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

Acibadem University60 enrolled

Overview

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 Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

OTHER

Masking

SINGLE

Enrollment

Conditions

Stress

Interventions

Nature-Based Virtual RealityOTHER

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.

2D Nature VideoOTHER

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.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 25 YearsHealthy volunteers:

Medical Language ↔ Plain English

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.

Outcomes

Primary Outcomes

State Anxiety (STAI-State Score)

Change in state anxiety levels measured using the State-Trait Anxiety Inventory (STAI-State) to evaluate OSCE-related anxiety in nursing students.

Time frame: Baseline (pre-intervention, before OSCE) and immediately after the OSCE examination (post-OSCE).

Subjective Distress (SUD Score)

Change in subjective stress levels assessed using the Subjective Units of Distress Scale (SUD).

Time frame: Baseline (pre-intervention), immediately after the intervention (post-intervention), and immediately after the OSCE examination (post-OSCE).

Physiological Stress Response (LF/HF Ratio)

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.

Time frame: Baseline (pre-intervention) and immediately after the intervention (post-intervention).