Virtual Reality Training in Nasogastric Catheter Application for Nursing Students

Overview

Nasogastric catheter insertion is a complex psychomotor nursing skill in which incorrect placement can cause serious harm, including pulmonary aspiration, pneumothorax and death. Nurses are professionally responsible for the procedure from their first day in clinical practice, so competence must be acquired before graduation. The final-year students eligible for this trial had an unusual educational history. They took the Fundamentals of Nursing course, in which nasogastric catheter application is first taught, in the spring semester of 2019-2020. Face-to-face teaching was suspended in March 2020 because of the COVID-19 pandemic and the course was completed online, so the cohort received no hands-on laboratory training in that course. Clinical practice was further disrupted by the Kahramanmaras earthquakes of February 2023. Opportunities for repeated individual practice of this skill therefore remained limited throughout their education. This single-centre, pretest-posttest randomised controlled trial compared immersive virtual reality training with traditional simulator-based practice in nasogastric catheter application. Eighty-five final-year nursing students at Eskisehir Osmangazi University were randomised to a virtual reality group or a traditional method group, and 78 completed the study. Both groups received the same theoretical and demonstration training; they then practised the procedure either in an immersive virtual reality application or on a medium-fidelity simulator, up to three times each. The outcomes assessed were psychomotor skill performance, performance on safety-critical procedural steps, knowledge, self-confidence, anxiety and motivation. Data collection took place between 14 March and 20 May 2024.

BACKGROUND Serious complications of incorrect nasogastric catheter placement include pulmonary aspiration, pneumothorax, abscess, haemothorax, bronchopleural fistula and perforation, and such complications can be fatal. Under the Turkish Nursing Regulation, assessment of patients' nutritional needs and the application of nasogastric catheters for feeding are the responsibility of the nurse, and nasogastric catheter placement, care and removal are listed as required practical skills in the Turkish Nursing National Core Education Programme. Previous studies of virtual reality-based nasogastric catheter training in nursing education have been conducted with first- and second-year students. No published study had examined the effect of immersive virtual reality training in final-year students who are about to enter professional practice, nor evaluated knowledge, skill, self-confidence, anxiety and motivation together within a single controlled design. HYPOTHESES H1: There is a significant difference in skill scores between students trained by the traditional method and those trained by the virtual reality method. H2: There is a significant difference in critical procedural step scores between the two groups. H3: There is a significant difference in knowledge scores between the two groups. H4: There is a significant difference in self-confidence scores between the two groups. H5: There is a significant difference in anxiety scores between the two groups. H6: There is a significant difference in motivation scores between the two groups. DESIGN AND SETTING Single-centre, two-arm, parallel-group, pretest-posttest randomised controlled trial with 1:1 allocation, conducted in the Department of Nursing, Faculty of Health Sciences, Eskisehir Osmangazi University, Eskisehir, Turkey, during the spring semester of the 2023-2024 academic year. Group allocation is reported according to the CONSORT statement. PARTICIPANTS AND SAMPLE SIZE The study population comprised the 135 fourth-year nursing students enrolled in the department. Sample size was calculated with G\*Power 3.1.9.4 from the mean and standard deviation of the nasogastric catheter insertion skill checklist reported in a reference study, with a two-tailed test, alpha 0.05, power 0.95 and effect size d = 0.85, giving 76 participants in total and a minimum of 38 per group. Allowing for 10% attrition, the target was raised to 84. Eighty-five eligible and consenting students were randomised. RANDOMISATION All stages of randomisation were carried out by an independent statistician who took no other part in the study. The 85 students were stratified by sex, grade point average, knowledge test pretest score and skill checklist pretest score, and allocated to two groups using the RAND() function in Microsoft Excel so that the groups were homogeneous. Which group served as the intervention arm was decided by blinded lottery. This produced an intervention group of 42 and a control group of 43. BLINDING Because of the nature of the intervention, neither the participants nor the researcher delivering the training could be masked. Masking was applied at outcome assessment and data analysis. The two independent observers who scored the skill checklist were postgraduate students in Fundamentals of Nursing who took no other part in the study and were not informed of group allocation. The statistician who analysed the data was a different person from the one who performed the randomisation and was also masked; groups were coded as 1 and 2 before data entry. PROCEDURES All participants first completed the informed consent form, personal information form, knowledge test and the self-confidence and anxiety visual analog scales, and were assessed on a medium-fidelity simulator using the skill checklist (pretest, 14-25 March 2024). Randomisation followed. One week after randomisation, all participants received identical theoretical training (a 50-minute PowerPoint presentation validated by three subject experts) and demonstration training on a medium-fidelity simulator (30 minutes per group, five groups). One week later, the two arms entered a free practice period held simultaneously to limit contamination. Participants in the virtual reality arm were instructed in the use of the headset and controllers and completed the procedure in the virtual reality application up to three times. Participants in the traditional method arm practised the procedure on a medium-fidelity simulator up to three times under researcher supervision. At least two weeks after free practice, each participant performed nasogastric catheter insertion and removal on the medium-fidelity simulator and was scored independently by the two masked observers; performance duration was recorded. Immediately afterwards, participants completed the knowledge test, the self-confidence and anxiety visual analog scales and the motivation scale (posttest, 11-20 May 2024). VIRTUAL REALITY APPLICATION The application was developed in Unity 2022.3.18f1 with the XR Interaction Toolkit 2.1 for the Oculus Quest 2 platform. It comprises two modules: nasogastric catheter insertion (53 procedural steps) and removal (32 procedural steps). Each step is a separate scene set in a hospital room seen from the nurse's perspective, with all required materials within reach and a reference screen displaying the materials needed at each step. Guidance is provided by a message box displaying the current step and by synchronised audio narration. Applicability was assessed by three experts and the application was revised in line with their recommendations before use. MEASUREMENT INSTRUMENTS Nasogastric Catheter Application Knowledge Test: 25 multiple-choice items, score range 0-25, KR-20 = 0.82. Nasogastric Catheter Application Checklist: 85 steps (53 insertion, 32 removal), each scored 0, 1 or 2, total range 0-170, inter-rater ICC = 0.983. Critical Procedural Step score: 30 safety-critical items identified by an eight-member expert panel using the Lawshe technique, total range 0-60, inter-rater ICC = 0.980. Self-Confidence and Anxiety Visual Analog Scales: 10 cm scales, range 0-10 each. Instructional Material Motivation Scale for Single-Use: 14 items, five-point Likert format, range 14-70, Cronbach's alpha 0.91. STATISTICAL ANALYSIS Analyses were performed with SPSS 22.0 at a two-sided significance level of 0.05. Normality was assessed using skewness and kurtosis, coefficients of variation, detrended plots and histograms. Baseline comparability was tested with independent-samples t-tests and chi-square tests. Repeated measures across groups were compared with two-way analysis of variance with repeated measures, with the group by time interaction as the effect of primary interest; between-group comparisons used Tukey's test and effect sizes are reported as eta-squared. Motivation, measured only after the intervention, was compared with an independent-samples t-test. SAFETY No invasive procedure was performed on any participant. The only foreseeable risk was cybersickness from the head-mounted display. A safe working boundary was drawn in the virtual environment, the teleportation feature was used to limit motion-related discomfort, and exposure was capped at three sessions per participant. Participants were observed for discomfort and asked directly about symptoms during and after use. ETHICS Ethical approval was granted by the Non-Interventional Clinical Research Ethics Committee of Gaziantep Islam Science and Technology University on 21 March 2023 (Protocol no. 2023/209, Decision no. 209.23.13). Institutional permissions were obtained from the university where the study was conducted. Written informed consent was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki. After data collection ended, participants in the control arm who wished to try the virtual reality application were invited to do so.