Effects of Nature-Based Virtual Reality and 2D Nature Videos on OSCE Exam Stress in Nursing Students

Objective Structured Clinical Examinations (OSCEs) are widely used in nursing education to assess clinical skills but are known to induce significant psychological and physiological stress due to performance anxiety, time pressure, and observation. Exam-related stress has been associated with changes in heart rate variability (HRV), particularly increased low-frequency/high-frequency (LF/HF) ratios, reflecting heightened sympathetic activity. Such stress may negatively affect cognitive performance, clinical competence, and professional readiness. Nature-based virtual reality (VR) has emerged as a promising intervention for stress reduction by providing immersive, calming environments that promote relaxation and autonomic regulation. Previous studies suggest that short VR-based nature sessions can effectively reduce anxiety and may be more effective than two-dimensional (2D) nature videos, which represent a more accessible but less immersive alternative. However, evidence regarding the use of VR and 2D nature videos for managing stress during high-stakes clinical examinations such as OSCEs is limited. This randomized controlled study aims to compare the effectiveness of nature-based VR and 2D nature videos in reducing OSCE-related stress among third-year nursing students using physiological (PPG-derived LF/HF ratio) and subjective (STAI and SUD) outcome measures.