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INTRODUCTION The aim of this study was to comparatively evaluate the learning outcomes achieved by first-year radiography students educated with either virtual reality (VR) simulation training or physical simulation training. The implementation of VR has been proposed to enhance learning in radiography students and provide a more effective and efficient approach to simulation. However, the learning outcomes achieved with this approach have not been widely investigated. METHODS Through stratified randomisation, 188 radiography students were allocated to one of two matched groups: a VR group (using Virtual Medical Coaching's Radiography simulation) and a physical simulation group (using Philips' X-ray equipment). Both groups were taught 31 radiography views over one 25-week semester. Both groups were assessed in an Objective Structured Clinical Examination (OSCE), using actors as patients in a physical X-ray environment. Assessment was conducted by assigning objective count scores for five assessment criteria. RESULTS The VR group achieved shorter OSCE duration and fewer errors in moving equipment and patient positioning: these results were statistically significant (P < 0.00). There was no significant difference in the frequency of errors in radiographic exposure setting between the VR and the physical simulation group. The current findings concur with the limited number of published studies concerning VR simulation in radiography. CONCLUSIONS The results of this study demonstrated superior effectiveness and efficiency in the VR group. This provides preliminary evidence to introduce VR simulation in the host institution and provide evidence that it may be possible to replace the use of physical simulation across other years of the degree. Further research investigating these possibilities is warranted.