# Reducing Stress while Enhancing Self-Efficacy and Knowledge: Virtual Training for Inexperienced Nursing Students in the Operating Room

Inas Redjem, Arnaud Huaulmé, Jérôme Chapoul, Mathieu Risy, Florian

Nouviale, Alexandre Audinot, Valérie Gouranton, Estelle Michinov, Pierre

Jannin

► To cite this version:

Inas Redjem, Arnaud Huaulmé, Jérôme Chapoul, Mathieu Risy, Florian Nouviale, et al.. Reducing Stress while Enhancing Self-Efficacy and Knowledge: Virtual Training for Inexperienced Nursing Students in the Operating Room. Doctoral Consortium Laval Virtual, Laval Virtual, Apr 2024, Laval, France. **hal-04616264**

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Submitted on 18 Jun 2024

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# Reducing Stress while Enhancing Self-Efficacy and Knowledge: Virtual Training for Inexperienced Nursing Students in the Operating Room

Inas Redjem, Arnaud Huaulmé, Jérôme Chapoul, Mathieu Risy, Florian

Nouviale, Alexandre Audinot, Valérie Gouranton, Estelle Michinov, Pierre

Jannin

► To cite this version:

Inas Redjem, Arnaud Huaulmé, Jérôme Chapoul, Mathieu Risy, Florian Nouviale, et al. Reducing Stress while Enhancing Self-Efficacy and Knowledge: Virtual Training for Inexperienced Nursing Students in the Operating Room. Laval Virtual 2024 - Doctoral Consortium, Laval Virtual, Apr 2024, Laval, France. pp.1-2. [hal-04616264](https://hal.science/hal-04616264v1)

HAL Id: hal-04616264

https://hal.science/hal-04616264v1

Submitted on 18 Jun 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
Reducing stress while enhancing self-efficacy and
knowledge : virtual training for inexperienced
nursing students in the operating room

Inas Redjem
LP3C, univesité Rennes 2
LTSI- Inserm, Université Rennes
Rennes, France
inas.redjem@univ-rennes2.fr

Arnaud Huaulmé
LTSI- Inserm, Université Rennes
Rennes, France

Jérôme Chapoul
LTSI- Inserm, Université Rennes
Rennes, France

Mathieu Risy
INSA Rennes
IRISA, Université Rennes
Rennes, France

Florian Nouviale
INSA Rennes
IRISA, Université Rennes
Rennes, France

Alexandre Audinot
INSA Rennes
IRISA, Université Rennes
Rennes, France

Valérie Gouranton
INSA Rennes
IRISA, Université Rennes
Rennes, France

Estelle Michinov
LP3C, Université Rennes 2
Rennes, France

Pierre Jannin
LTSI- Inserm, Université Rennes
Rennes, France

**Abstract**—The operating room (OR) is a demanding and high-pressure environment for healthcare professionals. This study aims to use virtual reality (VR) technology to introduce health profession students to the OR environment in a controlled and immersive way. Using a quasi-experimental design with pre-post measures we aim to investigate the effect of a VR OR simulation on students' anxiety, stress, self-efficacy and knowledge acquisition. We recruited 40 second-year nursing students without prior OR experience and divided them into two groups: one experiencing the OR through a VR display and the other through a slideshow presentation of the same environment. We assessed anxiety, stress, self-efficacy and knowledge level before and after intervention. Results indicated a significant increase in self-efficacy for the two groups. The VR group also showed increase in anxiety in association with decrease in stress levels. Knowledge acquisition improved in both groups. This study underlines VR's potential as an effective tool for OR familiarization, significantly enhancing self-efficacy and reducing stress among nursing students.

**Keywords**—operating room, nursing, self-efficacy, virtual reality, training

I. INTRODUCTION

The operating room (OR) is a demanding and high-
pressure environment for healthcare professionals. However,
students often have limited exposure to this critical setting
during their training, leaving them ill-prepared to handle the
stress and anxiety [1] when they finally enter clinical practice
[2]. Simulation-based training is commonly used in health
profession education to bridge the gap between theory and
practice [3]. Virtual reality (VR) technology offers a
promising solution [4] by providing a realistic OR simulation
experience, allowing students to gain familiarity with the
environment and enhance their confidence before engaging
in actual practice.

This study aims to use VR technology to introduce health
profession students to the OR environment in a controlled
and immersive way. The goal is to investigate the effect of a
VR OR simulation on anxiety, stress, self-efficacy and
knowledge acquisition of nursing students.

II. METHOD

A. *Pedagogical material*

We have developed a VR training tool allowing students to immerse in the OR environment. Learners can navigate through the virtual OR, interact with the environment, and get detailed information about aseptic areas, medical staff, and various OR equipment.

B. *Participant recruitment*

We reached out to several nursing schools in order to
recruited second year nursing students who did not have any
prior OR experience. The recruitment criteria were designed
to ensure participants had no factors that could influence
their experience in the VR environment, such as motion
sickness, epilepsy, or cardiac issues.

C. *Design and procedure*

Our study employed a quasi-experimental design with
pre-post repeated measures. Participants were assigned to
one of the two experimental groups:

* VR operating room environment (n=24)

* Slideshow operating room environment (n=16)

The VR group experienced the OR through a head-
mounted VR display (HTV VIVE pro), providing a fully
immersive experience while the slideshow group viewed a
slideshow presentation depicting the same OR environment
shown in the VR simulation.

D. *Measures*

Participants completed the same four questionnaires both
before and after their experience with the virtual OR. We
assessed:

* Anxiety, measured with a six-item version of the State-Trait Anxiety Inventory (STAI) [5]

* Stress, using a visual analog scale ranging from 0 to 10. This scale allowed participants to indicate their
# Reducing stress while enhancing self-efficacy and knowledge : virtual training for inexperienced nursing students in the operating room

Inas Redjem
LP3C, univesité Rennes 2
LTSI- Inserm, Université Rennes
Rennes, France
inas.redjem@univ-rennes2.fr

Arnaud Huaulmé
LTSI- Inserm, Université Rennes
Rennes, France

Jérôme Chapoul
LTSI- Inserm, Université Rennes
Rennes, France

Mathieu Risy
INSA Rennes
IRISA, Université Rennes
Rennes, France

Florian Nouviale
INSA Rennes
IRISA, Université Rennes
Rennes, France

Alexandre Audinot
INSA Rennes
IRISA, Université Rennes
Rennes, France

Valérie Gouranton
INSA Rennes
IRISA, Université Rennes
Rennes, France

Estelle Michinov
LP3C, Université Rennes 2
Rennes, France

Pierre Jannin
LTSI- Inserm, Université Rennes
Rennes, France

**Abstract**—The operating room (OR) is a demanding and high-pressure environment for healthcare professionals. This study aims to use virtual reality (VR) technology to introduce health profession students to the OR environment in a controlled and immersive way. Using a quasi-experimental design with pre-post measures we aim to investigate the effect of a VR OR simulation on students' anxiety, stress, self-efficacy and knowledge acquisition. We recruited 40 second-year nursing students without prior OR experience and divided them into two groups: one experiencing the OR through a VR display and the other through a slideshow presentation of the same environment. We assessed anxiety, stress, self-efficacy and knowledge level before and after intervention. Results indicated a significant increase in self-efficacy for the two groups. The VR group also showed increase in anxiety in association with decrease in stress levels. Knowledge acquisition improved in both groups. This study underlines VR's potential as an effective tool for OR familiarization, significantly enhancing self-efficacy and reducing stress among nursing students.

**Keywords**—operating room, nursing, self-efficacy, virtual reality, training

## I. INTRODUCTION

The operating room (OR) is a demanding and high-pressure environment for healthcare professionals. However, students often have limited exposure to this critical setting during their training, leaving them ill-prepared to handle the stress and anxiety [1] when they finally enter clinical practice [2]. Simulation-based training is commonly used in health profession education to bridge the gap between theory and practice [3]. Virtual reality (VR) technology offers a promising solution [4] by providing a realistic OR simulation experience, allowing students to gain familiarity with the environment and enhance their confidence before engaging in actual practice.

This study aims to use VR technology to introduce health profession students to the OR environment in a controlled and immersive way. The goal is to investigate the effect of a VR OR simulation on anxiety, stress, self-efficacy and knowledge acquisition of nursing students.

## II. METHOD

### A. Pedagogical material

We have developed a VR training tool allowing students to immerse in the OR environment. Learners can navigate through the virtual OR, interact with the environment, and get detailed information about aseptic areas, medical staff, and various OR equipment.

### B. Participant recruitment

We reached out to several nursing schools in order to recruit second year nursing students who did not have any prior OR experience. The recruitment criteria were designed to ensure participants had no factors that could influence their experience in the VR environment, such as motion sickness, epilepsy, or cardiac issues.

### C. Design and procedure

Our study employed a quasi-experimental design with pre-post repeated measures. Participants were assigned to one of the two experimental groups:

* VR operating room environment (n=24)

* Slideshow operating room environment (n=16)

The VR group experienced the OR through a head-mounted VR display (HTV VIVE pro), providing a fully immersive experience while the slideshow group viewed a slideshow presentation depicting the same OR environment shown in the VR simulation.

### D. Measures

Participants completed the same four questionnaires both before and after their experience with the virtual OR. We assessed:

* Anxiety, measured with a six-item version of the State-Trait Anxiety Inventory (STAI) [5]

* Stress, using a visual analog scale ranging from 0 to 10. This scale allowed participants to indicate their
level of stress at the idea of being an intern in the OR
for the first time.

* Knowledge about OR equipment, medical staff and aseptic areas. Knowledge was assessed using a 9-item quiz (e.g. 'Who is the professional who manages the instrument table?')

* Self-efficacy, measured with a 9-item visual analog scale ranging from 0 to 100 (e.g. 'I feel confident recognizing some of the instruments used by the surgeon during knee surgery')

Furthermore, to measure the sense of presence,
participants completed the Slater-Usoh-Steed Presence
Questionnaire [6] after the intervention.

III. RESULTS

A. Participants

A total of 40 second-year nursing students were
recruited. They were divided into two groups, with 24
participants in the VR group and 16 in the slideshow group.

B. Immersion experience

An independent samples t-test was conducted to compare
the immersion score between the VR group and the
slideshow group. The VR group (M = 30.30, SD =5.57)
reported significantly higher level of immersion compared to
the slideshow group (M = 16.1, SD = 7.87). t(38) = -6.69, p
<0.001.

C. Anxiety

Due to non-parametric nature of the data, a Wilcoxon
signed-rank test was conducted to assess changes in anxiety
levels within the VR group before and after the intervention.
Analysis revealed a significant increase in anxiety from pre
(M = 50.4, SD = 6.83) to post-intervention (M=53.8, SD =
3.72) within the VR group, Z = 42.5, p = 0.02. This suggests
that the VR intervention led to a statistically significant
increase in anxiety levels among VR group participants.

D. Stress

Conversely, the VR group experienced a significant
reduction in stress level post-intervention compared to before
intervention as shown by a paired samples t-test, t(23) =
4.14, p<0.001.

E. Self-efficacy

Both the VR and slideshow groups showed an increase in
self-efficacy following the intervention. A Wilcoxon signed-
rank test conducted to investigate differences within the VR
group showed a significant increase in self efficacy scores
following the intervention, Z = 300, p<0.001. For the
slideshow group, a paired samples t-test was used and
showed a significant improvement in self-efficacy, t(15) =
5.80, p<0.001.

Upon further analysis using difference scores and
conducting a Mann-Whitney test on these differences, it was
found that VR was more effective than slideshow
presentations in enhancing self-efficacy among nursing
students. U = 65.5, p<0.001.

F. Knowledge acquisition

Regarding knowledge acquisition, both groups exhibited
improvements with no significant difference between the VR

and slideshow group. Paired samples t-test were performed.
The analysis revealed a significant improvement in
knowledge scores, t(15), = 4.25, p<0.001, with mean scores
increasing from pre-intervention (X=3.13, SD=1.29) to post-
intervention (X=5.05, SD=1.71) for the slideshow group. We
also found a significant improvement in knowledge scores,
t(23), = 7.27, p<0.001, with mean scores increasing from
pre-intervention (X=2.97, SD=1.29) to post-intervention
(X=5.26, SD=1.17) for the VR group.

IV. DISCUSSION

The findings from this study underscore the significant potential of virtual reality technology for familiarizing nursing students with the high-pressure OR environment. The immersive VR simulation was associated with enhanced self-efficacy among participants, which is a critical factor for students preparing to enter clinical settings. The increase in anxiety within the VR group, associated with the reduction in stress, offers a nuanced perspective on the immersive experience's impact. While the heightened realism may initially elevate anxiety, the exposure appears to ultimately foster a more profound adaptability to clinical stressors.

The significant improvement in self-efficacy, particularly
noted in the VR group compared to the slideshow group,
highlights VR's unique capacity to engage students actively,
enhancing their confidence in OR-related tasks. However,
the increase in knowledge acquisition, showing no
significant difference between VR and slideshow
presentations, suggests that while VR offers a more engaging
and immersive learning experience, the effectiveness in
conveying factual information might be comparable to more
traditional educational tools.

Future research could explore impacts of VR training on
clinical performance, associated with more interaction of
learners with the VR environment further delineating the
specific aspects of VR simulations that most effectively
contribute to student learning and confidence.

ACKNOWLEDGMENT

This work was supported by state aid managed by the
French National Research Agency under the France 2030
program, bearing the reference ANR-21-DMES-0001.

REFERENCES

[1] M. Pulido-Martos, J. M. Augusto-Landa, et E. Lopez-Zafra, « Sources of stress in nursing students: a systematic review of quantitative studies », *International Nursing Review*, vol. 59, n° 1, p. 15-25, mars 2012.

[2] R. Fink, M. Krugman, K. Casey, et C. Goode, « The Graduate Nurse Experience: Qualitative Residency Program Outcomes », *JONA: The Journal of Nursing Administration*, vol. 38, n° 7/8, p. 341-348, juill. 2008.

[3] H.-H. Lin, « Effectiveness of simulation-based learning on student nurses’ self-efficacy and performance while learning fundamental nursing skills », *THC*, vol. 24, n° s1, p. S369-S375, déc. 2015.

[4] J. Norman, « Systematic review of the literature on simulation in nursing education », *ABNF J*, vol. 23, n° 2, p. 24-28, 2012.

[5] T. M. Marteau et H. Bekker, « The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) », *Br J Clin Psychol*, vol. 31, n° 3, p. 301-306, sept. 1992.

[6] M. Usoh, E. Catena, S. Arman, et M. Slater, « Using Presence Questionnaires in Reality », *Presence: Teleoperators & Virtual Environments*, vol. 9, n° 5, p. 497-503, oct. 2000.
level of stress at the idea of being an intern in the OR
for the first time.

* Knowledge about OR equipment, medical staff and aseptic areas. Knowledge was assessed using a 9-item quiz (e.g. 'Who is the professional who manages the instrument table?')

* Self-efficacy, measured with a 9-item visual analog scale ranging from 0 to 100 (e.g. 'I feel confident recognizing some of the instruments used by the surgeon during knee surgery')

Furthermore, to measure the sense of presence,
participants completed the Slater-Usoh-Steed Presence
Questionnaire [6] after the intervention.

III. RESULTS

A. Participants

A total of 40 second-year nursing students were
recruited. They were divided into two groups, with 24
participants in the VR group and 16 in the slideshow group.

B. Immersion experience

An independent samples t-test was conducted to compare
the immersion score between the VR group and the
slideshow group. The VR group (M = 30.30, SD =5.57)
reported significantly higher level of immersion compared to
the slideshow group (M = 16.1, SD = 7.87). t(38) = -6.69, p
<0.001.

C. Anxiety

Due to non-parametric nature of the data, a Wilcoxon
signed-rank test was conducted to assess changes in anxiety
levels within the VR group before and after the intervention.
Analysis revealed a significant increase in anxiety from pre
(M = 50.4, SD = 6.83) to post-intervention (M=53.8, SD =
3.72) within the VR group, Z = 42.5, p = 0.02. This suggests
that the VR intervention led to a statistically significant
increase in anxiety levels among VR group participants.

D. Stress

Conversely, the VR group experienced a significant
reduction in stress level post-intervention compared to before
intervention as shown by a paired samples t-test, t(23) =
4.14, p<0.001.

E. Self-efficacy

Both the VR and slideshow groups showed an increase in
self-efficacy following the intervention. A Wilcoxon signed-
rank test conducted to investigate differences within the VR
group showed a significant increase in self efficacy scores
following the intervention, Z = 300, p<0.001. For the
slideshow group, a paired samples t-test was used and
showed a significant improvement in self-efficacy, t(15) =
5.80, p<0.001.

Upon further analysis using difference scores and
conducting a Mann-Whitney test on these differences, it was
found that VR was more effective than slideshow
presentations in enhancing self-efficacy among nursing
students. U = 65.5, p<0.001.

F. Knowledge acquisition

Regarding knowledge acquisition, both groups exhibited
improvements with no significant difference between the VR

and slideshow group. Paired samples t-test were performed.
The analysis revealed a significant improvement in
knowledge scores, t(15), = 4.25, p<0.001, with mean scores
increasing from pre-intervention (X=3.13, SD=1.29) to post-
intervention (X=5.05, SD=1.71) for the slideshow group. We
also found a significant improvement in knowledge scores,
t(23), = 7.27, p<0.001, with mean scores increasing from
pre-intervention (X=2.97, SD=1.29) to post-intervention
(X=5.26, SD=1.17) for the VR group.

IV. DISCUSSION

The findings from this study underscore the significant
potential of virtual reality technology for familiarizing
nursing students with the high-pressure OR environment.
The immersive VR simulation was associated with enhanced
self-efficacy among participants, which is a critical factor for
students preparing to enter clinical settings. The increase in
anxiety within the VR group, associated with the reduction in
stress, offers a nuanced perspective on the immersive
experience's impact. While the heightened realism may
initially elevate anxiety, the exposure appears to ultimately
foster a more profound adaptability to clinical stressors.

The significant improvement in self-efficacy, particularly
noted in the VR group compared to the slideshow group,
highlights VR's unique capacity to engage students actively,
enhancing their confidence in OR-related tasks. However,
the increase in knowledge acquisition, showing no
significant difference between VR and slideshow
presentations, suggests that while VR offers a more engaging
and immersive learning experience, the effectiveness in
conveying factual information might be comparable to more
traditional educational tools.

Future research could explore impacts of VR training on
clinical performance, associated with more interaction of
learners with the VR environment further delineating the
specific aspects of VR simulations that most effectively
contribute to student learning and confidence.

ACKNOWLEDGMENT

This work was supported by state aid managed by the
French National Research Agency under the France 2030
program, bearing the reference ANR-21-DMES-0001.

REFERENCES

[1] M. Pulido-Martos, J. M. Augusto-Landa, et E. Lopez-Zafra, « Sources of stress in nursing students: a systematic review of quantitative studies », *International Nursing Review*, vol. 59, n° 1, p. 15-25, mars 2012.

[2] R. Fink, M. Krugman, K. Casey, et C. Goode, « The Graduate Nurse Experience: Qualitative Residency Program Outcomes », *JONA: The Journal of Nursing Administration*, vol. 38, n° 7/8, p. 341-348, juill. 2008.

[3] H.-H. Lin, « Effectiveness of simulation-based learning on student nurses’ self-efficacy and performance while learning fundamental nursing skills », *THC*, vol. 24, n° s1, p. S369-S375, déc. 2015.

[4] J. Norman, « Systematic review of the literature on simulation in nursing education », *ABNF J*, vol. 23, n° 2, p. 24-28, 2012.

[5] T. M. Marteau et H. Bekker, « The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) », *Br J Clin Psychol*, vol. 31, n° 3, p. 301-306, sept. 1992.

[6] M. Usoh, E. Catena, S. Arman, et M. Slater, « Using Presence Questionnaires in Reality », *Presence: Teleoperators & Virtual Environments*, vol. 9, n° 5, p. 497-503, oct. 2000.