Virtual Reality Cave vs. Simulated Home for Community Nursing Education: A Crossover Trial Comparing Student Competence, Confidence, and Satisfaction

Comparing Virtual Reality CAVE and Simulated Home Experiences on Self-Perceived Clinical Competence, Self-Confidence, and Satisfaction in Community Health Nursing: A Crossover Randomized Controlled Trial

Background and Purpose

Community health nursing is essential for providing healthcare to individuals in home and neighborhood settings. As healthcare delivery shifts from hospitals to community environments, nursing students require practical training to develop competencies in conducting home visits. However, the availability of sufficient community-based training sites remains limited, and initial home visit experiences are often associated with student anxiety.

This study evaluated whether an immersive virtual reality technology, VR CAVE (Cave Automatic Virtual Environment), can provide training outcomes comparable to traditional practice conducted in a simulated home apartment. VR CAVE generates a room-sized three-dimensional environment that allows users to navigate and interact with realistic home settings without requiring physical props or dedicated space.

Methods

A crossover randomized controlled trial was conducted with 150 final-year nursing students at the University of Hong Kong from August 2024 to May 2025. Participants were randomly assigned to experience both training modalities in different sequences: one group received VR CAVE training followed by simulated home training, while the other group followed the reverse order. A three-week washout period was implemented between training sessions to minimize carryover effects.

Each training session included two realistic home visit scenarios: (1) a 70-year-old male with chronic lung disease living alone with respiratory distress and a urinary catheter, and (2) a 65-year-old female undergoing treatment for tuberculosis in a poorly ventilated apartment. Participants were required to identify environmental hazards, assess patient conditions, and formulate appropriate nursing care decisions.

The VR CAVE system projected life-sized three-dimensional home environments onto surrounding walls, incorporating approximately twenty interactive elements per scenario, such as smoke effects, labored breathing sounds, medication containers, and mobility aids. Participants navigated freely within the virtual space and interacted with objects. The traditional simulated home consisted of a physical mock apartment equipped with real props and comparable layouts.

Outcomes were measured using validated instruments assessing three domains: self-perceived clinical competence (confidence in nursing skills), self-confidence in applying learned knowledge, and satisfaction with the learning experience.

Results

Both VR CAVE and traditional simulated home training resulted in significant improvements in clinical competence, self-confidence, and satisfaction. Comparable levels of skill development were observed between participants trained using VR CAVE and those trained in the simulated home. No statistically significant difference in competence scores was identified between the two methods after completion of both training modalities (p=0.345).

Higher satisfaction and self-confidence scores were observed following VR CAVE sessions (mean scores ranging from 4.31 to 4.39 out of 5) compared to the simulated home. These findings suggest that the virtual reality approach may offer a more engaging and confidence-enhancing learning experience, despite similar effectiveness in skill acquisition.

Significance

The findings demonstrate that VR CAVE technology is comparable to traditional hands-on simulation in teaching community nursing skills. Key implications include:

Mitigation of space and resource constraints: Virtual environments allow the creation of diverse home settings without reliance on physical infrastructure or repeated reconfiguration of equipment.

Expansion of training capacity: Increased access to practice opportunities is achievable without dependence on physical space or clinical placement availability.

Enhanced learner engagement: Higher satisfaction levels indicate potential benefits in learner motivation and confidence prior to real-world placements.

Adaptability of training scenarios: Virtual environments can be readily modified to represent varied home conditions and patient cases, supporting comprehensive preparation for clinical practice.

Overall, VR CAVE represents a valuable adjunct to conventional training methods in preparing nursing students for community-based healthcare roles, particularly in contexts with limited access to real-world training environments.

Study Overview

• Status: Completed
• Conditions: Chronic Obstructive Pulmonary Disease; Pulmonary Tuberculosis; Community Health Nursing Education
• Intervention / Treatment: Other: VR CAVE Immersive Simulation for Community Health Nursing Education; Other: Traditional Simulated Home Environment for Community Health Nursing Training

• Study Type: Interventional
• Enrollment (Actual): 150
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Hong Kong
  • Hong Kong, Hong Kong
    • School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

• Full-time Year-5 undergraduate nursing students enrolled in the Community and Global Health Nursing course at the University of Hong Kong
• Age 18 years or older
• Able to communicate in English
• Willing to participate voluntarily in the study
• Provided written informed consent via online platform (Qualtrics)

Exclusion Criteria:

• Students not enrolled in the Community and Global Health Nursing course
• Students unable to attend both simulation sessions separated by the 3-week washout period
• Students who do not provide informed consent
• Students unable to complete online questionnaires via Qualtrics platform

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: VR CAVE (Cave Automatic Virtual Environment) Simulation for Community Health Nursing; Participants receive immersive virtual reality-based home visit simulation using VR CAVE technology. The intervention consists of two 20-minute standardized community health nursing scenarios (COPD patient and tuberculosis patient) projected as life-sized 3D environments with approximately 20 interactive clinical cues per case. Students navigate virtual home settings, identify health hazards, assess patient needs, and apply community nursing principles. Each session is followed by structured debriefing using Kolb's Experiential Learning Theory framework to promote reflection and conceptualization.	Other: VR CAVE Immersive Simulation for Community Health Nursing Education; Immersive virtual reality educational intervention using Cave Automatic Virtual Environment (VR CAVE) technology that projects life-sized 3D home environments onto room-scale walls. Students experience two 20-minute standardized community health nursing scenarios: (1) home visit to a 70-year-old COPD patient with Foley catheter living in public housing, and (2) home visit to a 65-year-old tuberculosis patient in poorly ventilated flat. Each virtual environment contains approximately 20 interactive clinical cues including animated smoke, ambient sounds (labored breathing, environmental noise), and responsive objects (medication packaging, mobility aids). Students physically navigate the virtual space, identify health hazards, assess patient needs, and apply community nursing principles. Sessions are followed by structured debriefing using Kolb's Experiential Learning Theory framework (Concrete Experience, Reflective Observation, Abstract Conceptualization, Active Experimentation).; Other: Traditional Simulated Home Environment for Community Health Nursing Training; Traditional simulation-based educational intervention conducted in a physical mock apartment laboratory setting. Students experience identical two 20-minute standardized community health nursing scenarios: (1) home visit to a 70-year-old COPD patient with Foley catheter living in public housing, and (2) home visit to a 65-year-old tuberculosis patient in poorly ventilated flat. The simulated apartment uses physical props, standardized room layouts, printed materials, and observational cues to replicate realistic home environments with the same 20 clinical elements present in the VR CAVE scenarios (medication storage, ventilation issues, mobility hazards, etc.). Students physically navigate the mock apartment space, identify environmental and health hazards, and apply community nursing assessment and intervention skills. Sessions are followed by structured debriefing using identical Kolb's Experiential Learning Theory framework as the VR CAVE intervention.
Active Comparator: Traditional Simulated Home Environment for Community Nursing; Participants receive traditional simulation-based home visit training in a physical mock apartment laboratory. The intervention uses the same two 20-minute standardized community health nursing scenarios (COPD patient and tuberculosis patient) with physical props, room layouts, and observational cues mirroring the VR scenarios. Students physically navigate the simulated apartment, identify clinical issues and environmental hazards, and apply community nursing principles. Each session is followed by structured debriefing identical to the VR CAVE arm, using Kolb's Experiential Learning Theory to facilitate reflection and learning.	Other: VR CAVE Immersive Simulation for Community Health Nursing Education; Immersive virtual reality educational intervention using Cave Automatic Virtual Environment (VR CAVE) technology that projects life-sized 3D home environments onto room-scale walls. Students experience two 20-minute standardized community health nursing scenarios: (1) home visit to a 70-year-old COPD patient with Foley catheter living in public housing, and (2) home visit to a 65-year-old tuberculosis patient in poorly ventilated flat. Each virtual environment contains approximately 20 interactive clinical cues including animated smoke, ambient sounds (labored breathing, environmental noise), and responsive objects (medication packaging, mobility aids). Students physically navigate the virtual space, identify health hazards, assess patient needs, and apply community nursing principles. Sessions are followed by structured debriefing using Kolb's Experiential Learning Theory framework (Concrete Experience, Reflective Observation, Abstract Conceptualization, Active Experimentation).; Other: Traditional Simulated Home Environment for Community Health Nursing Training; Traditional simulation-based educational intervention conducted in a physical mock apartment laboratory setting. Students experience identical two 20-minute standardized community health nursing scenarios: (1) home visit to a 70-year-old COPD patient with Foley catheter living in public housing, and (2) home visit to a 65-year-old tuberculosis patient in poorly ventilated flat. The simulated apartment uses physical props, standardized room layouts, printed materials, and observational cues to replicate realistic home environments with the same 20 clinical elements present in the VR CAVE scenarios (medication storage, ventilation issues, mobility hazards, etc.). Students physically navigate the mock apartment space, identify environmental and health hazards, and apply community nursing assessment and intervention skills. Sessions are followed by structured debriefing using identical Kolb's Experiential Learning Theory framework as the VR CAVE intervention.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Self-Perceived Clinical Competence Using Clinical Competence Questionnaire (CCQ) Total Score from Baseline to Post-Test 1	Self-perceived clinical competence measured using the Clinical Competence Questionnaire (CCQ), a 47-item validated instrument based on Benner's "Novice to Expert" model. The CCQ assesses four domains: nursing professional behaviors, general performance, core nursing skills, and advanced nursing skills. Each item is scored on a 5-point Likert scale. Total CCQ score ranges from 47 to 235, with higher scores indicating greater perceived competence. Change is calculated as post-intervention score minus baseline score. Cronbach's alpha: 0.98.	Baseline and immediately post-intervention (approximately 20 minutes after completing first simulation session)
Change in Self-Perceived Clinical Competence Using Clinical Competence Questionnaire (CCQ) Total Score from Baseline to Post-Test 2	Self-perceived clinical competence measured using the Clinical Competence Questionnaire (CCQ), a 47-item validated instrument based on Benner's "Novice to Expert" model. The CCQ assesses four domains: nursing professional behaviors, general performance, core nursing skills, and advanced nursing skills. Each item is scored on a 5-point Likert scale. Total CCQ score ranges from 47 to 235, with higher scores indicating greater perceived competence. Change is calculated as post-crossover score minus baseline score. Cronbach's alpha: 0.98.	Baseline and immediately after crossover intervention (approximately 3 weeks and 20 minutes after first intervention)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Student Satisfaction with Learning at Post-Test 1 Using Satisfaction Subscale of SSS (5-item, 5-point Likert scale)	Student satisfaction with simulation-based learning experience measured using the 5-item Satisfaction subscale of the Student Satisfaction and Self-Confidence in Learning Scale (SSS), developed by the National League for Nursing. Each item is rated on a 5-point Likert scale (1=Strongly Disagree to 5=Strongly Agree). Subscale scores range from 5 to 25, with higher scores indicating greater satisfaction with teaching methods used during simulation. Cronbach's alpha: 0.87-0.90.	Immediately after completing first simulation session (approximately 20 minutes post-intervention)
Self-Confidence in Learning at Post-Test 1 Using Self-Confidence Subscale of SSS (8-item, 5-point Likert scale)	Student self-confidence in applying knowledge acquired through simulation measured using the 8-item Self-Confidence subscale of the Student Satisfaction and Self-Confidence in Learning Scale (SSS). Each item is rated on a 5-point Likert scale (1=Strongly Disagree to 5=Strongly Agree). Subscale scores range from 8 to 40, with higher scores indicating greater confidence in ability to apply simulation learning. Cronbach's alpha: 0.87-0.90.	Immediately after completing first simulation session (approximately 20 minutes post-intervention)
Student Satisfaction with Learning at Post-Test 2 Using Satisfaction Subscale of SSS (5-item, 5-point Likert scale)	Student satisfaction with simulation-based learning experience measured using the 5-item Satisfaction subscale of the Student Satisfaction and Self-Confidence in Learning Scale (SSS) after crossover intervention. Each item is rated on a 5-point Likert scale (1=Strongly Disagree to 5=Strongly Agree). Subscale scores range from 5 to 25, with higher scores indicating greater satisfaction. Cronbach's alpha: 0.87-0.90.	Immediately after completing second simulation session following 3-week washout period (approximately 3 weeks and 20 minutes after first intervention)
Self-Confidence in Learning at Post-Test 2 Using Self-Confidence Subscale of SSS (8-item, 5-point Likert scale)	Student self-confidence in applying knowledge acquired through simulation measured using the 8-item Self-Confidence subscale of the Student Satisfaction and Self-Confidence in Learning Scale (SSS) after crossover intervention. Each item is rated on a 5-point Likert scale (1=Strongly Disagree to 5=Strongly Agree). Subscale scores range from 8 to 40, with higher scores indicating greater confidence. Cronbach's alpha: 0.87-0.90.	Immediately after completing second simulation session following 3-week washout period (approximately 3 weeks and 20 minutes after first intervention)

Collaborators and Investigators

• Sponsor: The University of Hong Kong

Study record dates

Study Major Dates

• Study Start (Actual): August 1, 2024
• Primary Completion (Actual): May 30, 2025
• Study Completion (Actual): July 15, 2025

Study Registration Dates

• First Submitted: May 7, 2026
• First Submitted That Met QC Criteria: May 14, 2026
• First Posted (Actual): May 19, 2026

Study Record Updates

• Last Update Posted (Actual): May 19, 2026
• Last Update Submitted That Met QC Criteria: May 14, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: Randomized Controlled Trial; Simulation; Nursing Education; Community Nursing; VR Cave; Cave Automatic Virtual Environment; Simulation in Nursing
• Additional Relevant MeSH Terms: Pathologic Processes; Chronic Disease; Disease Attributes; Respiratory Tract Infections; Infections; Respiratory Tract Diseases; Lung Diseases; Lung Diseases, Obstructive; Gram-Positive Bacterial Infections; Bacterial Infections; Bacterial Infections and Mycoses; Actinomycetales Infections; Mycobacterium Infections; Tuberculosis; Pathological Conditions, Signs and Symptoms; Pulmonary Disease, Chronic Obstructive; Tuberculosis, Pulmonary
• Other Study ID Numbers: EA240481

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data (IPD) will not be shared publicly. The ethical approval from the Human Research Ethics Committee of the University of Hong Kong (Ref: EA240481) requires protection of participant confidentiality. Only aggregate data and anonymized results will be published in peer-reviewed journals. De-identified datasets may be available upon reasonable request to the corresponding author, subject to institutional data sharing policies and ethical approval.

Drug and device information, study documents

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