post-OSCE).
Physiological Stress Response (LF/HF Ratio)
Time Frame: Baseline (pre-intervention) and immediately after the intervention (post-intervention).
Change in physiological stress response assessed by heart rate variability (HRV), expressed as the low-frequency/high-frequency (LF/HF) ratio derived from photoplethysmography (PPG) recordings.
Baseline (pre-intervention) and immediately after the intervention (post-intervention).

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Acibadem University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

December 2, 2025

Primary Completion (Actual)

January 2, 2026

Study Completion (Actual)

January 2, 2026

Study Registration Dates

First Submitted

January 13, 2026

First Submitted That Met QC Criteria

January 13, 2026

First Posted (Actual)

January 20, 2026

Study Record Updates

Last Update Posted (Actual)

January 20, 2026

Last Update Submitted That Met QC Criteria

January 13, 2026

Last Verified

January 1, 2026

More Information

Terms related to this study

Other Study ID Numbers

  • 2025-15/572

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

IPD Plan Description

Individual participant data (IPD) will not be publicly shared due to privacy concerns and the sensitive nature of maternal and infant health information. However, anonymized data may be made available upon reasonable request to the corresponding author after publication of the study results.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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