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LiuP, etal. BMJ Open 2024;14:e082847. doi:10.1136/bmjopen-2023-082847
Open access
Effects of virtual reality OSCE on
nursing students’ education: a study
protocol for systematic review and meta-
analysis
Ping Liu,1 Xuan Dong,1 Fei Liu,2 Haixia Fu 1
To cite: LiuP, DongX, LiuF,
etal. Effects of virtual reality
OSCE on nursing students’
education: a study protocol
for systematic review and
meta- analysis. BMJ Open
2024;14:e082847. doi:10.1136/
bmjopen-2023-082847
►Prepublication history
and additional supplemental
material for this paper are
available online. To view these
les, please visit the journal
online (https://doi.org/10.1136/
bmjopen-2023-082847).
Received 05 December 2023
Accepted 14 May 2024
1Afliated Hospital of Nanjing
University of Chinese Medicine,
Nanjing, Jiangsu, China
2Jiangsu Province Hospital,
Nanjing, Jiangsu, China
Correspondence to
Professor Haixia Fu;
18626469889@ 163. com
Protocol
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Introduction Virtual objective structured clinical
examination (OSCE) has been shown to inuence the
performance of nursing students. However, its specic
effects, particularly students’ competence, stress, anxiety,
condence, satisfaction with virtual reality OSCE and
examiners’ satisfaction, remain unclear.
Method and analysis This study aims to assess the
effects of virtual reality OSCE on nursing students’
education. The study follows the Preferred Reporting
Items for Systematic Review and Meta- Analysis Protocol
guidelines. A literature search is performed on electronic
databases, namely, PubMed, Web of Science, CINAHL,
EBSCO, EMBASE and the Cochrane Library. The inclusion
criteria adhere to the PICOS principle, encompassing
nursing students, including those studying in school
and those engaged in hospital internship. This review
includes studies on the use of virtual reality OSCE as
an assessment tool, compared with traditional clinical
examinations, such as in- person OSCE. The outcome
assessments encompass (1) competence, (2) stress, (3)
anxiety, (4) condence, (5) student satisfaction with virtual
reality OSCE and (6) examiners’ satisfaction. These studies
are designed as randomised controlled trials (RCTs) or
quasi- experimental research. The search time is from
the inception of each database to 30 June 2023, without
language restriction. Studies for inclusion are screened by
two reviewers for data extraction dependently. Any dispute
is resolved through discussion. Unresolved disputes are
decided by consulting a third author. For the risk of bias
(ROB) assessment, the Cochrane ROB tool for RCTs and
the risk of bias in non- randomised studies of intervention
tool are used. Moreover, RevMan V.5.3 is used for meta-
analysis.
Ethics and dissemination This study protocol does not
include any clinical research and thus does not require
ethical approval. Research ndings are published in a
peer- reviewed journal.
PROSPERO registration number CRD42023437685.
INTRODUCTION
The objective structured clinical exam-
ination (OSCE) provides an objective,
orderly and organised assessment frame-
work, in which medical schools, hospitals,
or medical or examination institutions can
add corresponding assessment contents and
methods according to their teaching and
examination syllabus.1 This method tests the
clinical abilities of nurses or nursing students
by simulating clinical scenarios.2 It is also
a clinical ability assessment method that
emphasises knowledge, skills and attitude.3
Candidates conduct practical tests through a
series of predesigned exam stations, including
standardised patients (SP), practical oper-
ations on medical simulators, collection of
clinical data and document retrieval.4 The
exam station is divided into long and short
stations, with a duration ranging from 5 min
to 20 min; candidates are evaluated by the
examiner or SP.5
However, given that the OSCE requires
a person- in- person offline operation, some
objective factors, such as the restrictions of
the COVID- 19 epidemic some time ago,6–8
the development of virtual reality (VR) tech-
nology in the field of nursing education,9–11
and the increasingly popular cross- regional
and multicentre joint training,12 13 exist. As
a result, the traditional offline OSCE cannot
satisfy the requirements of modern nursing
education.
VR OSCE refers to the implementation
of traditional OSCE on VR devices and the
use of VR technology.14 More applications
are developed in the fields of medical and
nursing education.15–17 Compared with
STRENGTHS AND LIMITATIONS OF THIS STUDY
⇒We strictly follow the recommendations of the
Cochrane handbook for systematic reviews of inter-
ventions to ensure a rigorous research process.
⇒The search algorithm will be developed by an expe-
rienced librarian to ensure the comprehensiveness
of the literature retrieval and processing.
⇒The limited quantity and quality of the original re-
search may reduce the reliability of the evidence.
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Open access
traditional OSCE, VR OSCE has some significant advan-
tages. It can be carried out without physical distance
limitations, thereby allowing participation from long
distances, multiple locations and simultaneous engage-
ment, making it highly accessible.18 Modern VR devices
are more popular among young people.19 Meanwhile,
research has shown that these devices can increase partic-
ipants’ confidence, allowing them to perform better in
exams.20 With the rapid development of VR OSCE, its
application in the field of nursing education is gradually
increasing, playing an important and irreplaceable role
in the assessment of nursing students.21 22
Nevertheless, the effects of VR OSCE as an assessment
method for nursing students are controversial. Some
studies showed that VR OSCE can improve confidence
and competence among nursing students,23 24 whereas
others presented no significant growth.17 Although VR
OSCE demonstrates potential in improving the assess-
ment of nursing students, adequate evidence confirming
the effects of VR OSCE as an assessment method for
nursing students is lacking.
To the best of our knowledge, a meta- analysis of the
effects of VR OSCE on the education performance of
nursing students has not yet been carried out. A system-
atic review23 has reported the implementation of VR
OSCE, strengthening confidence in the virtual environ-
ment. However, their study population includes health
professionals, rather than nursing students exclusively.
Another systematic review25 has reported that OSCE is a
more credible assessment format than the virtual style in
evaluating the clinical competence of nursing students.
Therefore, assessing the effects of VR OSCE for nursing
students is urgently necessary. In this study, we aim to
systematically evaluate the effectiveness of VR OSCE as
an assessment method, particularly in terms of students’
competence, stress, anxiety, confidence, satisfaction with
VR OSCE and examiners’ satisfaction.
METHODS
Aim
This study aims to assess the effects of VR OSCE on
nursing students’ education.
Registration
This protocol study is conducted in accordance with the
Preferred Reporting Items for Systematic Review and
Meta- Analysis Protocols (PRISMA) guidelines26 and has
been registered in the International Prospective Register
of Systematic Reviews (PROSPERO) with registration
number CRD42023437685.
Search strategy
Electronic data search is carried out on PubMed, Web of
Science, CINAHL, EBSCO, EMBASE and the Cochrane
Library. In addition, references of included papers are
searched to identify additional eligible studies. For studies
without full text or with missing original data, the original
authors are contacted. Finally, the research that contains
sufficient information to assess eligibility for inclusion
criteria is also included.
We establish the search strategy by using preretrieval
PubMed. Search terms related to “virtual” are as follows:
“virtual reality” OR “virtual” OR “online” OR “digital”
OR “remote” OR “electronic” OR “video” OR “web”. The
Boolean operator “OR” is used to combine these terms
with different syntaxes adapted to each original database.
The keywords used to capture the concept of “OSCE”
include “OSCE” OR “objective structured clinical exam-
ination” OR “clinical simulation in nursing” OR “high
fidelity simulation training” OR “clinical examination”
OR “clinical assessment” OR “clinical skill assessment”
OR “clinical competence” OR “clinical performance”. We
use the Boolean operator “OR” to combine these search
terms with different syntaxes adapted to each database.
Search terms related to “nursing students” are “students,
nursing” OR “nursing student*” OR “pupil nurse*” OR
“nurse intern” OR “nursing staff” OR “nurse education”
Similarly, the Boolean operator “OR” is used to combine
the search terms with different syntaxes adapted to each
database.
We use the Boolean operator “‘AND” to combine
the three search terms, namely, “virtual,” “OSCE” and
“nursing students”. The search time is from the inception
of each database to 30 June 2023, and no language restric-
tion is considered. References of included studies are
searched for additional identification. For studies without
original data, we attempt to contact the original authors
to obtain the required information. The search algorithm
will be developed by an experienced librarian to ensure
the comprehensiveness of the literature retrieval and
processing. The search strategy is shown in online supple-
mental appendix.
Eligibility criteria
Population
Nursing students comprising those studying in school
and engaging in hospital internships are included.
Intervention
Studies on the use of VR OSCE as an assessment tool.
Comparator
Studies on the use of traditional clinical examinations,
such as in- person OSCE as assessment tools.
Outcome
We assess the outcome list as follows: (1) competence, (2)
stress, (3) anxiety, (4) confidence, (5) students’ satisfaction
with VR OSCE and (6) examiners’ satisfaction. Compe-
tence refers to the ability of an individual to complete
a task appropriately.27 It can be assessed using different
instruments, such as the nurse competency scale.28 Stress
is a cognitive and behavioural experience composed
of psychological stress source and psychological stress
response.29 It can be assessed using instruments, such as
the Perceived Stress Scale.30 Anxiety is a restless emotion
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caused by excessive concerns about the safety of family
members or one’s own life, future and destiny.31 It can
be assessed using different instruments, such as state–trait
anxiety inventory32 and Self- rating Anxiety Scale.33 Confi-
dence refers to a psychological characteristic that reflects
an individual’s level of trust in his ability to successfully
complete a certain activity; it is a positive and effective
expression of self- worth, self- respect and self- awareness,
as well as a psychological state.34 It can be assessed using
student satisfaction and self- confidence in the learning
scale.35 Satisfaction is a psychological state that refers to
a person’s subjective evaluation of the quality of a rela-
tionship.36 It can be assessed using the Simulated Clin-
ical Experience Satisfaction Scale,37 Clinical Learning
Environment, Supervision and Nurse Teacher Scale38
and some self- made scales.39 Data extracted by additional
scales can also be applied to this study.
Study design
This study includes randomised controlled trials (RCTs)
and quasi- experimental studies, focusing on VR OSCE
groups versus traditional clinical examination groups.
Exclusion criteria
The exclusion criteria are as follows: (1) outcome
measures are inappropriate and relevant data cannot be
obtained from original authors; (2) animal experiments,
reviews, notes, editorials or errata articles and (3) dupli-
cate published literature.
Study selection and data extraction
Study selection
Preliminary search results are downloaded from the
software ‘EndNote V.X9’. First, on accessing titles and
abstracts using the function ‘Find duplicates’ of the soft-
ware, we delete duplicate articles by comparing titles and
authors. Second, we enter the manual screening stage,
where the preliminary screening allows removing docu-
ments that do not satisfy the requirements by reading
the titles and abstracts of included articles. Third, we
download the remaining documents to obtain, read
the full texts and then remove documents that do not
satisfy the requirements. Fourth, for documents with
missing texts or original data, we attempt to contact the
authors to obtain information. If such an attempt is still
unsuccessful, then we delete the related documents and
provide reasons. Finally, references of included docu-
ments in the final study are reviewed and assessed for
additional research that may satisfy the inclusion criteria.
Two of the present authors (PL and XD) independently
conducted the literature retrieval. Disputes are resolved
through discussion, and unresolved issues are decided on
by consulting the research director (HF). The selection
process is conducted according to the PRISMA flow chart.
Data extraction
Data for extraction include the following information:
(1) Basic information of each study, including author,
publication year and country (or region); (2) Participant
characteristics: sample size, grouping and sample size
of each group, mean age and gender; (3) Intervention
method characteristics: study design, specific interven-
tion and control methods, VR intervention duration, and
comparator; (4) Research results: result measurement
method, data type, statistical data and results. Outcome
data are expressed as mean±SD (M±SD). If data are
provided in other formats, such as median range or
median IQR, then M±SD values are calculated following
the recommendations of the Cochrane Handbook for
Systematic Reviews of Interventions.40 (5) Other infor-
mation includes support from funding institutions and
potential conflicts of interest. Two of the authors (PL
and XD) conduct data extraction independently, and any
dispute is settled by discussion. Unresolved disputes are
decided on by consulting the third author (HF). The data
extraction method is to manually fill in the Excel table,
the extracted data are input into the software RevMan
V.5.3 for meta- analysis.
Quality assessment of included studies
For randomised trials, we use the Cochrane risk- of- bias
(ROB) tool41 to evaluate the bias risk of RCT. Seven
criteria are included, namely, random sequence genera-
tion, allocation concealment, participant and personnel
blinding, outcome assessment blinding, incomplete data
outcome, selective outcome reporting, and other biases.
Risk bias level is classified as high, unclear and low. We
select the risk of bias in non- randomised studies of inter-
vention42 tool for non- RCT studies to evaluate the ROB.
The ROB includes issues related to confounding, partici-
pant selection, intervention classification, deviation from
intended intervention, missing data, outcome measure-
ment, reported result selection and overall bias.
The research quality will be assessed by applying GRADE
(Grading of Recommendations Assessment, Develop-
ment and Evaluation) approach,43 and calculating the
between- rater agreement coefficient. The kappa coeffi-
cients will be classified according to the study of Landis
and Koch44 as follows: 0.0–0.20=slight agreement, 0.21–
0.40=fair agreement, 0.41–0.60=moderate agreement,
0.61–0.80=substantial agreement and 0.81–1.00=nearly
perfect agreement.45
The two authors (PL and XD) independently evaluate
the ROB for each included study and evidence quality.
Any dispute is resolved through discussion. Unresolved
disputes are decided on by consulting the third author
(HF).
Data synthesis and statistical analysis
Data synthesis
SPSS V.22.0 and RevMan V.5.3 software will be used for
statistical analysis. For continuous data, if the measure-
ment methods used in each study are the same, then we
select the weighted mean difference model for statistical
analysis; otherwise, the standardised mean difference
model is preferred. For dichotomous data, the OR value is
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Open access
calculated. All effective quantities are expressed with 95%
CI. A p<0.05 indicates a statistically significant difference.
Heterogeneity assessment
I2 test is used to assess the heterogeneity level. According
to the Cochrane handbook, large heterogeneity exists
when I2>50%. If p>0.1 and I2<50%, then a fixed effect
model is used; otherwise, if p<0.1 and I2>50%, then the
random effect model is applied. If conditions permit,
then we collect quantitative data for meta- analysis; other-
wise, data are presented in narrative form. Sensitivity and
subgroup analyses are performed to explain possible
heterogeneity sources.
Subgroup analysis
If significant heterogeneity (I2>50%) is found and the
heterogeneity source cannot be detected through sensi-
tivity analysis, then a subgroup analysis is conducted.
Grouping analysis can be applied to basic research infor-
mation, subject characteristics, intervention methods,
intervention duration, sample size or other aspects.
Sensitivity analysis
When heterogeneity is large, the leave- one- out method is
used to determine whether it is caused by a certain study.
For example, we remove one study to determine whether
heterogeneity decreases. This method is used to test each
study to find the possible heterogeneity source.
Publication bias assessment
For 10 or more studies available for meta- analysis, we use
funnel plot to measure the publication bias level. Specif-
ically, the method evaluates whether the funnel plot is
symmetrical through visual inspection using the Egger’s
test with a significance level of 5%.46 If less than 10 items
exist, then we determine whether publication bias exists
according to the characteristics of the included studies.
Evidence quality
The quality of each evidence is assessed using the GRADE
rating scale.47 We classify the quality as high, moderate,
low or very low according to the consideration of ROB,
inconsistency (heterogeneity), indirectness, imprecision
and publication bias.48 The results start with ‘high’-quality
evidence and are then degraded according to the prob-
lems in each field. Results can also be enhanced when the
evidence shows that all possible confounding factors and
other deviations increase confidence in the estimated
effect. The two authors (PL and XD) score each area of
comparison and resolve differences through consensus.
Unresolved disputes are decided on by consulting the
third author (HF).
Expected dates for research
The literature search is from 30 June 2023 to 31 January
2024, data extraction is from 1 February 2024 to 31 March
2024, quality evaluation is from 1 April 2024 to 30 April
2024, the meta- analysis is from 1 May 2024 to 30 June
2024 and evidence quality evaluation is from 1 July 2024
to 31 July 2024.
Patient and public involvement
Our study will not involve or did not involve patients
or the public in the design, execution or planning for
reporting and dissemination.
Future directions and clinical implications
With the continuous improvement and development of
VR technology, it has been applied in clinical research
and has achieved satisfactory treatment results.49 Previous
studies showed that VR plays a certain role in the treat-
ment of psychological conditions in ICU patients, but
the specific efficacy remains controversial.39 50 We further
analyse which aspects of VR have positive therapeutic
effects on the psychological conditions of ICU patients,
which aspects have no therapeutic effects, and which have
adverse effects. We also explore the possible causes and
reasons. How to maximise the advantages of VR in clinical
intervention will become the future development direc-
tion. This concept has clinical significance for providing
more scientific intervention plans and a theoretical basis
for the application of VR in the treatment of psycholog-
ical disorders in ICU patients.
Ethics and dissemination
This protocol study does not carry out clinical research
and thus does not require ethical approval. Research
findings will be published in a peer- reviewed journal.
Contributors PL contributed to the rst rudimentary draft and revision of the
manuscript. XD contributed to the data collection and data analysis. FL contributed
to the conception, rst draft and revision of the manuscript. HF had primary
responsibility for the overall content as the guarantor.
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It
has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
been peer- reviewed. Any opinions or recommendations discussed are solely
those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability
and responsibility arising from any reliance placed on the content. Where the
content includes any translated material, BMJ does not warrant the accuracy and
reliability of the translations (including but not limited to local regulations, clinical
guidelines, terminology, drug names and drug dosages), and is not responsible
for any error and/or omissions arising from translation and adaptation or
otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
HaixiaFu http://orcid.org/0009-0004-2941-5565
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