ABSTRACT
To explore the potential of virtual reality (VR) as a training tool for basic life support (BLS) and other emergency procedures to achieve higher levels of knowledge in the cognitive, psychomotor, and affective domains. Sixty trainees, divided into two groups of thirty each, were trained first using conventional methods, followed by VR devices, and then crossed over in this randomized crossover trial. Data indicators included a pre-validated set of thirty-one mixed response questions administered via Google Forms and a checklist of twelve parameters. Assessment was performed using “Direct observation of procedural skills” at four time periods, at T0 (before training), T1 (post-completion of training with the conventional or immersive technique), T2 (post-completion of training with the immersive or conventional technique), and T3 (post-three months of last training with either the conventional or immersive technique). Inferential statistics were performed using the Chi-square test for categorical variables and analysis of variance (ANOVA) for continuous variables. Intra-group comparison revealed a significant difference from T0 to T3 for all parameters in groups I and II, except for the “compression depth” parameter in group I. Inter-group comparison at T0 and T3 revealed no statistically significant difference between the two techniques. Overall satisfaction levels from T0 to T3 in both groups revealed an increasing learning preference for the VR method (46.6%–73.3% in group I and 50%–80% in group II). Immersive teaching-learning methods using VR provided a scalable and consistent learning experience, highlighting its utility for BLS training in remote or resource-constrained environments. Trainees’ preferences and VR’s ability to foster a desired teaching-learning environment are promising signs, warranting exploration of its long-term synergistic impact with other immersive teaching-learning methods.
KEYWORDS: Cardiopulmonary resuscitation, simulation training, virtual reality exposure therapy
Introduction
Nonmedico combatants (NMCs), especially field nursing assistants, play a crucial role in augmenting healthcare delivery in tactical casualty care and pre-hospital care settings. Being in the vicinity of emergencies in difficult, hostile, and war-like terrains, their training regimen warrants absolute adherence.[1]
The conventional training regimen for NMCs generally includes time-tested teaching-learning (TL) methods such as lectures and narrations using boards, projectors, role plays, and computer-based presentations.[2] However, in the era of competency-based medical education (CBME), traditional education methodologies used in field nursing training have several limitations. These methods are one- to two-dimensional, offer limited exposure to real-time hostile terrains, where individuals are expected to perform learned skills efficiently, and lack assessment aligned with CBME protocols to ensure the acquisition of higher levels of knowledge and the development of competencies.[3] Furthermore, traditional basic life support (BLS) training faces challenges, including inconsistent instructor quality across sessions, the inability to safely replicate high-stress tactical environments, limited opportunities for repetitive practice without resource expenditure, and difficulty in objectively assessing psychomotor skills under realistic conditions.
The need for immersive teaching methods such as virtual reality (VR) is necessitated to address these gaps for nonmedical trainees by providing standardized, scalable training that simulates hostile field conditions safely. VR offers the advantages of being two- to three-dimensional in nature, creating realistic scenarios for high-risk situations with limited real-world practice opportunities, generating interest in learning while also ensuring active participation, fostering the development of psychomotor skills, and facilitating long-term memory and retention of acquired knowledge.[4,5,6]
The rationale for this study stems from the need to objectively compare conventional BLS training with VR-based immersive simulation among NMCs to determine whether technology-enhanced methods can deliver superior competency acquisition, skill retention, and trainee satisfaction in remote or resource-constrained settings.
Materials and Methods
This mixed-method prospective randomized crossover study comprised 60 healthy, disease-free NMCs enrolled during routine nursing training at a tertiary care military institute. Individuals with imminent postings and those with a history of head-neck injury or spasm, claustrophobia, and compromised vision were excluded from the study. Ethical clearance was obtained from the institutional ethical committee vide Approval No: IEC/2024/045. Written informed consent was obtained from all study participants.
NMCs were recruited using a simple random sampling technique. Participants were enrolled sequentially by generating numbers from the “Randomizer” mobile application applied to the subset population to provide an equal chance of selection for every eligible participant. Sample allocation was performed using the sealed opaque envelope method with participants assigned to two groups of 30 each, as follows: Group I initially received training using only conventional methods, and Group II initially received training with only VR methods; this was followed by a crossover after a six-week washout period. Subsequently, Group I received training using only VR methods, and Group II received training with only conventional methods [Figure 1]. Allocation concealment was maintained until intervention assignment.
Figure 1.
Workflow diagram of the study
NMCs underwent a scheduled four-week field nursing training program using validated, structured training modules, including but not limited to cardiopulmonary resuscitation (CPR). A total of four hours of BLS training was delivered over four weeks (one hour per week). Conventional training comprised boards, slides/PPT, and didactic lectures, followed by CPR practical demonstrations using mannequins. Immersive training was conducted using the MetaQuest2 HMD VR device and the Virtual Reality- Combat Medical Care [VR-CMC] (Secunderabad) and First Aid Training app (WGmbH VR) [Figure 2].
Figure 2.
Pictorial representation of methodology (available freely on the open domain on the Oculus Meta app store, having creative common license of free attribution)
Qualitative subjective assessment was carried out using a questionnaire designed with Google Forms and validated by ten experts (Cronbach’s alpha = 0.87). The questionnaire comprised 31 questions: six demographic and practice-related questions, fourteen multiple-choice multiple-response questions, ten Likert scale items graded from 0–5 (from “least” to “more” confidence), and one open-ended feedback question. Trainees were assisted by a standard BLS-trained faculty member in case of ambiguity or difficulty in interpretation. Objective assessment was performed using a checklist of 12 parameters, adapted from the American Heart Association recommendations for CPR and validated by ten experts, demonstrating good inter-rater reliability (ICC = 0.89). Performance was rated as “adequate” (“a”) or “inadequate” (“i”) performance.[7] Data were recorded for both groups at four time periods: T0 (pre-training), T1 (post-training with the conventional/immersive technique), T2 (post-training with the immersive/conventional technique), and T3 (post-three months of last training). Workplace-based assessment using “direct observation of procedural skills” (DOPS) was conducted in a simulated environment mimicking a difficult hostile, war-like conflict zone by two independent blinded assessors (excellent ICC = 0.92).
Inferential statistics using SPSS version 25.0 (IBM Corp., 2017) were performed for each of the twelve variables for objective assessment, measured at four points, repeated-measures analysis of variance was conducted within groups to account for the crossover design, with Bonferroni post-hoc correction. Intergroup comparison at T0 and T3 were performed using the Chi-square test (or Fisher’s exact test, as appropriate). A P value <0.05 was considered statistically significant.
Results
Demographic, temporal, and practice characteristics of the enrolled participants are shown in Supplementary Table S1. Most learners in both groups reported “a desire for learning” using the immersive method over the period from T0 to T3. The majority of learners in both groups found conventional methods to be monotonous, trainer-oriented, boring, theoretical, and difficult to recall, revise, and implement. Similarly, over 63% of learners in both groups reported that the immersive technique was easy to understand and grasp, and allowed greater one-to-one interaction and inclusiveness [Table 1].
Table S1.
Percentage distribution of demographic, temporal, and practice characteristics of enrolled samples (n=60)
| Questions | Category | Group I (30) (%) | Group II (30) (%) |
|---|---|---|---|
| Age | Less than 30 years | 19 (63.3%) | 17 (56.6%) |
| More than 30 years | 11 (36.6%) | 13 (43.3%) | |
| Years in service | Less than 5 years | 9 (30.0%) | 11 (36.6%) |
| 5–10 years | 10 (33.3%) | 6 (20.0%) | |
| More than 10 years | 11 (36.6%) | 13 (43.3%) | |
| Educational qualification | Matriculation and below | 6 (20.0%) | 4 (13.3%) |
| Higher secondary education | 22 (73.3%) | 24 (80.0%) | |
| Graduate | 2 (6.6%) | 1 (3.3%) | |
| Postgraduate | 0 (0.0%) | 1 (3.3%) | |
| Do you have any exposure to Immersive learning tools such as Virtual/Augmented/Mixed reality devices? | Yes | 3 (10.0%) | 2 (6.6%) |
| No | 27 (90.0%) | 28 (93.3%) | |
| Maybe | 0 (0.0%) | 0 (0.0%) | |
| Do you use a smartphone? | Yes | 30 (100.0%) | 30 (100.0%) |
| No | 0 (0.0%) | 0 (0.0%) | |
| Maybe | 0 (0.0%) | 0 (0.0%) |
Table 1.
Frequency distribution of knowledge and attitude of enrolled samples in Group I and Group II (30 per group)
| Questions | Options | Group I | Group II | ||||||
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| Time Periods | Time Periods | ||||||||
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| T0 | T1 | T2 | T3 | T0 | T1 | T2 | T3 | ||
| Given the choice, which method would you prefer for BLS? | Board/chart classroom | 8 (26.6%) | 7 (23.3%) | 5 (16.6%) | 5 (16.6%) | 4 (13.3%) | 4 (13.3%) | 4 (13.3%) | 2 (6.6%) |
| VR/AR/MR | 14 (46.6%) | 19 (63.3%) | 20 (66.6%) | 22 (73.3%) | 15 (50.0%) | 19 (63.3%) | 22 (73.3%) | 24 (80.0%) | |
| Both | 7 (23.3%) | 4 (13.3%) | 5 (16.6%) | 3 (10.0%) | 3 (10.0%) | 6 (20.0%) | 3 (10.0%) | 4 (13.3%) | |
| Not sure | 1 (3.3%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 8 (26.6%) | 1 (3.3%) | 1 (3.3%) | 0 (0.0%) | |
| Please provide limitations of conventional training methods, if any | Monotonous and trainer-oriented | 8 (26.6%) | 7 (23.3%) | 8 (26.6%) | 6 (20.0%) | 9 (30.0%) | 5 (16.6%) | 2 (6.6%) | 3 (10.0%) |
| Boring and theoretical due to technical jargons | 5 (16.6%) | 6 (20.0%) | 4 (13.3%) | 6 (20.0%) | 5 (16.6%) | 5 (16.6%) | 3 (10.0%) | 2 (6.6%) | |
| Difficult to recollect, revise, and implement | 3 (10.0%) | 2 (6.6%) | 4 (13.3%) | 5 (16.6%) | 2 (6.6%) | 3 (10.0%) | 4 (13.3%) | 2 (6.6%) | |
| All of them | 12 (40.0%) | 14 (46.6%) | 14 (46.6%) | 13 (43.3%) | 13 (43.3%) | 13 (43.3%) | 20 (66.6%) | 22 (73.3%) | |
| None of them | 2 (6.6%) | 1 (3.3%) | 0 (0.0%) | 0 (0.0%) | 1 (3.3%) | 4 (13.3%) | 1 (3.3%) | 1 (3.3%) | |
| Please provide the limitations of the VR/AR/MR-based immersive training method, if any | Expensive and technique sensitive | 3 (10.0%) | 2 (6.6%) | 4 (13.3%) | 2 (6.6%) | 2 (6.6%) | 3 (10.0%) | 2 (6.6%) | 3 (10.0%) |
| Claustrophobic and straining | 4 (13.3%) | 3 (10.0%) | 3 (10.0%) | 2 (6.6%) | 3 (10.0%) | 2 (6.60%) | 4 (13.3%) | 3 (10.0%) | |
| Classroom team learning is missing | 3 (10.0%) | 2 (6.6%) | 4 (13.3%) | 3 (10.0%) | 5 (16.6%) | 2 (6.6%) | 5 (16.6%) | 2 (6.6%) | |
| difficult to recollect, revise, and implement | 2 (6.6%) | 1 (3.3%) | 0 (0.0%) | 2 (6.6%) | 1 (3.3%) | 3 (10.0%) | 3 (10.0%) | 2 (6.6%) | |
| Motion sickness | 5 (16.6%) | 1 (3.3%) | 1 (3.3%) | 2 (6.6%) | 2 (6.6%) | 4 (13.3%) | 2 (6.6%) | 1 (3.3%) | |
| All | 13 (43.3%) | 21 (70.0%) | 18 (60.0%) | 19 (63.3%) | 15 (50.0%) | 14 (46.6%) | 14 (46.6%) | 18 (60.0%) | |
| None | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 2 (6.6%) | 0 (0.0%) | 2 (6.6%) | 1 (3.3%) | |
| Please provide the advantages of conventional training methods, if any | One-to-one interaction with the trainer helps in learning | 4 (13.3%) | 2 (6.6%) | 4 (13.3%) | 3 (10.0%) | 3 (10.0%) | 4 (13.3%) | 2 (6.6%) | 3 (10.0%) |
| Easy to understand and grasp | 3 (10.0%) | 2 (6.6%) | 2 (6.6%) | 3 (10.0%) | 2 (6.6%) | 1 (3.3%) | 3 (10.0%) | 2 (6.6%) | |
| More interactive and inclusive | 3 (10.0%) | 3 (10.0%) | 2 (6.6%) | 4 (13.3%) | 1 (3.3%) | 2 (6.6%) | 3 (10.0%) | 4 (13.3%) | |
BLS=Basic life support, VR=Virtual reality, AR=Augmented reality, MR=Mixed reality
Approximately 43%–63.30% of learners in Group I and 50%–60% in Group II reported that the immersive method had limitations, including being claustrophobic, straining, and expensive, as well as lacking a classroom-like environment. Nevertheless, over 40% of learners across both groups noted that the immersive technique offered advantages such as longer memory retention and a real-time experience, along with increased excitement and interest [Table 1].
Overall satisfaction levels from T0 to T3 in both groups indicated that the majority of learners showed an increasing preference for the immersive technique across various steps of BLS, including confidence in performing CPR, detecting breathing irregularities, clearing the airway, providing mask ventilation, performing chest compressions, conducting basic vital checks, automated external defibrillator (AED) application, following the correct BLS sequence, and leading a BLS team. Satisfaction levels were statistically significant on the Likert scale, with more than the 50th percentile showing positive or strongly positive responses (scale: 1–5) [Table 2; Supplementary Tables S2 and S3]. Intragroup comparisons showed significant differences from T0 to T3 for all parameters in both groups, except for the “compression depth” parameter in Group I, indicating a positive impact of both TL tools [Tables 3 and 4].
Table 2.
Overall satisfaction level of all the enrolled samples at T3 in both groups (n=60)
| Questions | Conventional technique | Immersive technique | Both | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
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| T0 | T1 | T2 | T3 | T0 | T1 | T2 | T3 | T0 | T1 | T2 | T3 | |
| Which is the better method of learning after which you feel more confident giving BLS? | 12 (20.0%) | 10 (16.6%) | 14 (23.3%) | 15 (25.0%) | 22 (36.6%) | 26 (43.3%) | 28 (46.6%) | 32 (53.3%) | 26 (43.3%) | 24 (40.0%) | 18 (30.0%) | 13 (21.6%) |
| Which is the better method of learning after which you feel more confident in detecting irregular breath? | 18 (30.0%) | 24 (40.0%) | 26 (43.3%) | 31 (51.6%) | 12 (20.0%) | 25 (41.6%) | 20 (33.3%) | 19 (31.6%) | 30 (5.0%) | 11 (36.6%) | 15 (50.0%) | 10 (16.6%) |
| Which is the better method of learning after which you feel more confident in clearing the airway maneuver? | 32 (53.3%) | 38 (63.3%) | 31 (51.6%) | 39 (6.5%) | 18 (30.0%) | 19 (31.6%) | 20 (33.3%) | 12 (20.0%) | 10 (16.6%) | 3 (5.0%) | 9 (15.0%) | 9 (15.0%) |
| Which is the better method of learning after which you feel more confident in providing mask ventilation? | 22 (36.6%) | 32 (53.3%) | 28 (46.6%) | 31 (51.6%) | 18 (30.0%) | 14 (23.3%) | 12 (20.0%) | 17 (28.3%) | 20 (33.3%) | 16 (26.6%) | 20 (33.3%) | 12 (20.0%) |
| Which is the better method of learning after which you feel more confident in providing high-quality chest compression? | 20 (33.3%) | 22 (36.6%) | 22 (36.6%) | 21 (35%) | 22 (36.6%) | 21 (35.0%) | 28 (46.6 %) | 18 (30.0%) | 18 (30.0%) | 10 (16.6%) | 20 (33.3%) | 21 (35.0%) |
| Which is the better method of learning after which you feel more confident in providing an AED application? | 30 (50.0%) | 32 (53.3%) | 34 (56.6%) | 29 (48.3%) | 20 (33.3%) | 24 (40.0%) | 21 (35.0%) | 25 (35.0%) | 10 (16.6%) | 6 (10.0%) | 5 (8.3%) | 6 (10.0%) |
| Which is the better method of learning after which you feel more confident in performing the correct sequence of BLS? | 18 (30.0%) | 22 (36.6%) | 29 (48.3%) | 28 (46.6%) | 22 (36.6%) | 21 (35.0%) | 20 (33.3%) | 18 (30.0%) | 20 (33.3%) | 18 (30.0%) | 13 (21.6%) | 14 (23.4%) |
| Which is the better method of learning after which you feel more confident in leading a BLS team? | 22 (36.6%) | 26 (43.3%) | 21 (35.0%) | 20 (33.3%) | 24 (40.0%) | 21 (35.0%) | 18 (30.0%) | 22 (36.6%) | 14 (23.3%) | 13 (21.6%) | 21 (35.0%) | 18 (30.0%) |
| Which is the better method of learning after which you feel more confident in emergency identification? | 20 (33.3%) | 21 (35.0%) | 26 (43.3%) | 22 (36.6%) | 20 (33.3%) | 25 (41.6%) | 22 (36.6%) | 25 (41.6%) | 20 (33.3%) | 14 (23.3%) | 12 (20.0%) | 1 (1.6%) |
| Which is the better method of learning after which you feel more confident in basic checks of vitals? | 20 (33.3%) | 24 (40.0%) | 24 (40.0%) | 22 (36.6%) | 22 (36.6%) | 28 (46.6%) | 21 (35.0%) | 23 (38.3%) | 18 (30.0%) | 8 (13.3%) | 13 (21.6%) | 15 (25.0%) |
BLS=Basic life support, AED=Automated external defibrillator
Table S2.
Overall satisfaction level at T3 time period of all the enrolled samples in both groups for the conventional method at Likert Scale of 1–5 (1=not at all; 5=extreme) (n=60)
| Variable | Likert’s scores | ||||
|---|---|---|---|---|---|
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| 1 | 2 | 3 | 4 | 5 | |
| How confident do you feel in detecting irregular breath? | 10 (16.6%) | 9 (15.0%) | 41 (68.3%) | ||
| How confident do you feel in clearing the airway maneuver? | 13 (21.6%) | 3 (5.1%) | 44 (73.3%) | ||
| How confident do you feel in providing mask ventilation? | 10 (16.6%) | 38 (63.3%) | 12 (20.0%) | ||
| How confident do you feel in providing high-quality chest compression? | 18 (30.0%) | 22 (36.6%) | 20 (33.3%) | ||
| How confident do you feel in providing an AED application? | 23 (38.3%) | 24 (40.0%) | 13 (21.6%) | ||
| How much confidence do you feel in performing the correct sequence of BLS? | 11 (18.3%) | 23 (38.3%) | 12 (20.0%) | 14 (23.3%) | |
| How confident do you feel in leading the BLS team? | 9 (15%) | 32 (53.3%) | 14 (23.3%) | 5 (8.3%) | |
| How confident do you feel in an emergency situation? | 21 (35.0%) | 39 (48.3%) | |||
| How confident do you feel in performing the basic checks of vital signs? | 5 (8.3%) | 15 (25.0%) | 34 (71.6%) | 6 (10.0%) | |
BLS=Basic life support, AED=Automated external defibrillator
Table S3.
Overall satisfaction level at T3 of all the enrolled samples in both groups for immersive method on Likert Scale of 1–`5 (1=not at all; 5=extreme) (n=60)
| Variable | Likert’s scores | ||||
|---|---|---|---|---|---|
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| 1 | 2 | 3 | 4 | 5 | |
| How confident do you feel in detecting irregular breath? | 2 (3.3%) | 19 (31.6%) | 16 (26.6%) | 23 (38.3%) | |
| How confident do you feel in clearing the airway maneuver? | 4 (6.6%) | 34 (56.6%) | 13 (21.6%) | 9 (15.0%) | |
| How confident do you feel in providing mask ventilation? | 14 (23.3%) | 38 (63.3%) | 8 (13.3%) | ||
| How confident do you feel in providing high-quality chest compression? | 19 (31.6%) | 29 (48.3%) | 12 (20.0%) | ||
| How confident do you feel in providing an AED application? | 5 (8.3%) | 16 (26.6%) | 23 (38.3%) | 16 (26.6%) | |
| How much confidence do you feel in performing the correct sequence of BLS? | 9 (15.0%) | 20 (33.3%) | 21 (3.5%) | 10 (16.6%) | |
| How confident do you feel in leading the BLS team? | 12 (20.0%) | 19 (31.6%) | 21 (35.0%) | 8 (13.3%) | |
| How confident do you feel in emergency identification? | 7 (11.6%) | 22 (36.6%) | 31 (51.6%) | ||
| How confident do you feel in performing the basic checks of vital signs? | 32 (53.3%) | 23 (38.3%) | 5 (8.3%) | ||
BLS=Basic life support, AED=Automated external defibrillator
Table 3.
Descriptive statistics and intragroup comparisons at different observation periods within Group I (using repeated-measures ANOVA)
| Variables | Pre-Training (T0) | After conventional training (T1) | After Immersive training (T2) | Follow up after three months (T3) | P | ||||
|---|---|---|---|---|---|---|---|---|---|
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| a | i | a | i | a | i | a | i | ||
| Situation Identification | 7 (23.3%) | 23 (76.6%) | 29 (96.6%) | 1 (3.3%) | 28 (93.3%) | 2 (6.6%) | 26 (86.6%) | 4 (13.3%) | 0.00001* |
| Reaction Time | 2 (6.6%) | 28 (93.3%) | 13 (43.3%) | 17 (56.6%) | 18 (60.0%) | 12 (40.0%) | 14 (46.6%) | 16 (53.3%) | 0.000197* |
| Call for help | 9 (30.0%) | 21 (70.0%) | 28 (93.3%) | 2 (6.6%) | 28 (93.3%) | 2 (6.6%) | 21 (70.0%) | 9 (30.0%) | 0.00001* |
| Assessing the patient’s consciousness | 1 (3.3%) | 29 (96.6%) | 27 (90.0%) | 3 (10.0%) | 25 (83.3%) | 5 (16.6%) | 19 (63.3%) | 11 (36.6%) | 0.00001* |
| Assessing the safety of the patient | 1 (3.3%) | 29 (96.6%) | 28 (93.3%) | 2 (6.6%) | 28 (93.3%) | 2 (6.6%) | 20 (66.6%) | 10 (33.3%) | 0.00001* |
| Compression numbers | 2 (6.6%) | 28 (93.3%) | 25 (83.3%) | 5 (16.6%) | 25 (83.3%) | 5 (16%) | 18 (60.0%) | 12 (40.0%) | 0.00001* |
| Compression time | 1 (3.3%) | 29 (96.6%) | 17 (56.6%) | 13 (43.3%) | 20 (66.6%) | 10 (33.3%) | 15 (50.0%) | 15 (50.0%) | 0.00001* |
| Angle applied during compression | 3 (10.0%) | 27 (90.0%) | 19 (63.3%) | 11 (36.6%) | 19 (63.3%) | 11 (36.6%) | 15 (50.0%) | 15 (50.0%) | 0.00004* |
| Compression depth | 12 (40.0%) | 18 (60.0%) | 19 (63.3%) | 11 (36.6%) | 19 (63.3%) | 11 (36.6%) | 13 (43.3%) | 17 (56.6%) | 0.12636 |
| Location of compression | 16 (53.3%) | 14 (46.6%) | 29 (96.6%) | 1 (3.3%) | 29 (96.6%) | 1 (3.3%) | 25 (83.3%) | 5 (16.6%) | 0.00001* |
| Pause between compression | 2 (6.6%) | 28 (93.3%) | 14 (46.6%) | 16 (53.3%) | 18 (60.0%) | 12 (40.0%) | 16 (53.3%) | 14 (46.6%) | 0.000093* |
| Airway maneuver | 3 (10.0%) | 27 (90.0%) | 18 (60.0%) | 12 (40.0%) | 26 (86.6%) | 4 (I3.3%) | 22 (73.3%) | 8 (26.6%) | 0.00001* |
a=Adequate performance, i=Inadequate performance, ANOVA – Analysis of variance. *P<0.05 is significant
Table 4.
Descriptive statistics and intragroup comparisons at different observation periods within Group II (using repeated-measures ANOVA)
| Variables | Pre-Training (T0) | After conventional training (T1) | After Immersive training (T2) | Follow up after three months (T3) | P | ||||
|---|---|---|---|---|---|---|---|---|---|
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| a | i | a | i | a | i | a | i | ||
| Situation Identification | 3 (15.0%) | 27 (90.0%) | 28 (93.3%) | 2 (6.6%) | 25 (83.3%) | 5 (16.6%) | 25 (83.3%) | 5 (16.6%) | 0.00001* |
| Reaction Time | 7 (23.3%) | 23 (76.6%) | 19 (63.3%) | 11 (36.6%) | 29 (96.6%) | 1 (3.3%) | 15 (50.0%) | 15 (50.0%) | 0.00001* |
| Call for help | 11 (36.6%) | 19 (63.3%) | 26 (86.6%) | 4 (13.3%) | 28 (93.3%) | 2 (6.6%) | 19 (63.3%) | 11 (36.6%) | 0.00001* |
| Assessing patients’ consciousness | 6 (30.0%) | 24 (80.0%) | 28 (93.3%) | 2 (6.6%) | 29 (96.6%) | 1 (3.3%) | 19 (63.3%) | 11 (36.6%) | 0.00001* |
| Assessing the safety of the patient | 3 (15.0%) | 27 (90.0%) | 29 (96.6%) | 1 (3.3%) | 29 (96.6%) | 1 (3.3%) | 19 (63.3%) | 11 (36.6%) | 0.00001* |
| Compression numbers | 7 (23.3%) | 23 (76.6%) | 28 (93.3%) | 2 (6.6%) | 26 (86.6%) | 4 (13.3%) | 17 (56.6%) | 13 (43.3%) | 0.00001* |
| Compression time | 9 (30.0%) | 21 (70.0%) | 26 (86.6%) | 4 (13.3%) | 24 (80.0%) | 6 (20.0%) | 11 (36.6%) | 19 (63.3%) | 0.00001* |
| Angle applied during compression | 3 (15.0%) | 27 (90.0%) | 24 (80.0%) | 6 (20.0%) | 22 (73.3%) | 8 (26.6%) | 16 (53.3%) | 14 (46.6%) | 0.00001* |
| Compression depth | 13 (43.3%) | 17 (56.6%) | 24 (80.0%) | 6 (20.0%) | 28 (93.3%) | 2 (6.6%) | 14 (46.6%) | 16 (53.3%) | 0.00001* |
| Location of compression | 11 (36.6%) | 19 (63.3%) | 29 (96.6%) | 1 (3.3%) | 28 (93.3%) | 2 (6.6%) | 24 (80.0%) | 6 (20.0%) | 0.00001* |
| Pause between compression | 2 (6.6%) | 28 (93.3%) | 19 (63.3%) | 11 (36.6%) | 24 (80.0%) | 6 (20.0%) | 12 (40.0%) | 18 (60.0%) | 0.00001* |
| Airway maneuver | 1 (3.3%) | 29 (96.6%) | 23 (76.6%) | 7 (23.3%) | 25 (83.3%) | 5 (16.6%) | 17 (56.6%) | 13 (43.3%) | 0.00001* |
a=Adequate performance, i=Inadequate performance, ANOVA – Analysis of variance
Intergroup comparisons at T0 and T3 revealed no statistically significant difference between the conventional and immersive techniques [Table 5].
Table 5.
Intergroup comparisons for the variables at T0 and T3 time periods between Group I and Group II (using Chi-square test)
| Variables | Pre-Training, T0 (Group-I) | Pre-Training, T0 (Group-II) | P | Follow up after three months, T3 (Group-I) | Follow up after three months, T3 (Group-II) | P | ||||
|---|---|---|---|---|---|---|---|---|---|---|
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| a | i | a | i | a | i | a | i | |||
| Situation Identification | 7 (23.3%) | 23 (76.6%) | 3 (10.0%) | 27 (90.0%) | 0.165857 | 26 (86.6%) | 4 (13.3%) | 25 (83.3%) | 5 (16.6%) | 0.80238 |
| Reaction Time | 2 (6.6%) | 28 (93.3%) | 7 (23.3%) | 23 (76.6%) | 0.070645 | 14 (46.6%) | 16 (53.3%) | 15 (50.0%) | 15 (50.0%) | 0.796143 |
| Call for help | 9 (30.0%) | 21 (70.0%) | 11 (36.6%) | 19 (63.3%) | 0.583882 | 21 (70.0%) | 9 (30.0%) | 19 (63.3%) | 11 (36.6%) | 0.583882 |
| Assessing patients’ consciousness | 1 (3.3%) | 29 (96.6%) | 6 (20.0%) | 24 (80.0%) | 0.044352 | 19 (63.3%) | 11 (36.6%) | 19 (63.3%) | 11 (36.6%) | 1 |
| Assessing the safety of the patient | 1 (3.3%) | 29 (96.6%) | 3 (10.0%) | 27 (90.0%) | 0.300623 | 20 (66.6%) | 10 (33.3%) | 19 (63.3%) | 11 (36.6%) | 0.786648 |
| Compression numbers | 2 (6.6%) | 28 (93.3%) | 7 (23.3%) | 23 (76.6%) | 0.070645 | 18 (60.0%) | 12 (40.0%) | 17 (56.6%) | 13 (43.3%) | 0.793428 |
| Compression time | 1 (3.3%) | 29 (96.6%) | 9 (30.0%) | 21 (70.0%) | 0.005584 | 15 (50.0%) | 15 (50.0%) | 11 (36.6%) | 19 (63.3%) | 0.29736 |
| Angle applied during compression | 3 (10.0%) | 27 (90.0%) | 3 (100%) | 27 (90.0%) | 1 | 15 (50.0%) | 15 (50.0%) | 16 (53.3%) | 14 (46.6%) | 0.796143 |
| Compression depth | 12 (40.0%) | 18 (60.0%) | 13 (43.3%) | 17 (56.6%) | 0.793428 | 13 (43.3%) | 17 (56.6%) | 14 (46.6%) | 16 (53.3%) | 0.79525 |
| Location of compression | 16 (53.3%) | 14 (46.6%) | 11 (36.6%) | 19 (63.3%) | 0.432111 | 25 (83.3%) | 05 (16.6%) | 24 (80.0%) | 6 (20.0%) | 0.738649 |
| Pause between compression | 2 (6.6%) | 28 (93.3%) | 2 (6.6%) | 28 (93.3%) | 1 | 16 (53.3%) | 14 (46.6%) | 12 (40.0%) | 18 (60.0%) | 0.300623 |
| Airway maneuver | 3 (10.0%) | 27 (90.0%) | 1 (3.3%) | 29 (96.6%) | 0.300623 | 22 (73.3%) | 8 (26.6%) | 17 (56.6%) | 13 (43.3%) | 0.17595 |
a=Adequate performance, i=Inadequate performance
Discussion
The present study employed a two-arm crossover design in which participants experienced both conventional and VR training methods, allowing for a more robust comparison and reducing the effect of confounders. Although deemed effective, conventional simulation methods using role-play and mannequins are resource-intensive, requiring trained personnel and large spaces for scenario recreation. Frequent relocation of trained manpower, along with maintenance and wear and tear of simulation assets, further contributes to the loss of trained resources over time.[8]
Despite limited prior exposure to VR among participants (only 8% had prior experience), a strong preference for VR training emerged during the study (over 73%). Learners described conventional methods as monotonous, theoretical, and difficult to remember, whereas VR was perceived to promote longer-term memory retention and a more engaging learning experience. However, some participants reported concerns related to claustrophobia, cost, and the absence of a traditional classroom environment. Although the MetaQuest 2 represents a significant upfront investment, its scalability enables cost-effective training for large cohorts over time, particularly in remote military settings where instructor availability is limited. The results of the present study are consistent with previous research,[9,10] which has shown that VR can surpass conventional methods in developing psychomotor skills essential for prehospital care.
While both conventional and VR training methods demonstrated improvement within groups, the absence of a statistically significant difference in learner performance between groups at baseline and at the end of the course indicates that both approaches are effective for knowledge acquisition. However, VR training resulted in a statistically significant increase in learner satisfaction across all time points (T0–T3), indicating that it may be a more motivating and engaging approach for field nursing training of NMCs, even if it does not necessarily produce superior objective outcomes.
The effectiveness of immersive technology was found to be comparable to conventional methods, with additional benefits including greater learner preference, engagement, and satisfaction with VR-based tools. Similar findings have been reported by Moll-Khosrawi et al.,[11] who noted that VR-based training can be easily disseminated in remote locations or among large groups during unprecedented situations (e.g., pandemics), facilitating consistent learning experiences and overcoming limitations associated with instructor-led training.
Concurring with the findings of J. Pottle,[12] the present study also demonstrated positive reception and wide acceptance of immersive tools in teaching and learning. Lie et al.[13] further emphasized the role of VR in enhancing nontechnical and soft skills in healthcare education. The results of this study are also consistent with those of previous studies,[10,14] which showed that interactive simulations are more effective than static textbooks or lectures in presenting complex information, facilitating deeper understanding, and positively influencing the cognitive domain of learning.
The study also suggests that the immersive and interactive nature of VR fosters higher levels of student motivation and engagement compared to conventional lectures. This may be attributed to the ability of VR simulations to provide a safe and controlled environment for practice, thereby promoting a sense of accomplishment and enhancing learner confidence. Additionally, through the incorporation of role-play elements, VR experiences can be designed to cultivate empathy and social skills, enabling a better understanding of patients’ needs and anxieties.[15]
Strengths of the study: These include a randomized crossover design minimizing intersubject variability, multi-domain learning assessment covering all learning domains (cognitive, psychomotor, and affective), a three-month retention evaluation indicating sustained skill maintenance, an objective DOPS-based skill assessment reducing subjectivity, and comprehensive satisfaction tracking capturing evolving learner preferences.
Limitations of the Study: A single-center study with a small sample size limiting generalizability, the absence of real-life field performance evaluation, and the possible novelty effect of VR among mostly VR-naive participants (92% first-time users) are a few limitations of the study.
In synergy with conventional training, the TL methods using VR provided an engaging, standardized, and reproducible learning experience useful for remote training and in pandemic or disaster-resilient scenarios.
Future studies are warranted to explore VR implementation strategies for broader healthcare trainees, including medical doctors, long-term skill retention beyond three months, and mitigating novelty effects through repeated exposure.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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