Boosting electrocardiography leads location training through virtual reality simulation: effects on skill performance and learner satisfaction

Boosting electrocardiography leads location training through virtual reality simulation: effects on skill performance and learner satisfaction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Boosting electrocardiography leads location training through virtual reality simulation: effects on skill performance and learner satisfaction Fatemeh Kermanian, Parham Safiyari, Gholamreza Hassanzadeh, Rita Mojtahedzadeh, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8298517/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background The purpose of this study was to investigate the effect of electrocardiography lead placement training on the performance and satisfaction of medical students using VR and compare it with training on a real patient and training on a mannequin. Methods This was a true experimental study. Ninety undergraduate medical students in the internal medicine rotation course were included in the study. The simulation software for the insertion of electrocardiography lead placement training was designed. The students were then divided into three groups. Practical training for lead placement was conducted via three methods: training on a real patient, a mannequin, and training through VR simulation. The course was evaluated through the DOPS (Direct Observation of Procedural Skills) test and the satisfaction survey form. Results The analysis of the DOPS test scores revealed a significant difference between the VR group and the other two groups (patient: 15.2 (1.89), mannequin: 15.3 (1.71) and VR: 17.5 (1.35)) (P value < 0.001). The results of the survey also indicated that the satisfaction of the students in the VR group was significantly greater than that of the other two groups of patients: (0.24) 1.74, (0.18) 1.76 and (0.18) 2.35 (P value < 0.001). Conclusion Considering the attractiveness of VR, the use of this software along with other teaching models in anatomy education can increase the motivation and satisfaction of learners. Virtual reality Simulation Medical education Anatomy Figures Figure 1 Figure 2 Background Anatomy is the most relevant basic discipline for daily clinical activity. Two common pedagogies are cadaveric dissection and examination of prosected samples. However, the number of cases in which anatomy courses are delivered through the traditional dissection mode is declining due to limited access. Technological advancements have opened new opportunities to investigate novel teaching methods. Before computers were used in medical education, textbooks, cadavers, anatomical models, and live patients were some of the only pedagogical tools available ( 1 ). The implementation of virtual 3D (Three Dimentional) training methods has the potential to dissolve the growing misalignment between learning and teaching in undergraduate medical curricula. Virtual reality (VR) offers benefits for learners and educators, providing cost-effective and repeatable clinical training on demand ( 2 – 4 ). VR uses software to create an immersive simulated environment. Unlike traditional user interfaces, VR places the user inside an experience, where they can engage with the environment and virtual characters in a way that feels real ( 5 ). VR is a wide notion that has different tools. There are three main categories of VR simulators: screen-based VR, immersive VR environments and virtual worlds. Screen-based VR consists of an interface connected to mechanical devices and can be displayed on any screen but most commonly uses a desktop. This type of VR has commonly been used to develop technical psychomotor skills, such as for endoscopic surgery, because it can be used repeatedly and requires very little time to set up ( 6 ). Multiple studies have used VR-assisted surgical techniques to enhance surgical planning and navigation ( 7 – 10 ). While many studies exist on the use of virtual 3D environments for teaching anatomy ( 11 – 13 ), their use in surface anatomy teaching is unexplored. The virtual assessment scenarios currently reviewed in the literature focus primarily on clinical skills rather than anatomy ( 14 ). The use of VR in anatomy instruction provides two primary benefits. First, observers can freely adjust their observation viewpoint. Second, virtual anatomical structures can be disassembled and flipped for examination ( 15 ). There is a significant tendency toward educational approaches that facilitate the application of knowledge in practice ( 14 , 15 ). Clinical placements have significantly improved students’ practical skills, but an absence of extensive practical training can often prevent their ability to master these procedures. The main goal of virtual reality is to create a sense of presence in a virtual space. The created space must be believable and sufficiently interactive to require the user to perform specific actions. Recording the electrical activity of the heart is one of the primary procedures in emergency centers and is performed by medical staff every day. The correct placement of electrocardiography leads requires superficial anatomical knowledge. Numerous studies have shown that, in most cases, this placement is not performed correctly. The most common reasons for incorrect placement are patient obesity and a lack of familiarity with superficial signs of the chest wall. The most common errors are in the placement of leads V1 and V2 ( 16 , 17 ). Given the large crowd of students in the clinic and the inability to trial and error patients in clinics and teaching hospitals, we decided to design software to provide learners with the opportunity to repeatedly place leads, receive feedback, and try again in a safe environment that is completely similar to the clinic. The purpose of our study was to develop a VR-based system for electrocardiography lead placement to be used in a virtual environment. The aim was to augment the students’ spatial perception with a 3D model based on the surface anatomy of the anterior wall of the thorax. This study, therefore, aims to investigate how computer simulation in clinically oriented anatomy teaching can affect student performance and satisfaction. Methods Hardware and software: A unique clinical virtual environment (by using a desktop) with an emphasis on the bony landmarks of the anterior thoracic wall was created. A professional software producer prepared the software and added effects (e.g., thoracic cage movements). This virtual environment was verified for anatomic correctness by an experienced professor of anatomy. The 3D simulation system provides learners with a visualized bony thoracic wall. The interactive nature supports operations such as rotate, pick up, place, and move. The VR system used for the purpose of this study uses a static monitor as a display device. This software is similar to the real simulated environment in that the virtual patient lies on his or her back on the hospital bed, and the anatomical elements of the anterior chest wall, including the ribs and sternum, are clearly defined. Next, an electrocardiogram recording device with six precordial leads and two upper limb leads can be seen. Using the mouse, the surveyor lifts each of the leads and brings it near the patient, and by observing the surface elements of the thorax, the surveyor places the lead in the right place. After placing eight leads and pressing the end button, the program shows the results on the computer screen. If there is a mistake in placement, the wrong lead is identified, and the surveyor places it again. The user interacting with the VR system is shown in Fig. 1 . Implementation of the training program The study population consisted of all 90 fourth-year medical students who were enrolled in the cardiovascular disease course from 2023–2024 at Alborz University of Medical Sciences. The students were randomized into three groups via randomization software. The first group received patient-based training in the clinic. The second group received skill-lab training via a mannequin, and the last group received virtual simulation-based training via a computer. The content was the same for all groups, and the same teacher prepared it. Assessment Learners were evaluated through the DOPS test (Direct Observation of Procedural Skills). This test is a method specifically designed to evaluate procedural skills. In this method, the learner is observed while performing the procedure, their performance is evaluated on a checklist, and feedback is given to the learner. The process of observing the student took approximately 15 minutes, and providing feedback to him took approximately 5 minutes. The test was held one week after the class meeting. The evaluation checklist included ten areas of activity, each of which was scaled with degrees above the expected limit, within the expected limit, borderline limit, below the expected limit, and indifferent. The teacher recorded the quality of the clinical procedure in each area. If the student does not receive the desired grade in an area, after hearing the teacher's feedback, he should repeat the process. For the option "higher than expected", a score of 20 was given; for "within the expected range", a score of 17 was given; for "borderline", a score of 14 was given; for "lower than expected", a score of 10 was given; and for "no opinion", a score of 7 was included. The final grade of the student was the average of the grades obtained in ten fields. Satisfaction At the end of the tutorial, the satisfaction of the students was checked through an anonymous questionnaire containing 16 explicit statements. Answers were based on a three-point Likert scale. Possible selections were “agree”, “neutral”, and “disagree”. The questionnaire used in our study, has been published previously by Borim Nejad (Supp. 1). The face and content validity of this questionnaire was determined previously, and its reliability was 0.9 through retesting ( 18 ). Figure 2 provides a schematic overview of the design of this study. Data collection and analysis The questionnaire was distributed in a paper-based format to the students after they had used the various learning modalities. Results A total of 90 medical students in the cardiovascular disease course participated in this study. The mean age was 21 (0.7) years. Forty-three (47.7%) of the participants were male, and 47 (52.3%) were female. DOPS scoring The results of the descriptive statistics of the scores obtained by the three groups in the DOPS test are listed in Table 1 . Accordingly, the VR group, with an average score of 17.5 out of twenty points, obtained the highest score on this test. Table 1 Comparison of DOPS test scores among the study groups Group n Mean (SD) F * Sig. real patient 30 15.2(1.89) 17.2 0.00 mannequin 30 15.3(1.71) VR 30 17.5(1.35) *ANOVA The Shapiro‒Wilk test was used to examine the normality of the distribution, and the results indicated that the distributions were normal. The results of the ANOVA test revealed a significant difference in the test scores of the three groups. Tukey's post hoc test revealed a significant difference between the scores of the VR group with real patients and those of the mannequin groups. There was no significant difference between the scores of the real patient group and the mannequin groups (Table 2 ). Table 2 Tukey post hoc test of the DOPS results Groups Mean Difference Sig. Real patient Mannequin 0.06 0.98 VR 2.23 < 0.005 Mannequin Real patient 0.06 0.98 VR 2.16 < 0.005 VR Real patient 2.23 < 0.005 Mannequin 2.16 < 0.005 Satisfaction: The findings revealed that students' satisfaction in the VR group was greater than that in the other two groups. Given the normality of the distribution, a parametric ANOVA test was used for analytical statistics. These results revealed a significant difference in the test scores among the three groups (Table 3 ). Table 3 Comparison of satisfaction scores among groups Group Mean St. dev. F * Sig. real patient 1.74 0.24 79.6 0.00 mannequin 1.79 0.18 VR 2.35 0.18 * ANOVA Tukey's post hoc test revealed a significant difference between the scores of the VR group with real patients and those of the mannequin groups. There was no significant difference between the scores of the real patient group and the mannequin group (Table 4 ). Table 4 Tukey post hoc test results Groups Mean Difference Sig. VR Mannequin 0.05 0.58 VR 0.61 0 Mannequin Real patient 0.05 0.58 VR 0.05 0 VR Real patient 0.61 0 Mannequin 0.56 0 Discussion The present study aimed to compare the effects of electrocardiography lead placement training with three training methods, namely, mannequins, patients, and virtual reality, on the knowledge, performance, and satisfaction of medical students in the Faculty of Medicine of Alborz University of Medical Sciences. The results of the present study revealed a significant difference in DOPS test scores between the VR group with real patients and the mannequin group, whereas there was no significant difference in test scores between the real patient group and the mannequin group. This result indicates that there was a difference in VR group scores due to the use of VR. This result is consistent with those of numerous studies ( 19 – 22 ). The higher scores in the virtual reality group may be due to the greater need for a three-dimensional understanding of anatomically contiguous areas. Since anatomy books and atlases cannot teach three-dimensional information, which is especially important in regional anatomy and contiguous areas, virtual reality, with its great capabilities in this field, can be very useful for learners in understanding this concept ( 23 , 24 ). The other reason for this could be that the software provides feedback to the learner, allowing for repetition and error correction, which are advantages of the software. Similar studies also indicate greater learner consent with virtual reality-assisted learning ( 21 , 24 ). VR technology for anatomy education may also be an excellent resource for teachers where there are cultural or religious beliefs that limit the touch of patients or in institutions that may lack real patients. Learning via virtual reality in an environment that simulates the clinical environment increases student satisfaction by reducing generalized anxiety. In such a comprehensive educational environment, there is no fear of errors or patient reactions, which increases self-confidence and satisfaction ( 15 , 21 , 25 – 27 ). In addition, the enjoyable nature and potential for gamification of VR encourage engagement and independent learning. VR can provide a clinical scenario in a small space with less than a few minutes of setup. VR scenarios are repeatable. This allows learners to make mistakes safely and then learn through deliberate practice to improve performance. Additionally, simulators, which use clinical images, videos, and animations and the opportunity to perform repeated exercises and sometimes provide feedback, make students prefer learning with simulators over traditional models ( 28 ). Previous studies have cited its inclusive approach as one of the reasons for greater student satisfaction with virtual reality-assisted teaching ( 29 – 33 ). Despite these advantages, VR simulations are not suitable for every possible educational opportunity. Additionally, physical simulation should not replace clinical training. VR is just a technology used to deliver a learning technique. Some studies have reported adverse effects such as headaches, dizziness, and blurred vision in VR participants ( 20 , 29 ). Limitations of this study This study had three limitations. First, the sample size was small. Second, the Data was collected at a single time point in a single site. Third, this study reflects the views of students from one university in the Iran. All of these may affect the validity and accuracy of the relationships between variables such as difficulty. We intend to address this concern in future research by using multiple time points and multiple data sources to further validate our findings. Conclusion The use of simulation technology creates a very good situation for the learner so that the student can observe and act on variables, processes, and procedures in an active situation and interact and react with the environment. This leads to increased experience and can reduce medical errors, which are always major issues in the field of treatment. One way to reduce these errors is to increase the practical training of students, along with improving the quality of education. Given the limited number of cadavers in medical schools and the overcrowding of patients and trainees in teaching hospitals, the need to use simulations and create high-quality virtual spaces is a feasible solution to increase patient health and safety. The limitations of the present study include the small number of students, the short duration of the training, and the lack of complete readiness of the clinical environment for this type of training. Abbreviations VR Virtual Reality DOPS Direct Observation of Procedural Skills 3D Three dimentional Declarations Ethics approval and consent to participate Informed consent for data collection was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki; approval was granted by the Alborz University Ethics Research Committee (IR.ABZUMS.REC.1402.369). No identifying information was used to protect anonymity. All data collected in this study were kept confidential and used solely for research purposes. The information gathered was anonymous and could not be linked to any individual participant. Consent for publication Not applicable Availability of data and materials The datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request. Competing interests We have no conflicts of interest to disclose, and I can confirm that all authors have approved the manuscript for submission. Funding This project has received funding from the Alborz University of Medical Sciences under grant agreement No. 6640. Authors' contributions AM planned the study, collected, analysed, and interpreted the data in this paper. PS provided the VR tool used for the study and drafted a description of the software. RM supervised research, reviewed, and revised the paper. FK led the study design and interpretation as well as manuscript preparation and writing. 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Supplementary Files questionnaire.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 15 Apr, 2026 Reviews received at journal 15 Apr, 2026 Reviews received at journal 02 Apr, 2026 Reviewers agreed at journal 24 Mar, 2026 Reviewers agreed at journal 26 Feb, 2026 Reviewers agreed at journal 15 Feb, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviewers invited by journal 12 Jan, 2026 Editor assigned by journal 12 Jan, 2026 Editor invited by journal 12 Jan, 2026 Submission checks completed at journal 09 Jan, 2026 First submitted to journal 20 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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11:58:18","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94841,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8298517/v1/b00b21813b4a2f49d984e6f5.html"},{"id":100401424,"identity":"528547a3-3245-4d7e-9cdc-4d6b925a57c8","added_by":"auto","created_at":"2026-01-16 11:58:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":481897,"visible":true,"origin":"","legend":"\u003cp\u003eThe user interacting with the VR system\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8298517/v1/ec9c4d59ba20e2c030a3b166.png"},{"id":100400549,"identity":"c6495cfa-fb4b-4132-b4af-df8a3d46a378","added_by":"auto","created_at":"2026-01-16 11:58:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56624,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of the design of this study\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8298517/v1/cdffcdd4f7fa447778c85df6.png"},{"id":100412272,"identity":"165afba0-3ff9-462d-9d60-6c0dbe695199","added_by":"auto","created_at":"2026-01-16 13:14:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1310902,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8298517/v1/28b87ef2-2532-45bf-8a11-ea3d20c1ad7d.pdf"},{"id":100401342,"identity":"52c3c9e7-bad7-4173-ad8d-96377ff6158e","added_by":"auto","created_at":"2026-01-16 11:58:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20395,"visible":true,"origin":"","legend":"","description":"","filename":"questionnaire.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8298517/v1/1237ecd7055188f85460e1e2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Boosting electrocardiography leads location training through virtual reality simulation: effects on skill performance and learner satisfaction","fulltext":[{"header":"Background","content":"\u003cp\u003eAnatomy is the most relevant basic discipline for daily clinical activity. Two common pedagogies are cadaveric dissection and examination of prosected samples. However, the number of cases in which anatomy courses are delivered through the traditional dissection mode is declining due to limited access. Technological advancements have opened new opportunities to investigate novel teaching methods. Before computers were used in medical education, textbooks, cadavers, anatomical models, and live patients were some of the only pedagogical tools available (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The implementation of virtual 3D (Three Dimentional) training methods has the potential to dissolve the growing misalignment between learning and teaching in undergraduate medical curricula. Virtual reality (VR) offers benefits for learners and educators, providing cost-effective and repeatable clinical training on demand (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). VR uses software to create an immersive simulated environment. Unlike traditional user interfaces, VR places the user inside an experience, where they can engage with the environment and virtual characters in a way that feels real (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). VR is a wide notion that has different tools. There are three main categories of VR simulators: screen-based VR, immersive VR environments and virtual worlds. Screen-based VR consists of an interface connected to mechanical devices and can be displayed on any screen but most commonly uses a desktop. This type of VR has commonly been used to develop technical psychomotor skills, such as for endoscopic surgery, because it can be used repeatedly and requires very little time to set up (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Multiple studies have used VR-assisted surgical techniques to enhance surgical planning and navigation (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). While many studies exist on the use of virtual 3D environments for teaching anatomy (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), their use in surface anatomy teaching is unexplored. The virtual assessment scenarios currently reviewed in the literature focus primarily on clinical skills rather than anatomy (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The use of VR in anatomy instruction provides two primary benefits. First, observers can freely adjust their observation viewpoint. Second, virtual anatomical structures can be disassembled and flipped for examination (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). There is a significant tendency toward educational approaches that facilitate the application of knowledge in practice (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eClinical placements have significantly improved students\u0026rsquo; practical skills, but an absence of extensive practical training can often prevent their ability to master these procedures. The main goal of virtual reality is to create a sense of presence in a virtual space. The created space must be believable and sufficiently interactive to require the user to perform specific actions.\u003c/p\u003e \u003cp\u003eRecording the electrical activity of the heart is one of the primary procedures in emergency centers and is performed by medical staff every day. The correct placement of electrocardiography leads requires superficial anatomical knowledge. Numerous studies have shown that, in most cases, this placement is not performed correctly. The most common reasons for incorrect placement are patient obesity and a lack of familiarity with superficial signs of the chest wall. The most common errors are in the placement of leads V1 and V2 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the large crowd of students in the clinic and the inability to trial and error patients in clinics and teaching hospitals, we decided to design software to provide learners with the opportunity to repeatedly place leads, receive feedback, and try again in a safe environment that is completely similar to the clinic. The purpose of our study was to develop a VR-based system for electrocardiography lead placement to be used in a virtual environment. The aim was to augment the students\u0026rsquo; spatial perception with a 3D model based on the surface anatomy of the anterior wall of the thorax. This study, therefore, aims to investigate how computer simulation in clinically oriented anatomy teaching can affect student performance and satisfaction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHardware and software:\u003c/h2\u003e \u003cp\u003eA unique clinical virtual environment (by using a desktop) with an emphasis on the bony landmarks of the anterior thoracic wall was created. A professional software producer prepared the software and added effects (e.g., thoracic cage movements). This virtual environment was verified for anatomic correctness by an experienced professor of anatomy. The 3D simulation system provides learners with a visualized bony thoracic wall. The interactive nature supports operations such as rotate, pick up, place, and move. The VR system used for the purpose of this study uses a static monitor as a display device. This software is similar to the real simulated environment in that the virtual patient lies on his or her back on the hospital bed, and the anatomical elements of the anterior chest wall, including the ribs and sternum, are clearly defined. Next, an electrocardiogram recording device with six precordial leads and two upper limb leads can be seen. Using the mouse, the surveyor lifts each of the leads and brings it near the patient, and by observing the surface elements of the thorax, the surveyor places the lead in the right place. After placing eight leads and pressing the end button, the program shows the results on the computer screen. If there is a mistake in placement, the wrong lead is identified, and the surveyor places it again. The user interacting with the VR system is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplementation of the training program\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of all 90 fourth-year medical students who were enrolled in the cardiovascular disease course from 2023\u0026ndash;2024 at Alborz University of Medical Sciences. The students were randomized into three groups via randomization software. The first group received patient-based training in the clinic. The second group received skill-lab training via a mannequin, and the last group received virtual simulation-based training via a computer. The content was the same for all groups, and the same teacher prepared it.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eAssessment\u003c/h3\u003e\n\u003cp\u003eLearners were evaluated through the DOPS test (Direct Observation of Procedural Skills). This test is a method specifically designed to evaluate procedural skills. In this method, the learner is observed while performing the procedure, their performance is evaluated on a checklist, and feedback is given to the learner. The process of observing the student took approximately 15 minutes, and providing feedback to him took approximately 5 minutes. The test was held one week after the class meeting. The evaluation checklist included ten areas of activity, each of which was scaled with degrees above the expected limit, within the expected limit, borderline limit, below the expected limit, and indifferent. The teacher recorded the quality of the clinical procedure in each area. If the student does not receive the desired grade in an area, after hearing the teacher's feedback, he should repeat the process. For the option \"higher than expected\", a score of 20 was given; for \"within the expected range\", a score of 17 was given; for \"borderline\", a score of 14 was given; for \"lower than expected\", a score of 10 was given; and for \"no opinion\", a score of 7 was included. The final grade of the student was the average of the grades obtained in ten fields.\u003c/p\u003e\n\u003ch3\u003eSatisfaction\u003c/h3\u003e\n\u003cp\u003eAt the end of the tutorial, the satisfaction of the students was checked through an anonymous questionnaire containing 16 explicit statements. Answers were based on a three-point Likert scale. Possible selections were \u0026ldquo;agree\u0026rdquo;, \u0026ldquo;neutral\u0026rdquo;, and \u0026ldquo;disagree\u0026rdquo;. The questionnaire used in our study, has been published previously by Borim Nejad (Supp.\u0026nbsp;1). The face and content validity of this questionnaire was determined previously, and its reliability was 0.9 through retesting (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides a schematic overview of the design of this study.\u003c/p\u003e\n\u003ch3\u003eData collection and analysis\u003c/h3\u003e\n\u003cp\u003eThe questionnaire was distributed in a paper-based format to the students after they had used the various learning modalities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 90 medical students in the cardiovascular disease course participated in this study. The mean age was 21 (0.7) years. Forty-three (47.7%) of the participants were male, and 47 (52.3%) were female.\u003c/p\u003e\n\u003ch3\u003eDOPS scoring\u003c/h3\u003e\n\u003cp\u003eThe results of the descriptive statistics of the scores obtained by the three groups in the DOPS test are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Accordingly, the VR group, with an average score of 17.5 out of twenty points, obtained the highest score on this test.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of DOPS test scores among the study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ereal patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.2(1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.3(1.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.5(1.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e*ANOVA\u003c/h3\u003e\n\u003cp\u003eThe Shapiro‒Wilk test was used to examine the normality of the distribution, and the results indicated that the distributions were normal.\u003c/p\u003e \u003cp\u003eThe results of the ANOVA test revealed a significant difference in the test scores of the three groups. Tukey's post hoc test revealed a significant difference between the scores of the VR group with real patients and those of the mannequin groups. There was no significant difference between the scores of the real patient group and the mannequin groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTukey post hoc test of the DOPS results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Difference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReal patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReal patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReal patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSatisfaction:\u003c/h2\u003e \u003cp\u003eThe findings revealed that students' satisfaction in the VR group was greater than that in the other two groups. Given the normality of the distribution, a parametric ANOVA test was used for analytical statistics. These results revealed a significant difference in the test scores among the three groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of satisfaction scores among groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSt. dev.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ereal patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e79.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e* ANOVA\u003c/h2\u003e \u003cp\u003eTukey's post hoc test revealed a significant difference between the scores of the VR group with real patients and those of the mannequin groups. There was no significant difference between the scores of the real patient group and the mannequin group (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTukey post hoc test results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Difference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReal patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReal patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMannequin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to compare the effects of electrocardiography lead placement training with three training methods, namely, mannequins, patients, and virtual reality, on the knowledge, performance, and satisfaction of medical students in the Faculty of Medicine of Alborz University of Medical Sciences. The results of the present study revealed a significant difference in DOPS test scores between the VR group with real patients and the mannequin group, whereas there was no significant difference in test scores between the real patient group and the mannequin group. This result indicates that there was a difference in VR group scores due to the use of VR.\u003c/p\u003e \u003cp\u003eThis result is consistent with those of numerous studies (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The higher scores in the virtual reality group may be due to the greater need for a three-dimensional understanding of anatomically contiguous areas. Since anatomy books and atlases cannot teach three-dimensional information, which is especially important in regional anatomy and contiguous areas, virtual reality, with its great capabilities in this field, can be very useful for learners in understanding this concept (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The other reason for this could be that the software provides feedback to the learner, allowing for repetition and error correction, which are advantages of the software. Similar studies also indicate greater learner consent with virtual reality-assisted learning (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVR technology for anatomy education may also be an excellent resource for teachers where there are cultural or religious beliefs that limit the touch of patients or in institutions that may lack real patients. Learning via virtual reality in an environment that simulates the clinical environment increases student satisfaction by reducing generalized anxiety. In such a comprehensive educational environment, there is no fear of errors or patient reactions, which increases self-confidence and satisfaction (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In addition, the enjoyable nature and potential for gamification of VR encourage engagement and independent learning.\u003c/p\u003e \u003cp\u003eVR can provide a clinical scenario in a small space with less than a few minutes of setup. VR scenarios are repeatable. This allows learners to make mistakes safely and then learn through deliberate practice to improve performance.\u003c/p\u003e \u003cp\u003eAdditionally, simulators, which use clinical images, videos, and animations and the opportunity to perform repeated exercises and sometimes provide feedback, make students prefer learning with simulators over traditional models (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Previous studies have cited its inclusive approach as one of the reasons for greater student satisfaction with virtual reality-assisted teaching (\u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite these advantages, VR simulations are not suitable for every possible educational opportunity. Additionally, physical simulation should not replace clinical training. VR is just a technology used to deliver a learning technique. Some studies have reported adverse effects such as headaches, dizziness, and blurred vision in VR participants (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of this study\u003c/h2\u003e \u003cp\u003eThis study had three limitations. First, the sample size was small. Second, the Data was collected at a single time point in a single site. Third, this study reflects the views of students from one university in the Iran. All of these may affect the validity and accuracy of the relationships between variables such as difficulty. We intend to address this concern in future research by using multiple time points and multiple data sources to further validate our findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of simulation technology creates a very good situation for the learner so that the student can observe and act on variables, processes, and procedures in an active situation and interact and react with the environment. This leads to increased experience and can reduce medical errors, which are always major issues in the field of treatment. One way to reduce these errors is to increase the practical training of students, along with improving the quality of education. Given the limited number of cadavers in medical schools and the overcrowding of patients and trainees in teaching hospitals, the need to use simulations and create high-quality virtual spaces is a feasible solution to increase patient health and safety. The limitations of the present study include the small number of students, the short duration of the training, and the lack of complete readiness of the clinical environment for this type of training.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVirtual Reality\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDOPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDirect Observation of Procedural Skills\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e3D\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThree dimentional\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for data collection was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki; approval was granted by the Alborz University Ethics Research Committee (IR.ABZUMS.REC.1402.369). No identifying information was used to protect anonymity. All data collected in this study were kept confidential and used solely for research purposes. The information gathered was anonymous and could not be linked to any individual participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Competing interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe have no conflicts of interest to disclose, and I can confirm that all authors have approved the manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project has received funding from the Alborz University of Medical Sciences under grant agreement No. 6640.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAM planned the study, collected, analysed, and interpreted the data in this paper. PS provided the VR tool used for the study and drafted a description of the software. RM supervised research, reviewed, and revised the paper. FK led the study design and interpretation as well as manuscript preparation and writing. GRH conceived the idea for the project. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Acknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Smart University of Medical Sciences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eJinga M, Lee R, Chan K, Marway P, Nandapalan K, Rhode K, et al. Assessing the impact of 3D image segmentation workshops on anatomical education and image interpretation: A prospective pilot study. Anat Sci Educ. 2023; 16: 1024–1032.\u003c/li\u003e\n \u003cli\u003eQin Y, Haung Z, Yu J, Qing P, Su L, Liu R, et al. 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Anat Sci Educ. 2017; 10 (6): 549-59.\u003c/li\u003e\n \u003cli\u003eGuzman-Valenzuela C, Gomez-Gonzalez C, Rojas-Murphy Tagle A. Learning analytics in higher education: A preponderance of analytics but very little learning? Int J Educ Technol High Educ. 2021; 18 (1), 23: 1–9. doi: 10.1186/s41239-021-00258-x.\u003c/li\u003e\n \u003cli\u003eMandolini M, Brunzini A, Facco G, Mazzoli A, Forcellese A, Gigante A. Comparison of three 3D segmentation software tools for hip surgical planning. Sensors. 2022; doi.org/10.3390/s22145242.\u003c/li\u003e\n \u003cli\u003eKazoka D, Pilmane M, Edelmers E. Facilitating student understanding through incorporating digital images and 3D-printed models in a human anatomy course. Educ. Sci. 2021; 11(8): 380- 94. \u003c/li\u003e\n \u003cli\u003eWeidlich J, Fink A, Frey A, Jivet I, Gombert S, Menzel L, et al. Highly informative feedback using learning analytics: how feedback literacy moderates student perceptions of feedback. Int J Educ Technol High Educ. 2025; doi.org/10.1186/s41239-025-00539-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Virtual reality, Simulation, Medical education, Anatomy","lastPublishedDoi":"10.21203/rs.3.rs-8298517/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8298517/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe purpose of this study was to investigate the effect of electrocardiography lead placement training on the performance and satisfaction of medical students using VR and compare it with training on a real patient and training on a mannequin.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a true experimental study. Ninety undergraduate medical students in the internal medicine rotation course were included in the study. The simulation software for the insertion of electrocardiography lead placement training was designed. The students were then divided into three groups. Practical training for lead placement was conducted via three methods: training on a real patient, a mannequin, and training through VR simulation. The course was evaluated through the DOPS (Direct Observation of Procedural Skills) test and the satisfaction survey form.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis of the DOPS test scores revealed a significant difference between the VR group and the other two groups (patient: 15.2 (1.89), mannequin: 15.3 (1.71) and VR: 17.5 (1.35)) (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The results of the survey also indicated that the satisfaction of the students in the VR group was significantly greater than that of the other two groups of patients: (0.24) 1.74, (0.18) 1.76 and (0.18) 2.35 (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eConsidering the attractiveness of VR, the use of this software along with other teaching models in anatomy education can increase the motivation and satisfaction of learners.\u003c/p\u003e","manuscriptTitle":"Boosting electrocardiography leads location training through virtual reality simulation: effects on skill performance and learner satisfaction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 09:03:17","doi":"10.21203/rs.3.rs-8298517/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-15T06:00:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-15T04:37:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T05:18:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102047327373420444440176160796972496256","date":"2026-03-24T17:21:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225576405630440892681066970264611209678","date":"2026-02-26T08:50:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229068120058720770371248190910572619567","date":"2026-02-15T18:10:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145896678628943264532191188049573484615","date":"2026-01-24T13:53:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-12T12:47:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-12T12:45:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-12T07:15:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-09T14:15:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-12-20T08:21:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81635ea3-80c7-4ac2-bc70-7a671dc9c8e8","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T10:53:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 09:03:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8298517","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8298517","identity":"rs-8298517","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}