Development of a Virtual Reality Program for Internationally Standardized Non-Face-to-Face Nursing Practicum Education: Design and Validation of a Sensor-Integrated XR System

Extended reality (XR) has increasingly been applied to nursing practicum education; however, most systems rely on controller-based interfaces that limit precise capture of continuous fine motor performance and objective assessment. This study developed and validated a sensor-integrated, controller-free XR nursing practicum system (Smart Nursing v1.0) grounded in continuous precision sensing. Based on internationally standardized intravenous injection protocols, the system integrated optical hand tracking and speech recognition to quantify hand kinematics, spatial accuracy, procedural sequencing, and verbal compliance. A three-phase validation framework was implemented. Internal technical verification confirmed stable real-time performance (≥60 FPS) and consistent action recognition. In a user-based study involving 63 undergraduate nursing students, XR-based automated scores demonstrated high agreement with expert instructor ratings (ICC = 0.932, 95% CI = 0.91-0.96, <i>p</i> < 0.001). XR baseline scores significantly predicted post-training performance (β = 0.632, <i>p</i> < 0.001) and showed significant incremental validity beyond instructor pre-training scores (ΔR² = 0.186, <i>p</i> < 0.001). Independent verification confirmed high recognition accuracy (100%) and system stability. These findings indicate that precision sensing enables XR environments to function as reliable performance measurement systems, supporting standardized non-face-to-face nursing practicum education.