Table 3 Participants and outcomes

Adhikari et al., 2021 [57]

Third-year nursing students

19

Decision-making

• There was a 26.1% increase in mean confidence with decision-making scores on the NASC-CDM post-intervention (p < 0.001)

• There was a 23.4% decrease in anxiety with decision-making scores on NASC-CDM post-intervention (p < 0.001)

Anbro et al., 2020 [24]

Third-year medical and nursing students

Third-year medical students = 49

Third-year nursing students = 56

Participants using HTC Vive Headset with eye tracking = 22

Communication accuracy, situational awareness

• Seventeen participants increased their frequency of correct verbal responses posttest — 5 looked at the speaker longer, 11 looked at the environment longer, and 1 did not change

• Four participants did not increase their frequency of correct verbal responses posttest — two looked at the speaker longer, and two looked at the environment longer

• One participant decreased their frequency of correct verbal responses posttest — looked at the speaker longer

Atthill et al., 2021 [25]

Nursing students

Asynchronous debriefing = 32

Face-to-face debriefing = 32

Decision-making

• Both the asynchronous and face-to-face debriefing strategies showed an increase in self-confidence and decrease in anxiety with decision-making scores posttest

• There was a significant change in post-test scores for all asynchronous debriefing dimensions. There was only a change in Dimension 2 of NASC-CDM for self-confidence and Dimension 3 of NASC-CDM for anxiety and self-confidence in face-to-face debriefing groups

• The asynchronous debriefing strategy had a greater impact in reducing anxiety with relation to Dimension 1 of the NASC-CDM

Blanie et al., 2020 [26]

Second-year nursing students

Simulation by gaming group = 73

Traditional teaching group = 73

Clinical reasoning

• There was no significant difference between groups in the script concordance test (SCT) scores immediately after and 1 month after the intervention (p = 0.43, p = 0.77)

• There was no significant difference between groups in self-assessment of clinical reasoning knowledge after the intervention

• Students in the simulation group expressed significantly more satisfaction towards the training session compared to the traditional teaching group (p = 0.001)

• Students in the simulation group expressed more satisfaction towards the pedagogical tool compared to the traditional teaching group (p = 0.004)

• Students in the simulation group perceived the session to be more engaging, with increased motivation levels (p = 0.003)

• The global educational value (Would you recommend this training to students or colleagues?) was more positively significant in the simulation group (p = 0.002)

Bracq et al., 2021 [27]

Scrub nursing students, expert scrub nurses

Scrub nursing students = 18

Expert scrub nurses = 8

Situational awareness

• Post first simulation, 3 students assessed their performance as poor, 10 as average, and 5 as good

• The mean number of detected errors was higher in session 2 than session 1 (p < 0.001)

• The mean number of reported non-errors was higher in session 2 than session 1 (p = 0.004)

• Moderate risk detection rate was higher in session 2 than session 1 (p < 0.001)

• Subjective workload was higher in session 1 than session 2 (p = 0.006)

• Ease of use was higher in session 2 than session 1 (p = 0.019)

Carrard et al., 2020 [28]

Fourth-year medical students

64

Situational awareness (verbal and nonverbal communication and behaviours, management of emotional reactions, pauses, and silences)

• Students highlighted the benefit of the simulation providing self-observation via a video recording enabling them to have a critical view of their behaviour

• Some students noted that the simulation could be improved by indicating the “right” way of doing things (on-screen guidelines or examples)

Casler et al., 2022 [29]

Nursing students

68

Effect of asynchronous debriefing discussion on virtual simulation experience

• Overall mean debriefing experience scale (DES) scores increased post-discussion from 66.3/100 to 72.0/100

• All 20 items of the DES showed an increase in post-discussion. However, 14 of the 20 items showed statistically significant differences

• Fifty-one students described the combined debriefing strategy in positive terms and that the discussion-board debriefing exercises added value to their learning

Chen and Liou, 2022 [30]

Nursing students

82

Clinical judgement, decision-making

• Students reported that the AR simulation inspired empathy, improved clinical judgement and decision-making, provided a stress-free learning environment, and improved the efficiency of distance and self-learning

Cieslowski and Haas, 2023 [31]

Nursing students

110

Decision-making

• Students expressed that the scenario allowed them to critically think

• Students noted that the VR scenario imparted greater confidence and comfort before approaching the scenario in real life

Colonna et al., 2022 [32]

Fourth-year medical students, general surgery residents, surgical faculty

Fourth-year medical students = 6

General surgery residents = 18

Flight nurses = 2

Acute care surgeons = 4

Surgical oncologist = 1

Decision-making

• Participants noted the simulation’s ability to develop clinical decision-making ability. The Simulation Experience Scale (SSES) score for the clinical reasoning section was 4.31 ± 0.20 (mean ± SD)

Du et al., 2022 [33]

Fourth-year medical students

20

Decision-making

• Students’ knowledge acquisition scores after training were significantly higher than before training (p ≤ 0.001)

• In the real-world scenario-based test students’ non-technical skills (NTS), scores were significantly higher after training compared to before training (p ≤ 0.001)

• Total score obtained by students after training was significantly higher than before training (p ≤ 0.001)

• There was no significant difference between scores of technical skills before and after training (p = 0.69)

Fogg et al., 2020 [34]

Nursing students

234

Clinical judgement

• There were significant improvements in the Lasater Clinical Judgement Rubric (LCJR) scores after the simulation, compared to before (p = 0.000)

• LCJR ratings were significantly improved in the fields of noticing (p = 0.000), interpreting (p = 0.002), responding (p = 0.001), and reflecting (p = 0.01) after the simulation, compared to before

• The number of student attempts decreased significantly from the first case to the final case simulation (p = 0.000) — student attempts ranged from 1–13 on the first case to 1–5 on the last. Student scores in both cases ranged from 90 to 100%

Hu et al., 2022 [35]

Nursing students

Traditional teaching method = 80

Virtual reality mobile game-based application (VR-MGBA) group = 78

Decision-making

• Final test scores revealed significantly higher knowledge and decision-making retention in the game group compared to the traditional teaching group (p = 0.000)

• The game-based group displayed significantly higher scores for course interest and classmate cooperation compared to the traditional lecture group (p < 0.05)

Jayasundera et al., 2022 [36]

Third-year medical students

8

Decision-making

• The students demonstrated statistically significant improvements in their confidence with making appropriate and timely clinical decisions (p = 0.008), effectively managing a team (p = 0.031), and keeping patients updated (p = 0.031)

Sahin Karaduman and Basak, 2023 [37]

Third-year nursing students

Two virtual patient simulation group = 42

Virtual patient simulation and human patient simulation group = 42

Control (human patient simulation) = 42

Decision-making

• There were no statistically significant differences between groups in nursing confidence with clinical decision-making pre-test (p = 0.231) and posttest (p = 0.953)

• There were no statistically significant differences between groups in nursing anxiety with clinical decision-making pre-test (p = 0.605) and posttest (p = 0.907) scores

• There was a statistically significant difference between the pre-test and post-test nursing self-confidence and anxiety with decision-making scores in the virtual patient simulation group (p < 0.001)

• There was a statistically significant difference between the pre-test and post-test nursing self-confidence and anxiety with decision-making scores in the virtual patient + human patient simulation group (p = 0.042)

• There was a statistically significant difference between the pre-test and post-test nursing self-confidence and anxiety with decision-making scores in the control group (p < 0.001)

• The performance scores should be a statistically significant difference in simulation groups (p < 0.001). The highest performance score value was obtained in the virtual patient simulation group, and the lowest was obtained by the control group

Pardue et al., 2022 [38]

Nursing students

19

Clinical judgement

• Students engaged in virtual reality simulation scenarios successfully described and demonstrated one or more phases of nursing clinical judgement (i.e. effective noticing, effective interpreting, effective responding, effective reflecting)

Kim et al., 2023 [39]

Nursing students

Intervention group = 25

Control group = 23

Decision-making

• There was a significant increase in post-test scores in the intervention group from pre-test (p < 0.001). The control group also had a statistically significant increase in post-test knowledge scores (p = 0.017). The difference between the groups was not statistically significant (p = 0.594)

• The intervention group had significantly lower post-test anxiety with clinical decision-making scores than the control group (p = 0.031)

• The intervention group had significantly higher decision-making confidence scores in “knowing and acting” (p = 0.025) and “seeking information from clinical instructors” (p = 0.049) than the control group

• The intervention group reported good learning immersion in VR-based mixed simulations

Kiyozumi et al., 2022 [40]

Paramedical and medical students

Medical students = 5

Paramedical students = 9

Decision-making

• There was a statistically significant improvement of the number of clears in the scenarios between the first 5 min and the second 5 min (p = 0.0125)

• There was a statistically significant improvement in the number of clears between the first 5 min and the third 5 min (p = 0.0045)

• The difference between the number of clears in the second and third 5 min was not statistically significant (p = 0.0915)

Kleinheksel, 2014 [41]

Nursing students

130

Clinical reasoning

• The most significant predictor for the implications for practice reflection score was critical items discovered (p < 0.001)

• The number of red flag items (negatively correlated) was a significant predictor for the implications for practice reflection score (p = 0.031)

Lee et al., 2022 [42]

Nursing students

VR group = 56

Control group = 48

Problem-solving

• Problem-solving scores increased in both groups after the intervention. However, the improvement in the VR group was statistically significant in the decision-making, solution applying, and evaluation reflection domains (p < 0.05), while there was no statistically significant improvement in the control group

• The learning satisfaction in the VR group was significantly higher overall and for each examined item (p < 0.001)

Lee et al., 2023 [43]

Fourth-year nursing students

Experimental group = 17

Control group = 17

Decision-making

• There was a statistically significant difference between the experimental and control group’s decision-making scores posttest (p < 0.001)

• The post-test scores for confidence in performance was significantly different between the groups (p < 0.001)

Mahling et al., 2023 [44]

Fourth-year medical students

129

Decision-making

• 91% of respondents agreed that VR was useful in conveying complex issues quickly

• 80% of respondents agreed that VR should be used in examinations

Mascarenhas et al., 2023 [45]

N/A

510

Situational awareness

• 80% of learners “strongly agreed” or “agreed” that the intervention improved their situational awareness to identify hazards that can be present within the patient room

McCallum et al., 2011 [58]

Nursing students

5

Decision-making

• Students learnt clinical decision-making from the experience

Michelet et al., 2020 [46]

Fourth-year midwifery students

Debriefing group = 14

Control group = 14

Decision-making, situational awareness

• No significant difference between the groups with regard to knowledge acquisition and retention after intervention

• A significant difference was observed in the non-technical skills assessment between the two groups for session 1 (p = 0.02), which remained higher in favour of the debriefing group in session 2 (p = 0.08)

Middeke et al., 2018 [47]

Fifth-year medical students

Problem-based learning group (PBL) = 34

EMERGE group = 78

Clinical reasoning

• Students in the EMERGE group achieved significantly higher aggregate scores compared to the PBL group (p = 0.015)

• Students in the EMERGE group achieved significantly higher aggregate scores than students in the PBL group across all four cases (p < 0.001 (1–3); p = 0.004 (4))

Mills et al., 2020 [48]

Paramedical students

29

Decision-making

• Average heart rate was significantly higher during the live simulation compares to the VR simulation (p < 0.001)

• The live simulation took significantly longer to complete compared to the VR scenario (p < 0.001)

• No significant differences were observed in total score of satisfaction and importance components of simulation design scale (p > 0.05)

Park et al., 2022 [49]

Nursing students

Group 1 (virtual simulation (VS) followed by high fidelity simulation (HFS)) = 26

Group 2 (high-fidelity simulation followed by virtual simulation) = 26

Clinical reasoning

• After the first simulation, a significant difference was seen in clinical reasoning (p = 0.031) and problem-solving process (p = 0.006) with higher scores in the virtual simulation group than the high-fidelity simulation group

• The group that received VS first and HFS second had higher scores for reflective thinking (p < 0.001) and self-confidence (p = 0.013)

Rim and Shin, 2022 [50]

Nursing students

45

Clinical judgement

• Students rated their clinical judgement scores as higher post-session compared to pre-session

• Nursing competency scores significantly increased after the programme (p < 0.001)

Rogers, 2011 [51]

Nursing students

16

Problem-solving

• Students reflected that the simulation experience helped in construction of knowledge and development of problem-solving skills in a collaborative environment

Saab et al., 2021 [52]

Third-year nursing students

26

Decision-making

N/A

Sara et al., 2021 [53]

Nursing students

40

Clinical reasoning

• Students evaluated their clinical reasoning skills as best in collecting information and worst in establishing goals in all three phases

• There was a significant improvement in self-evaluated clinical reasoning skills from before the simulations to after the virtual reality simulation

Watari et al., 2020 [54]

Fourth-year medical students

169

Decision-making

• Participants showed a significant increase in their average total post-test scores compared to pre-test (p < 0.001)

• The rate of change between pre-test and post-test clinical reasoning answers was higher than knowledge answers (p < 0.008)

Williams et al., 2020 [55]

Nursing, practical nursing, and healthcare assistant students

Nursing = 27

Practical nursing = 12

Healthcare assistant = 7

Situational awareness (role awareness, positions of power)

• Students felt that the simulation provided them with an opportunity to discuss role challenges with their teammates

• The simulation highlighted that despite different roles and natural positions of power, all members of the team are equally important

Yang and Oh, 2022 [56]

Nursing students

Virtual reality group = 29

Simulation group = 28

Control group = 26

Problem-solving, clinical reasoning

• There was no significant difference in nursing knowledge scores between the virtual reality group and the simulation group. However, there was a significant difference in the scores between the virtual reality group and the control group (p < 0.001)

• The problem-solving ability score increased from pre-test to posttest in the virtual reality and simulation groups but decreased in the control groups. The VR group scores were significantly higher than both the other groups (p = 0.038)

• The clinical reasoning ability score of the three groups increased from pre- to post-intervention. However, the virtual reality group did not significantly improve in comparison to the simulation and control groups

• Self-confidence scores for all three groups increased post-intervention. The virtual reality group scores improved significantly compared to the other two groups

• There were no significant differences in the anxiety scores between groups, although all groups anxiety scores were reduced post-intervention

• There were no significant differences in learning motivation scores between the virtual reality group and the simulation group. However, the scores were higher compared to the control group