Virtual Reality Training in Nasogastric Tube Application for Nurses

BACKGROUND

Nasogastric tube application is widely used in inpatient wards and intensive care units for nutritional support, medication administration, assessment of gastric contents, gastric lavage, gastric emptying, and decompression. Although often regarded as a simple procedure, incorrect placement can cause pneumothorax, pneumonia, infection, vocal cord paralysis, and tube obstruction, and deaths associated with these complications have been reported. Under the Turkish Nursing Regulation, nasogastric tube application and the associated care and monitoring are among the duties of the nurse.

The literature indicates considerable variation in field practice among nurses performing this procedure. Virtual reality provides an immersive environment in which clinical procedures can be practiced repeatedly without risk to patients, allowing learners to progress at their own pace. Although several studies have examined virtual reality training in nursing students, few have addressed its effectiveness among practicing nurses. This trial was designed to address that gap.

DESIGN AND SETTING

Single-center, two-arm, parallel-group, pretest-posttest randomized controlled trial with 1:1 allocation, conducted at Eskisehir Osmangazi University Health Practice and Research Hospital, Türkiye, between July and September 2025. Group allocation is reported according to the CONSORT statement. The study was registered retrospectively: the first participant was enrolled on 7 July 2025, and registration was completed thereafter, but the interventions and the posttest measurements were performed after registration.

The virtual reality application and the assessment instruments used in this trial were developed and validated in a previous study conducted by the same research team with nursing students (ClinicalTrials.gov NCT05815979; doi 10.1002/jcal.70314).

PARTICIPANTS AND SAMPLE SIZE

The study population comprised nurses working in internal medicine, surgical, and intensive care units of the hospital. Sample size was calculated with G*Power 3.1.9.4 from the means and standard deviations of the nasogastric tube insertion skill checklist reported in a reference study (22.07 ± 4.06 and 26.27 ± 5.70), giving an effect size of d = 0.85. With a two-tailed independent-samples t-test, alpha 0.05, power 0.85, and 1:1 allocation, 52 participants were required, 26 per group. Allowing for 20% attrition, the target was raised to 32 per group and 64 in total. Sixty-five nurses were enrolled, and 62 completed the study.

RANDOMIZATION

An independent statistician performed all allocation procedures using the minimization technique, with age, sex, clinic of employment, pretest knowledge test score, and pretest skill checklist insertion and removal scores as balancing variables. Continuous variables were dichotomized at the overall sample mean. Each participant was assigned to the group producing the lowest overall imbalance; where both groups yielded equal imbalance, allocation was decided by lot. Minimization was carried out in Microsoft Excel after recruitment and all pretest measurements had been completed, so no allocation was made during enrollment, and the researchers could not predict the allocation outcome. Which group served as the intervention arm was then determined by drawing lots, producing 33 participants in the intervention group and 32 in the control group.

BLINDING

Participants and the researcher delivering the intervention could not be masked because of the nature of the intervention. The two raters who scored the skill checklist at the pretest and posttest assessments were not members of the research team and were not informed of participants' group allocation. Both raters assessed each participant simultaneously. The statistician who analyzed the data was a different person from the statistician who performed the allocation and was also masked; groups were coded as 1 and 2 before data entry.

PROCEDURES

Between 8 and 18 July 2025, participants completed the informed consent form, personal information form, and knowledge test; performed nasogastric tube insertion and removal on a medium-fidelity simulator for the pretest skill assessment; and completed the self-confidence and anxiety visual analog scales. The researcher then delivered a 30-minute theoretical session using a 33-slide presentation validated by three subject experts, followed on the same day by a 15-minute demonstration of the procedure on a medium-fidelity simulator.

Free practice sessions were held individually under researcher supervision between 23 July and 13 August 2025 for the control group and between 24 July and 13 August 2025 for the intervention group. Up to three sessions were permitted; all participants attended one session and experienced all 85 procedural steps. Practice time was 7 to 10 minutes in the intervention group and 5 to 10 minutes in the control group.

Posttest assessments were carried out between 11 August and 10 September 2025, at least two weeks after each participant's free practice session. Participants performed nasogastric tube insertion and removal on a medium-fidelity simulator and were scored simultaneously by the two masked raters. The knowledge test, the self-confidence and anxiety visual analog scales, and the motivation scale were administered after the skill assessment.

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 presents a virtual patient room containing a nurse and a patient, in which the user performs 53 nasogastric tube insertion steps and 32 removal steps in a fixed sequence. Written instructions appear in the user's field of view and are accompanied by simultaneous audio narration. The system requires the interaction defining a step to be completed before the next step loads, so steps cannot be skipped or reordered and incorrect actions are not possible. Performance was not scored within the application, and session data were not recorded. A teleportation feature supported safe navigation within the limited physical space.

MEASUREMENT INSTRUMENTS

Nasogastric Catheterization Application Knowledge Test: 25 multiple-choice items, score range 0-25.

Nasogastric Catheter Application Checklist: 85 steps (53 insertion, 32 removal), each scored 0, 1, or 2, total range 0-170; Cronbach's alpha 0.875 in this study.

Critical Procedural Steps: 30 safety-critical items drawn from the checklist (22 insertion, 8 removal), total range 0-60.

Self-Confidence and Anxiety Visual Analog Scales: 10 cm horizontal lines, range 0-10 each, scored by two independent raters.

Instructional Material Motivation Scale: 14 items, five-point Likert format, range 14-70; Cronbach's alpha 0.926 in this study.

STATISTICAL ANALYSIS

Analyses were performed with SPSS 25.0 at a two-sided significance level of 0.05. Distribution was examined using skewness and kurtosis values, coefficients of variation, detrended Q-Q plots, and histograms, with values within the plus or minus 2 range accepted. Baseline variables were compared with independent-samples t-tests or their nonparametric equivalents and with chi-square or Fisher's exact tests as appropriate. A two-factor mixed repeated-measures analysis of variance including the group-by-time interaction evaluated change in knowledge, skill, critical procedural step, self-confidence, and anxiety scores; homogeneity of variances was verified with Levene's test, and effect sizes are reported as eta-squared. Motivation, measured only at posttest, was compared with an independent-samples t-test. Inter-rater agreement for posttest skill scores was assessed with the intraclass correlation coefficient using a two-way random-effects model with absolute agreement.

SAFETY

The only foreseeable risk was cybersickness associated with the head-mounted display. Participants were informed before use that the headset could cause symptoms such as dizziness and nausea, a safe practice area was established, and the teleportation feature was used to limit motion-related discomfort. One participant in the intervention group experienced dizziness and was withdrawn from the study. No other participant reported any problem.

ETHICS

Ethical approval was obtained from the Non-Interventional Clinical Research Ethics Committee of Gaziantep Islam Science and Technology University (Decision no. 599.46.01, 15 May 2025; Protocol no. 2025/599). Institutional approval was obtained from the hospital where the study was conducted (4 June 2025; E-93213427-605-250094631). Written informed consent was obtained from all participants, who were informed of the purpose and method of the study, the voluntary nature of participation, and their right to withdraw at any time. The study was conducted in accordance with the Declaration of Helsinki. After the study was completed, nurses in the control group who wished to try the virtual reality application were given the same opportunity as the intervention group.

AMENDMENT TO THE ELIGIBLE POPULATION

The study was originally approved and registered with a sample restricted to newly graduated nurses. During recruitment the number of newly graduated nurses willing to participate proved insufficient, and the eligible population was therefore broadened to include all nurses working in the relevant units. A written application describing this change was submitted to the ethics committee, and the study title was revised accordingly. No change was made to the outcome measures or the planned analyses.

• Immersive Virtual Reality Training (Behavioral): An immersive virtual reality application developed in Unity 2022.3.18f1 with the XR Interaction Toolkit 2.1 for the Oculus Quest 2 platform, presenting a virtual patient room in which the user performs 53 nasogastric tube insertion steps and 32 removal steps in a fixed sequence. Written instructions in the user's field of view and simultaneous audio narration guide each step. The system requires the interaction defining a step to be completed before the next step loads, so steps cannot be skipped or reordered. Performance was not scored within the application and session data were not recorded.
• Conventional Simulator Practice (Behavioral): Individual practice of nasogastric tube insertion and removal on a medium-fidelity simulator, following the theoretical instruction and demonstration delivered by the researcher in accordance with the Nasogastric Catheter Application Checklist.

Primary outcomes

• Change in Nasogastric Catheter Application Skill Score [Baseline (pretest) and at least two weeks after the free practice session (posttest)]: Psychomotor performance in nasogastric tube insertion and removal, assessed with the Nasogastric Catheter Application Checklist. The checklist contains 85 steps (53 insertion, 32 removal). Each step scores 2 if performed completely, 1 if performed partially and 0 if not performed. The total score ranges from 0 to 170. Higher scores indicate better procedural skill.

Secondary outcomes

• Change in Critical Procedural Step Score [Baseline (pretest) and at least two weeks after the free practice session (posttest)]: Safety-critical subset of the Nasogastric Catheter Application Checklist, comprising 30 procedure-specific steps (22 insertion, 8 removal). Each step scores 0, 1 or 2, giving a total score from 0 to 60. Higher scores indicate safer performance of the procedure.
• Change in Nasogastric Catheter Application Knowledge Test Score [Baseline (pretest) and at least two weeks after the free practice session (posttest)]: Knowledge required for nasogastric tube application, assessed with a 25-item multiple-choice test, each item having five options. Correct answers score 1 and incorrect answers score 0, giving a total score from 0 to 25. Higher scores indicate greater knowledge.
• Change in Self-Confidence Score [Baseline (pretest) and at least two weeks after the free practice session (posttest)]: Self-confidence in performing nasogastric tube application, assessed with the Self-Confidence Visual Analog Scale, a 10 cm horizontal line anchored at 0 (no self-confidence) and 10 (very high self-confidence). The score is the distance in centimetres from the start of the line to the point marked by the participant. Higher scores indicate greater self-confidence.
• Change in Anxiety Score [Baseline (pretest) and at least two weeks after the free practice session (posttest)]: Anxiety related to performing nasogastric tube application, assessed with the Anxiety Visual Analog Scale, a 10 cm horizontal line anchored at 0 (no anxiety) and 10 (very high anxiety). The score is the distance in centimetres from the start of the line to the point marked by the participant. Higher scores indicate greater anxiety.
• Motivation Towards the Instructional Material [Posttest only, at least two weeks after the free practice session]: Motivation towards the instructional material used, assessed with the Instructional Material Motivation Scale, a unidimensional 14-item five-point Likert scale with no reverse-scored items. The total score ranges from 14 to 70. Higher scores indicate greater motivation.

Sex: All, ages: 18 Years to 65 Years, accepts healthy volunteers

Inclusion Criteria:

* Working as a nurse in an internal medicine, surgical or intensive care unit of the hospital where the study was conducted
* Volunteering to participate in the study
* Aged 18 years or over

Exclusion Criteria:

\- Working in outpatient clinics, physical therapy, psychiatry or paediatric clinics

• Ayşe Eminoğlu, Dr., Study director, ayse.eminoglu@gibtu.edu.tr