The Effect of Virtual Reality Technology in Ventrogluteal Injection Training
Condition: Nursing Caries; Nursing Education
Study type: Interventional

Summary: 
      Intramuscular injections are one of the nursing functions frequently used in clinical
      practice. Sites used for the purpose of intramuscular injection; dorsogluteal, ventrogluteal,
      deltoid region, vastus lateralis muscle and rectus femoris muscle . Intramuscular injections
      can cause many complications. The most important complication is sciatic nerve injury, which
      may occur as a result of injection especially in the dorsogluteal region. In order to prevent
      complications that may develop as a result of intramuscular injection, it should be
      emphasized that the ventrogluteal region should be preferred in the selection of
      intramuscular injection site and students should be provided with the necessary knowledge and
      skills regarding injection from this region. In nursing education, many different methods are
      used with technological developments. One of them is simulation applications. There are
      various types of simulation applications. One of these simulation applications is virtual
      reality technology.

      The goal of this interventional research is to evaluate the effect of ventrogluteal injection
      training developed by researchers and given to students through virtual reality glasses.
    

Detailed description: 
      The universe of the study consisted of first-year students enrolled in the "Basic Nursing and
      Clinical Skills" course in the nursing Turkish undergraduate program of Atatürk University
      Faculty of Nursing in the spring semester of the 2021-2022 academic year. The sample of the
      study consisted of students who had the research criteria and agreed to participate in the
      research. Prior to the study, a priori power analysis was performed to determine the sample
      size in this study. In the power analysis, it was determined that the sample size should be
      128, 64 interventional and 64 control, at a significance level of 0.05, with a confidence
      interval of 95%, for power of 80%. Considering the data losses, it was decided to collect
      data from a total of 142 students by including 10% reserve sample in this number.

      Inclusion criteria:

        -  Have not received previous application training for intramuscular injection

        -  Lack of experience in administering intramuscular injections

        -  Participation in the theoretical lecture presentation on intramuscular injection given
           by the instructor in the course "Basic Nursing and Clinical Skills"

        -  Absence of a health condition that prevents him from wearing virtual reality glasses and
           performing the study (Advanced vision problem, vertigo problem, etc.)

        -  Have not taken the Fundamentals of Nursing or Basic Nursing Care and Clinical Skills
           course before

        -  Understand the questions in forms and scales

        -  Willingness to participate in the study.

      Exclusion criteria:

        -  The student does not participate in at least one of the research phases

        -  Receive of the student practical training for intramuscular injection from another
           instructor during the research process.

      Variables of the research:

        -  Dependent Variable: After the application training with virtual reality simulation and
           intramuscular injection model, the knowledge evaluation scores, skill evaluation scores,
           motivation levels and anxiety levels of the students are dependent on the research.

        -  Independent Variable: Virtual reality simulation and application training with
           intramuscular injection model are independent variables of the research.

        -  Control Variable: The knowledge evaluation scores of the students before the application
           training are the control variable of the research.

      Data collection tools:

      "Introductory Questionnaire Form", "Intramuscular Injection Application to the Ventrogluteal
      Region Information Evaluation Form", "Motivation Scale for Teaching Material", "Status
      Anxiety Inventory" were used in data collection.

        -  Introductory Questionnaire Form: The form prepared by the researcher includes 9
           questions including sociodemographic characteristics of the students such as age, gender
           and information about ventrogluteal region injection

        -  Intramuscular Injection Application Information Evaluation Form in the Ventrogluteal
           Region: This form has been prepared by the researcher in line with the literature by
           taking expert opinions. The Information Evaluation Form is a form consisting of 22
           propositions in total that students can answer as "True", "False" and "I do not know".
           The form contains an equal number of "True" and "False" propositions. The form contains
           propositions that measure knowledge for ventrogluteal injection. The lowest score from
           the form is 0 and the highest score is 22. High scores obtained from the scale indicate
           that the level of information of the students is high.

        -  Intramuscular Injection to the Ventrogluteal Region Application Skill Evaluation Form:
           This form was prepared by the researcher based on the literature by taking expert
           opinions in order to evaluate the students' ability to apply intramuscular injection to
           the ventrogluteal region. The form includes intramuscular injection steps to the
           ventrogluteal region. The form contains 33 trading steps. The lowest score to be
           obtained from the form is 0 and the highest score is 100. High scores obtained from the
           scale indicate that the level of skill of the students is high.

        -  Motivation Scale for Instructional Material: The Cronbach alpha value of this scale,
           which consists of 33 items, has no inverse propositions and is of the five-point likert
           type, was found to be 0.97. The highest score that can be obtained from the scale is
           165, while the lowest score is 33 points. A high overall score means that their level of
           motivation for the teaching material is high.

        -  Situational Anxiety Inventory: Situational Anxiety Inventory, consists of a total of
           twenty items. In the Situational Anxiety Inventory, the answers are grouped under 4
           headings: "None", "A little", "Many", "Completely". Scores from the scale range from
           20-80. The high score received is the high anxiety; If the score is low, it means that
           the anxiety is low. The analysis of scores in order of percentage is done in a similar
           way. A low percentage rank indicates that anxiety is low; A high percentage rank
           indicates that anxiety is high. The average score range determined in the application of
           the scale is between 36-41.

      Pre-Application Phase:

      Pre-application was made to 6 students randomly selected from the universe who agreed to
      participate in the study. Students who participated in the pre-practice were not included in
      the actual implementation phase of the research.

      Data collection: The data were collected in the spring semester of the 2021-2022 academic
      year. The necessary explanations were made to the students who formed the sample of the
      research and their consent was obtained. Students whose consent was obtained were asked to
      fill out the "Introductory Questionnaire Form" and the "Intramuscular Injection Application
      Evaluation Form in the Ventrogluteal Region". All students who filled out these forms were
      shown the "Intramuscular Drug Administration Skill Video". According to the results of the
      students' knowledge evaluation scores, intervention and control groups were determined by
      randomization.

        -  Determination of Research Groups by Randomization: Students who met the criteria for
           inclusion in the study, who volunteered to participate in the research, who participated
           in the theoretical course presentation on intramuscular injection given by the
           instructor of the course in the "Basic Nursing and Clinical Skills" course were selected
           by randomization (n= 142) and included in the study. In the study, stratified sampling
           method was used for sample selection. In order to ensure that the students constituting
           the sample had similar characteristics, the knowledge levels of the students were
           determined by using the "Intramuscular Injection Application Information Evaluation Form
           in the Ventrogluteal Region" prepared by the researcher by taking expert opinions.
           According to the level of knowledge of the students; It was stratified into three groups
           as low , medium and high. First, students in the same group (Low, medium or high) with
           equal scores were randomly assigned to the intervention and control groups by lottery,
           respectively. After the students with equal scores were assigned to the groups, the
           remaining students were randomized first within the group and then between the groups.
           An equal number of intervention (n=71) and control groups (n=71) were created.

      The students, who were divided into intervention and control groups, participated in the
      training of intramuscular injection administration from the ventrogluteal region.

        -  The intervention group received its practical training with virtual reality glasses. In
           the training content, the procedure steps for intramuscular injection from the
           ventrogluteal region were explained and first shown 1 time by the researcher. Then, each
           of the researchers was enabled to practice with virtual reality glasses and the
           necessary feedback was made. Students who completed their education were asked to fill
           out the "Contract for Compliance with Student Research Rules" and "Motivation Scale for
           Teaching Material". After the training, an analysis session was held with the students.

        -  The control group performed the application training in intramuscular injection model.
           Later, the students participated in the practical training in groups of 5 people. The
           students in the control group were given the necessary training by the researcher on the
           intramuscular injection model by demonstration method. In the training content, the
           procedure steps for intramuscular injection from the ventrogluteal region were explained
           and first shown 1 time by the researcher. Then, each of the researchers was made to
           apply on the model and the necessary feedback was given. Students who completed their
           education were asked to fill out the "Contract for Compliance with Student Research
           Rules" and "Motivation Scale for Teaching Material".

      After all students' practical training in both the experimental and control groups was over,
      an exam (Objective Structured Clinical Exam/OSCE) was conducted to determine the students'
      anxiety, knowledge and skill status. "Intramuscular Injection Application Information
      Evaluation Form for Ventrogluteal Region" and "Status Anxiety Inventory" were applied to the
      students. The skill status of the students was evaluated by the researcher and recorded in
      the "Intramuscular Injection Application Skill Evaluation Form in the Ventrogluteal Region".

      After 1 month the 1st OSCE exam, students were subjected to the 2nd OSCE exam again. In this
      exam, which constitutes the follow-up stage, the procedures in the 1st OSCE exam were applied
      and evaluated by the researcher and recorded in the "Intramuscular Injection Application
      Skill Evaluation Form to the Ventrogluteal Region". In this exam, which constitutes the
      follow-up stage, the procedures in the 1st OSCE exam were applied and evaluated by the
      researcher and recorded in the "Intramuscular Injection Application Skill Evaluation Form to
      the Ventrogluteal Region".

      Evaluation of the data:

      In the evaluation of the data obtained from the research, the Statistical Package for Social
      Sciences (SPSS) 22.0 package program will be used. The normal distribution of the data will
      be looked at by the Shapiro Wilk test. Mean, standard deviation, median, min, max, number and
      percentages will be used to evaluate the data. In the comparison of the mean between two
      independent groups, if the variable is normally distributed, the independent sample t test;
      If it does not fall apart normally, Mann Whitney will be examined with a U test. In
      statistical comparisons, if the variable is normally distributed in the comparison of the
      mean between the two dependent groups, the paired sample t test; If it does not fall apart
      normally, it will be examined by Wilcoxon test. Chi-square test will be used in the
      comparisons between the two categorical groups. Statistical significance level will be
      accepted as p<0.05.

      Difficulties and limitations of the study:

      The limitation of this research is that it is carried out only with 1nd year nursing students
      studying at a university's nursing faculty.
    

Intervention name(s): Nursing students will be trained through virtual reality.
Intervention type(s): Behavioral
Intervention description(s): Nursing students will be trained through virtual reality.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: intramuscular injection; nursing; simulation; virtual reality; ventrogluteal injection