Application of mixed reality in prehospital emergency nursing education: A scoping review

Abstract

Aim

This paper provides a scoping review of the literature on prehospital emergency mixed reality (MR) nursing education and explores the impact of MR devices in prehospital emergency nursing education.

Background

The timely intervention of prehospital paramedics plays a critical role in emergency situations. Training in a real environment requires significant resource consumption and allows only limited training frequency and variability. Therefore, MR training environments with realistic simulations are necessary. Currently, little is known regarding which MR devices are appropriate for prehospital emergency nursing education and how their design meets various educational goals.

Methods

A scoping review was conducted following the Joanna Briggs Institute scoping review methodology. Peer-reviewed articles were searched across MEDLINE, EMBASE, CINAHL, Web of Science, SCOPUS, PUBMED and the Cochrane Library. Studies had to include MR simulations in the field of prehospital emergency nursing education.

Results

Twenty-one articles were identified. The analysis revealed that MR devices can be divided into three categories, desktop VR simulations, immersive VR simulations and MR simulations. MR is mostly used to simulate small accident scenes and disaster emergency response training. MR can obviously improve students' enthusiasm and learning efficiency but cannot change the learning results.

Conclusions

Various MR devices are widely used in prehospital emergency nursing education. This practice can obviously improve students' enthusiasm and learning efficiency. However, a gap remains between MR simulations and real simulations. Nevertheless, MR can be used as an auxiliary teaching resource. In the future, attempts can be made to develop MR devices combined with artificial intelligence.

1 Introduction

Prehospital emergency care is a crucial part of the emergency medical services (EMSs). Prehospital care is emergency medical care given to patients before arrival at the hospital after the activation of emergency medical services ( ^{Kironji et al., 2018}). Prehospital paramedics’ timely intervention plays a critical role in emergency situations such as cardiac arrests, car accidents and mass casualty incidents (MCIs). The mortality rate for patients with life-threatening injuries is 6 % in countries with well-educated prehospital paramedics,whereas it is 36 % in countries with few or no senior prehospital paramedics ( ^{World Health, 2014}). To guarantee the quality of prehospital emergency care, all emergency medical care should be provided by staff trained in prehospital care ( ^{World Health Organization. Regional Office for, 2020}). Studies have shown that effective first aid training can significantly improve the emergency response ability of nursing staff, thus reducing the mortality rate of prehospital care ( ^{Bhattarai et al., 2023}).

Traditional training techniques for prehospital emergency nursing education are broad and varied: from lectures and seminars, or practical tabletop exercises, to live drills including cards, actors or even sophisticated mannequins ( ^{Gunshin et al., 2020; Kim and Lee, 2020}). However, training in a real environment consumes significant resources and allows only limited training frequency and variability. In recent years, simulation-based education has become increasingly popular. The rapid evolution of high-fidelity simulation technology has led to the widespread use of novel training tools in medicine, with a particular focus on MR. Because of MR highly immersive nature and its ability to simulate emergency scenarios that cannot be simulated, MR-based training for prehospital emergency nurses has been increasingly recognized as an important additional modality to traditional training techniques ( ^{Paletta et al., 2022; Heldring et al., 2024}).

MR combines real world and digital elements. In MR, one can interact with and manipulate both physical as well as virtual items and environments via next generation sensing and imaging technologies. In other words, MR covers a broad spectrum that includes virtual reality (VR), augmented reality (AR) and various blends of these two MR types. The most used MR system is desktop VR, which requires only a simple device configuration and is easy to operate. Immersive VR devices are typically head-mounted displays (HMDs), such as Oculus Rift, Meta Quest or HTC Vive( ^{Radianti et al., 2020}). HMDs can be divided into many types: high-end VR, mobile VR or enhanced VR( ^{Jensen and Konradsen, 2018}). Given the wide variety of tools available in MR, it is necessary to systematically characterize the currently available MR products.

There are four main aspects of the application of mixed reality technology in nursing education. (1) Procedural skill training: Most of the simulators developed provide systematic procedural training for practising step-by-step interventions, usually focusing on aseptic noncontact techniques ( ^{Plotzky et al., 2021}). (2) Psychomotor skill training: Special tactile devices are used to simulate real-world nursing psychomotor skills ( ^{Harris et al., 2020; Rose et al., 2000}). (3) Emergency response: MCIs in the real world typically involves high costs and effort. The development of these scenarios using MR devices is relatively inexpensive and requires repeated training, but it is easily adaptable ( ^{Otero-Varela et al., 2023}). (4) Soft skill training: Empathy and soft skills are conveyed through text-based conversation, multiplayer capability for team training or role play ( ^{Jorissen and De Boi, 2018}). MR can be considered a very powerful educational tool. However, there are many types of prehospital care training skills and it is necessary to determine which aspects of prehospital emergency care can benefit from MR.

While mixed reality (MR) technology has demonstrated potential in nursing education, its application in prehospital emergency care training remains underexplored. In a meta-analysis, ^{Otero-Varela et al. (2023)} assessed the effectiveness of extended reality (XR) training methods, exploring the experience of medical first responders (MFRs) receiving such training. ^{Heldring et al. (2024)} systematically described the application of VR devices in MICs. However, these studies have significant limitations. First, MR applications primarily focus on singular events like MCIs rather than the whole process of prehospital emergency training (e.g., trauma care, cardiac arrest and critical patient transport). Furthermore, existing reviews address VR/XR devices without MR devices for prehospital training contexts. Moreover, the study populations of these reviews are all medical students or first responders, there is a lack of reviews on the training of nurses in prehospital emergency care. While the mapping review by ^{Plotzky et al. (2021)} underscored the potential of VR in nursing education, there is a lack of targeted analysis of the application of MR in the prehospital nursing education. There is no comprehensive synthesis of MR devices application in nursing education, especially prehospital emergency care. Although existing studies have confirmed that MR devices has unique advantages in the field of in prehospital emergency nursing education, it is necessary to further explore its specific application methods and scenarios, so as to provide scientific guidance for nursing education.

In this scoping review, we examine existing articles on prehospital emergency MR nursing education and explore the availability and impact of MR devices in this research field. Accordingly, the research questions are as follows:

• 1) Which MR devices can be used in prehospital emergency nursing education?
• 2) What nursing prehospital emergency scenarios and educational aims do MR address?
• 3) What is the impact of MR in prehospital emergency nursing education?

2 Methods

The proposed scoping review was conducted in accordance with the JBI methodology for scoping reviews ( ^{Peters et al., 2024}). Our reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (A. C. ^{Tricco et al., 2018}). The study commenced in mid-June 2024 and was completed by November 2024. The protocol was registered in the Open Science Framework (OSF) ( ^{Lu, 2024, September} 3).

2.1 Population

This review considered studies involving nursing personnel (e.g., nurses, nursing students and paramedics) in prehospital emergency nursing education as participants. The chosen population was expanded to include paramedical staff because, in most countries, paramedics and nurses carry out nearly identical critical procedures during prehospital emergency care, including cardiopulmonary resuscitation (CPR), bleeding control and trauma management. These skills represent the core competencies of emergency response, independent of their professional titles.

If, in the study results, a study population was presented in a way that combines it with the non - target population, making it impossible to extract data specifically from the target population, the study was excluded.

2.2 Concepts

MR unites real world and digital elements. MR covers a broad spectrum that includes virtual reality (VR), augmented reality (AR), extended reality (XR) and various blends of both. Therefore, in this review we included MR, VR, AR and XR as the study concepts.

2.3 Context

This scoping review considered a study context that included prehospital emergencies. In this review, we define the prehospital emergency environment as the scene of an accident that occurred outside the hospital and in the ambulance whereby the patient was being transferred.

2.4 Search strategy

A comprehensive search of the literature in the following electronic databases was performed: MEDLINE (Ovid), EMBASE (Elsevier), CINAHL (EBSCO), Web of Science, SCOPUS(Ovid), PUBMED and the Cochrane Library. Grey literature was searched for through Google Scholar. Seven databases were searched for English language articles published with no time restrictions. The adopted search string was: (“mixed reality” OR “Virtual Reality” OR “Augmented Reality”) AND (“prehospital emergency” OR “out of hospital” OR “first aid ambulance”) AND (“nurs*” OR “paramedic*”). A full search strategy, including the MeSH terms, keywords that were used is detailed in ^{Supplementary Table} A. The reference lists of all included studies were manually searched to locate additional relevant reports. Primary sources of all types could be included. Research using all methodologies was accepted. The search was conducted in July 2024. All the identified references were imported into the reference manager software EndNote 21 and any duplicate records were removed.

2.5 Identifying relevant studies

First, a limited search using keywords was conducted in the databases of PUBMED. In all the retrieved articles, an analysis of the words contained within the titles, abstracts and index terms was performed to develop a full search strategy. Combinations and truncated variations of the following search terms were used for each database search: mixed reality, augmented reality, virtual reality, prehospital emergency care, nurse and paramedic. A full list of searched databases is included in ^{Supplementary Table} B. Second, a second search using all the identified keywords and index terms was performed across all the databases. For a more comprehensive searching, the search strategy was modified depending on the databases. Finally, the reference lists of all the articles included in this scoping review were screened to identify additional sources. Experienced librarians were consulted in the process of searching. Two reviewers with knowledge of the topic performed the data collection and screening independently.

2.6 Study selection

Literature screening followed a three-step screening process ( ^{Peters et al., 2024}), consisting of a pilot screening as well as a title and abstract screening, followed by a full-text review. First, two reviewers (L.L. and S.F.) randomly selected 25 titles/abstracts as a sample. The entire team was screened using the eligibility criteria and then, the team met for differential discussion to modify the eligibility criteria. The team commenced full screening only when 75 % (or greater) agreement was achieved. In both steps, two independent reviewers (L.L. and Y.X.) screened the articles according to the eligibility criteria. In the case of discrepancies in the analysis, a third reviewer (X.T.) with a background in nursing education from the research team was consulted.

2.7 Data extraction

We conducted pilot data extraction to improve the quality and consistency of the results. Educational objectives were mapped to the nursing scenarios and tasks that had to be performed during simulations, as well as to how scenarios and tasks were implemented. To describe and summarize the results more intuitively, we used a narrative and tabular approach to generalize the extracted data, including authors, year of publication, country where the study was performed, study design, characteristics of participants, educational objectives, environment/nursing context, simulation design/type of mixed reality used and main findings. The characteristics of each study were extracted independently by two researchers.

3 Results

The literature search identified a total of 2748 potential articles, of which 21 records were included in the sample. After title and abstract screening, 2590 articles were excluded according to the inclusion criteria, leaving 158 articles for full-text review. After a review of the reference lists of the 146 articles identified, 12 additional articles were added. ^{Fig. 1} presents a flow diagram describing each step of the inclusion and exclusion process based on the PRISMA guidelines (Andrea C. ^{Tricco et al., 2018}). Among the 21 articles, five are from Europe, 10 from North America, two from Australia and 5 from Asia.

3.1 Types and characteristics of MR devices

Among the 21 studies, the MR devices involved could be divided into three categories: desktop VR systems (computers, mice, touch screens) and immersive VR systems (e.g., helmet displays, interactive controllers) and MR systems (immersive VR systems that incorporate real scenes). In the field of prehospital emergency nursing education, the more commonly used MR devices are immersive VR devices such as: the Samsung Gear VR® helmet and the HTC Vive( ^{Ferrandini Price et al., 2018}; ^{Bucher et al., 2019}). These devices are now widely commercially available and supported by mature VR software such as the VROnSite platform ( ^{Paletta et al., 2022}).

Unlike live simulations, VR alone can only reproduce sight and sound ( ^{Harada et al., 2024}). However, MR in effect “blends” real-world objects of training relevance with virtual reality reconstructions of operational contexts. MR complements the simulation shortcomings of VR devices, which can only simulate only vision and sound ( ^{Harada et al., 2024}). For example, HMD was combined with a high-fidelity human simulation model to simulate out-of-hospital cardiopulmonary resuscitation and supplement the lack of real tactile stimulation in simple HMD ( ^{Zechner et al., 2023; Rushton et al., 2020}) or, in another example, combined with endurance running on a treadmill to increase physical stress ( ^{Paletta et al., 2022}).

The initial development of MR training involves many costs, including the cost of MR devices and the cost to train professional teachers ( ^{Shujuan et al., 2022}). However, after adaptation, both students and faculty would benefit in the long term ( ^{Aebersold et al., 2018}) because of the low energy consumption, repeated usability and ease of updating of MR training.

3.2 Nursing prehospital emergency scenarios and educational objectives

Different MR devices are suitable for different nursing scenarios and skill training. Desktop VR is mostly used for procedural skills training, postdisaster decontamination capacity training and simple first-aid process training ( ^{Athanasopoulou et al., 2024; Farra et al., 2015; Ulrich et al., 2014; Cicero et al., 2022}). However, these devices do not simulate a specific environment only the mouse and keyboard provide tactile stimulation, which is very different from reality. This type of simulation is simple to implement but not immersive ( ^{Cicero et al., 2022}).However, common prehospital emergency response training (e.g., disaster preparedness training, basic life support training, prehospital triage training, etc.) usually uses immersive VR ( ^{Tunc et al., 2024; Paletta et al., 2022; Ferrandini Price et al., 2018; Bucher et al., 2019; Mills et al., 2020; Shujuan et al., 2022; Chang et al., 2022; Rushton et al., 2020}). Immersive VR mostly simulates traffic accident injuries and small-scale accident scenes, which are commonly encountered prehospital accident sites ( ^{Paletta et al., 2022}). Compared with augmented VR, immersive VR has the characteristics of high immersion, lower cost, lower professionalism requirements and simpler training implementation ( ^{Rushton et al., 2020}).

MR devices are mostly used to simulate mass casualty or major incident situations ( ^{Zechner et al., 2023; Wilkerson et al., 2008; Rushton et al., 2020; Lee et al., 2024; Broneder et al., 2023}). MR devices can simulate perilous scenarios that are impossible to create ( ^{Zechner et al., 2023; Wilkerson et al., 2008; Chang et al., 2022}). MR devices can be personalized for simulation scene editing. The mature scene editor function can transform and adjust a scene according to training needs ( ^{Zechner et al., 2023}). MR is mainly used for large-scale disaster training and team cooperation ability training. It is highly immersive and can increase psychological stress. Most of the simulated prehospital scenarios were large-scale disasters (e.g., fires, earthquakes, terrorist attacks) ( ^{Zechner et al., 2023; Wilkerson et al., 2008; Lee et al., 2024; Broneder et al., 2023}). However, this type of device requires costly and complex instrumentation and professional instructors are required for offsite guidance.

3.3 Repercussions of MR devices in prehospital emergency nursing education

MR technology has become a key training component in many industries ( ^{Das, 2023}) and the impact of MR on prehospital first aid education is multifaceted. MR use reportedly increases satisfaction ( ^{Athanasopoulou et al., 2024; Mills et al., 2020; Cicero et al., 2022; Lee et al., 2024}), confidence ( ^{Tunc et al., 2024; Shujuan et al., 2022}), physical strain ( ^{Paletta et al., 2022}), learning efficiency ( ^{Davidson et al., 2024}). self-efficacy ( ^{Farra et al., 2015; Cicero et al., 2022}), performance ( ^{Wilkerson et al., 2008; Rushton et al., 2020; Davidson et al., 2024; Athanasopoulou et al., 2024; Shujuan et al., 2022; Farra et al., 2015; Ulrich et al., 2014}), communication ( ^{Davidson et al., 2024}). The situated-MR approach lends itself better to entrain sequences of actions rather than declarative knowledge ( ^{Bucher et al., 2019}).

There is little evidence of the challenges posed by and negative repercussions of using MR devices in prehospital emergency nursing education. One study reported a decline in students' confidence after MR training. Compared with the familiar environment, the strangeness of the MR environment and the high pressure caused by immersion reduced students' confidence in Octave ( ^{Rushton et al., 2020}). MR devices cause different types of pressure for trainees depending on the first aid skill being trained. Clinical Simulation(CS) creates a more stressful training experience so that it should not be substituted for by the use of VR but should be complemented with it ( ^{Ferrandini Price et al., 2018}). Several studies have shown that MR, as an educational tool, cannot improve the learning outcomes of students (the results achieved are the same as those achieved through real simulation learning), but it can improve learning efficiency ( ^{Ferrandini Price et al., 2018; Davidson et al., 2024}). Owing to the characteristics of MR devices, certain students experience motion sickness and dizziness symptoms when using them ( ^{Shujuan et al., 2022}).

4 Discussion

This scoping review aimed to explore the impact of MR in nurses’ prehospital emergency education and provide recommendations for future research in this area. The results show that students find MR beneficial for their learning and that it motivates them to engage in the learning situation. MR simulations enable students to interact with phenomena that are beyond the reach of realistic simulations. However, this depends on the MR hardware and training content. Additionally, most MR devices used in research are trained on self-designed software and the device development is not mature.

4.1 Current problems with MR devices and how to offset them

Immersive MR technology has emerged as a pivotal tool across a diverse array of industries, such as aviation, health sciences and security services, with the capacity to augment learning experiences, expedite skill mastery and facilitate knowledge retention within a condensed time frame ( ^{Das, 2023}).At present, immersive MR technology has been widely used in nursing theory education, nursing skills training, clinical nursing and other nursing professional nursing fields.

The results of our review show that current MR technology also has several disadvantages: (1) The cost of learning and maintenance is high ( ^{Williams et al., 2018}). The learning curve of MR devices is initially steep and then flat. Beginners need professional guidance and a considerable investment of labour and time to learn how to use MR devices ( ^{Aebersold et al., 2018}). Moreover, the initial cost of MR device development is high and regular maintenance and updates are required to maintain the best functioning of the device; (2) There are limitations to interaction and feedback. In the interaction process between device users and virtual patients, the problem of poor responsiveness is prominent ( ^{Zechner et al., 2023}). In certain scenarios, virtual patients are slow to respond to the user's operation behaviour and the meaning of feedback is not obvious, which makes it difficult to provide an effective response, resulting in a decrease in the user's immersion experience; (3) Tactile simulation is missing. MR devices can simulate only hearing and vision. In the construction of the virtual world, MR cannot achieve haptic simulation even temporarily and thus, there is a significant gap between MR and real scene simulation. Users mostly interact with the simulated environment through a handset, which makes it difficult to provide the feel of the real world and the real experience of object interaction; (4) Individualized training is not possible at present( ^{Zechner et al., 2023}). Owing to differences in each person's perception of stress, it is difficult to carry out individualized training with current MR devices. In the same training situation, training results are affected by the different pressures that different individuals feel. Functional modules related to pressure detectors and scenario regulation must be further developed; and (5) There is a risk of motion sickness. After HMD was used for 15 min, motion sickness was reported by 22 % of the participants ( ^{Munafo et al., 2017}).

Nevertheless, MR software and hardware are currently being actively developed by large companies such as Apple, Microsoft, Facebook and Google and will become much more common in the near future ( ^{Munzer et al., 2019}). Second, owing to the significant advantages of MR devices such as low energy consumption, repeated usability and easy updating, both students and teachers benefit in the long run from using MR devices ( ^{Shujuan et al., 2022}). The latest results show that MR has evolved over time in several ways. MR training that previously had to be conducted by a professional can now enable learners to practice at their own pace and receive targeted feedback to help improve their learning efficiency ( ^{Tunc et al., 2024}). While once it was impossible for many users to interact during MR training, now it is possible to cultivate teamwork ability using MR. The availability of MR devices is rapidly increasing, and the devices are becoming increasingly accepted ( ^{Davidson et al., 2024}). Haptic feedback is not impossible in the virtual world and haptic simulation gloves are currently being developed and are expected to be available to consumers at an affordable price within the next decade ( ^{Qi et al., 2023}).

Many studies have investigated how to alleviate motion sickness. Research shows that chewing gum while using MR devices can reduce motion sickness symptoms ( ^{Kaufeld et al., 2022}). Additionally, a scientific report indicated that precisely adjusting the pupillary distance to match the individual's state can significantly reduce motion sickness symptoms caused by mismatched visual imaging and perception ( ^{Stanney et al., 2020}); reducing acceleration and deceleration that do not match the real world can also reduce the occurrence of motion sickness symptoms ( ^{Holla and Berg, 2022}). We recommend that VR content can also be presented on a computer as a backup approach when motion sickness arises. Currently, artificial intelligence (AI) is thriving. With AI's powerful data processing capabilities, intelligent decision-making ability and precise simulation ability, it can be used to manage multiple patients' virtual avatars simultaneously to achieve the same interaction effects as real-world humans experience. MR scenes can now be edited or otherwise adjusted individually ( ^{Zechner et al., 2023}), which will allow for a more effective and scalable training environment. Deeply integrating AI algorithms with MR devices is a key means to unlock the great potential of MR devices and align medical education with technological development trends; such integration is expected to open a new landscape of MR technology applications ( ^{Zechner et al., 2023}).

4.2 Broad promise of MR devices in the field of prehospital nursing education

The study findings indicate that MR devices have been widely used in various prehospital emergency environments and skill training. Currently, MR devices are often used to simulate common out-of-hospital emergencies such as car accidents ( ^{Zechner et al., 2023; Rushton et al., 2020; Paletta et al., 2022; Bucher et al., 2019; Mills et al., 2020}). This may be because car accidents are common, simulation is relatively easy and the cost of such simulation is low, facilitating wide access to such training. In general, simple MR devices (HMDs) can be used to simulate a complete emergency response process and can ensure positive training effects. However, at present, the emphasis remains on process training and there is still a lack of precision in skill training ( ^{Harada et al., 2024}).

Second, MR can also be employed to simulate large-scale disasters, such as explosions in chemical plants, fires and earthquakes ( ^{Wilkerson et al., 2008; Cicero et al., 2017; Broneder et al., 2023; Shujuan et al., 2022}). In this respect, MR offers an unprecedented advantage, offering users the chance to immerse themselves in scenarios that are hard to replicate through traditional simulation. When simulating a large disaster environment, the trainer must interact with the surrounding environment. For example, highly realistic human body models have been developed for CPR ( ^{Wilkerson et al., 2008; Rushton et al., 2020}) and treadmills have been incorporated to simulate real environmental pressure ( ^{Zechner et al., 2023}). Currently, this type of simulation is scarce, probably due to the high cost of development and the demand for special hardware. Additionally, current MR training skills focus mainly on operation processes or team collaboration ability training and fail to achieve precise skill training ( ^{Harada et al., 2024}). Therefore, MR devices require further development to lower their high operational cost, enhance the functionality of their hard and software and realize fine-grained operation simulations. Despite certain challenges, the application prospects of MR in the field of prehospital emergency nursing education remain highly promising. Through the adoption of the most advanced technologies and design schemes, MR can further narrow the gap between the virtual and real worlds, resulting in more efficient and authentic training experiences for prehospital emergency nursing education.

4.3 The application potential of MR needs to be further explored

Our results show that the application of MR devices can significantly improve learning motivation, promote high-level interactive and collaborative interpersonal development and promote proactive and experiential learning. However, it is important to note that although the use of MR devices as a teaching medium can improve learning efficiency and learning experience it cannot change learning outcomes ( ^{Lee et al., 2024}). The effectiveness of educational technology depends on the teaching method adopted rather than the teaching medium itself. While continuously seeking to improve MR devices, efforts should also be made to optimize teaching methods and content to achieve the goal of improving learning effectiveness and efficiency.

Among the articles included in this review, some offer overly simplistic descriptions of training processes. What theoretical framework underpinned the development of the training content? What roles did trainees assume during the training process? What MR devices software and hardware were used? What was the specific training scheme? None of these questions were answered clearly. Not only different teaching tools but also diverse training methods can have an impact on students' learning experiences and efficiencies. Several papers provide insufficient or even severely deficient descriptions of MR simulation processes. Some studies merely transfer desktop applications (such as multiple-choice games and sophisticated video games) to MR ( ^{Farra et al., 2015; Ulrich et al., 2014; Cicero et al., 2022}). These studies failed to fully exploit the immersiveness and interactivity of MR devices, thereby leaving the potential of MR underused. Therefore, we urge future authors to describe their MR simulations and training processes in detail when publishing their research.

With the advancement of the next generation digital revolution, virtual reality has made it possible to design new experiences that transcend time and space. This has also led to the concept of the metaverse, which refers to virtual reality that exists outside of reality ( ^{Kye et al., 2021}). In the future, as AI, ultrafast communication and hyperrealistic VR technologies converge, people may be able to live, shop, work, learn, socialize and entertain in VR. Metaverse-based education can avail itself of infinite virtual space and data amounts and has the advantage of offering interactive face-to-face education. The real-time data capture capabilities of MR, such as gesture tracking and physiological index monitoring, provide structured training data for AI algorithms.Therefore, we should seize the opportunity presented by the digital revolution and actively explore the possibility of using virtual reality in education.

4.4 Limitations

This study has several limitations. First, the concept of MR devices has not been standardized in the literature. We incorporate all the simulations related to MR, including augmented reality, virtual reality, mixed reality and video games based on VR. Subsequent studies could limit the inclusion criteria when defining MR devices. Second, among the studies reviewed in this paper, there was great heterogeneity in the methods and measures used to assess the outcomes of prehospital care training. Scoping reviews generally do not quantify the quality of evidence and are therefore amenable to a variety of study designs and methods, some of which may be of low quality. Finally, limited by publication circumstances, we had to exclude papers written in languages other than English from the scope of the study. However, it should be noted that this screening method may have led to the omission of relevant papers, which represents a limitation of our study.

5 Conclusion

At present, various MR devices are widely used in prehospital emergency nursing education. Training in a real environment consumes significant resources and allows only limited training frequency and variability. Therefore, MR training environments with realistic simulations are appealing. Our results show that the MR devices can be divided into three categories: desktop VR systems, immersive VR systems and MR systems. Furthermore, different MR devices are suitable for different nursing scenarios and skill training. For example, in the field of prehospital emergency care, the more commonly used MR devices are immersive VR devices. Specifically, they simulate scenarios such as traffic accident injuries and small-scale accident scenes, while also being commonly used to train skills such as basic life support and prehospital triage. Ultimately, the application of MR devices can significantly improve learning motivation, promote high-level interactive and collaborative interpersonal development and promote proactive and experiential learning.

However, due to the limitations of MR devices include insufficient resolution, an inability to simulate fine-grained activities, insufficient responsiveness of virtual characters and an inability to support intelligent control of complex scenes. A gap remains between MR simulations and real simulations. Nevertheless, MR can be used as an auxiliary teaching resource to improve students' learning enthusiasm and learning efficiency. In the future, attempts can be made to develop MR devices combined with artificial intelligence and longitudinal studies can be conducted to understand the long-term benefits and effectiveness of MR for prehospital emergency nursing education.

Authors' contributions

L Li conducted the data analyses and wrote the paper. L Li, SS Fa and T Xiao contributed to the study design and early drafts of the paper. L Li, YX Xing and Liling Mao collected the data. L Li and YX Xing screened the articles. SS Fan and Sq Zhou reviewed and edited the manuscript.

T Xiao is responsible for the overall content as the guarantor. T Xiao accepts full responsibility for the finished work and the conduct of the study, had access to the data and controlled the decision to publish. All authors have read and approved the final version of the manuscript.

CRediT authorship contribution statement

Tao Xiao: Writing – review & editing, Validation, Supervision, Methodology, Funding acquisition. Liling Mao: Methodology, Investigation, Data curation. Siqi Zhou: Writing – review & editing, Supervision. Yuxin Xing: Methodology, Formal analysis, Data curation. Sisi Fan: Supervision, Methodology, Formal analysis, Conceptualization. Lu Li: Writing – review & editing, Writing – original draft, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation.

Consent for publication

Not applicable

Funding sources

This study was supported by Postgraduate Education and Teaching Reform Project of Central South University ( 2024JGB068).

This study was supported by the Fundamental Research Funds for the Central Universities of Central South University ( 2025ZZTS0865).

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supporting information

Supplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2025.104415.

Appendix A Supplementary material

Supplementary material

Supplementary material

Table 1

Study and MR simulation characteristics and main results of the included studies.

Authors / year/Country	Aims	Study design	Outcome Variable /Participants	Environment	Simulation design / Type of Mixed Reality Used	Educational objectives	Main findings
( Zechner et al.,2023) Austria	To investigate how immersive technology can support and potentially enhance training for medical emergency response services.	A mixed-methods approach	User experience, end-user requirements / 123 Medical first responders (MFRs) (47 female, 76 male) and contextual interviews with 30 MFRs and trainers (16 female, 14 male)	Accident scene (Country Road Bus Crash Tunnel Accident)	Multi player role playing interactive environment/MR: provided by refence, integrates a wireless headset (HTC Vive Focus 3, full-body tracking)	MCI training	This study summarizes key features essential for an effective MR training system, including flexible scenario design, added realism through patient simulator manikins and objective performance assessment.
( Wilkerson et al.,2008) USA	To better understand the possible utility of immersive virtual reality simulation for training first responders in a mass casualty event.	A descriptive study	Performance of training experience and suggestions/15 active paramedics with at least 4 years of experience	Accident scene (a terrorist explosion at a sporting event)	Single player interactive environment with multiple tasks/VR: a high-resolution, cave automatic virtual environment (CAVE) integrated with a high-fidelity human patient simulator (HPS), lightweight liquid crystal display (LCD) shutter glasses for stereoscopic viewing	MCI training	The study found that in immersive VR simulation training, they have a high evaluation of the training experience. This exercise has the advantage of being repeatable and highly immersive.
( Tunc et al.,2024) USA	To evaluate the feasibility of a VR pediatric resuscitation simulation for pre-hospital providers during a work shift and impact on their self-reported confidence in caring for pediatric patients.	Quasi-experimental design with pre- and post-intervention questionnaires	EMTs' confidence/25 EMTs and 13 paramedics	Undefined	Multi player interactive environment/VR: Meta Quest 2 (Meta Inc,USA) provided	Prehospital pediatric resuscitation training	VR simulation is a feasible in situ training tool without a need for a facilitator and enhances confidence in the pediatric resuscitation by pre-hospital providers.
( Rushton et al.,2020) UK	To explore the use of immersive VR technologies in an unfamiliar environment for the students, compared to the familiar environments of the immersive video technology and no immersive clinical skills room	A mixed-methods approach	Skills performance, confidence /208 nursing students (no immersive, n = 55; immersive, n = 73; Octave, n = 80)	Out-of-hospital environment (streets, houses, road traffic)	Multi player interactive environment/VR:The “Octave” VR facility + shutter glasses to present three-dimensional (3D) visual cues, HPS(surrounded by stereo wall and floor projection)	Basic life support training	VR devices can increase their confidence and teamwork ability to deal with emergencies.
( Paletta et al.,2022) Austria	To investigate human factors, i.e, physical strain as well as cognitive-emotional stress levels in the context of situation reporting, under rather realistically simulated mission conditions	An exploratory pilot study	Physical strain, EDA-based stress, situation awareness-based risk stratification/Firemen (n = 7); paramedics (n = 6)	Accident scene (car accident with injured persons and inflammable liquid)	Multi player interactive environment/VR: the VROnSite platform: HMD, a two-handed gamepad and an omnidirectional treadmill to allow real walking	Emergency response training	VR environments can effectively simulate the psychological stress of real-world mission scenarios.
( Lee et al.,2024) Korea	To investigate the educational effects of and satisfaction with an MR-based trauma decision-making simulator.	Quasi-experimental design with pre- and post-intervention questionnaires	Degree of declarative knowledge mastery, the time took to complete the MR, satisfaction /7 trauma nurses, 19 medical students, 14 nursing students	Undefined	Single player, open interactive environment/MR:Holones 2 HMD (Microsoft Corp, Redmond, WA), HPS	Prehospital trauma nursing training	After the short-term (30 minutes) MR training, participants' declarative knowledge increased significantly. Training satisfaction was high, and satisfaction was not related to XR experience.
( Kiyozumi et al., 2022) Japan	To create VR content for the initial assessment segment of the Japan Prehospital Trauma Evaluation and Care (JPTEC) and verify its educational effectiveness.	An observational study	The number of clears (making the correct decision and completing the initial assessment)/Five medical and nine paramedical students	Prehospital trauma scene	Single player, multiple-choice-point/VR:HMD:IDEALENS K4 (Idea Technology Co,Ltd,Chengdu, Sichuan, China)	Prehospital trauma nursing training	This study VR content is efficient and easy to use, and students learn well.VR training enables trainees to practice repeatedly multiple times within a short period.
( Harada et al.,2024) Japan	To verify the educational usefulness of simple triage and rapid treatment (START) using VR originally developed for students.	An analytical prospective randomized controlled trial (RCT)	Written and practical tests/70 paramedic students (the VR groups n = 33; the live lecture groups n = 29)	Eight scenarios	Single player/VR+AR: a Pico G2 4 K VR head-mounted display (Pico Technology Co, Ltd. Beijing, Haidian Qu, China), an iPad (Apple Inc,Cupertino, CA, USA)	START training	VR Pros: Reduces teacher prep, reusable; student-centered role-playing enhances active learning and practical skills. VR Cons: Lacks real-time progress tracking (impairs retention); limited to audiovisual simulation, missing tactile feedback
( Ferrandini Price et al.,2018) Spain	The main objective of this study was to compare the efficiency of VR versus clinical simulation (CS) in performing START triage in a MCI.	Control-group design with pre- and post-tests	The basal and post levels of salivary α-amylase activity, heart rate, systolic arterial pressure, diastolic arterial pressure/70 nursing master's degree students (VR: 35, CS:35)	Undefined	Single player/VR: HMD: a Samsung Gear VR® helmet	START training	The VR method is as efficient as clinical simulation. The clinical simulation creates a more stressful training experience for the student, so that is should not be substituted by the use of VR.
( Davidson et al.,2024) Australian	To test whether HWDs and tablet computers (TABs) would change the team processes and patient care of paramedic trainee teams.	A crossover randomized controlled trial	Number and duration of attention switches toward the mobile device/40 paramedic students	Prehospital simulation environment (a workplace, a home child-minding environment, a hotel bar)	Multi player role playing interactive environment/Head-worn displays (HWDs) (Vuzix M300XL)	Prehospital teamwork training	HMDs may let prehospital teams monitor each other's performance more efficiently.Using HMDs requires less communication than using TABs.
( Cicero et al.,2017) USA	To assess the efficacy of the serious video game “60 Seconds to Survival” (60S) for EMS disaster triage learning.	RCT(a pilot study)/play 60S (intervention) or serve as controls	Triage accuracy /EMS providers including paramedics, paramedic students, and EMTs. (n = 62)	MCI (school shooting, house fire, tornado)	Single player, multiple-choice-point/The video game 60S	Disaster triage training	Participants who played 60S demonstrated improved triage accuracy, but have no significant difference in triage performance.
( Bucher et al.,2019) Germany	To introduce a VR application and present an evaluation of the VR system.	A mixed-methods approach	The specific impressions the role of authenticity or its usability/participants, who never had a first aid course (29), had only one first aid course (59) or were graduated nurse (19)	Out-of-hospital environment (in a busy street, in an elevator, in a forest at twilight)	Single player interactive environment with multiple tasks/VR:HMD: The HTC Vive, VReanimate	Basic life support training	VReanimate II helps to improve first aid knowledge, but the influence of the existing knowledge base of the participants on the results cannot be excluded.
( Broneder et al.,2023) Austria	To introduce a MR application,and present an evaluation of the system	A mixed-methods approach	Usage feedback (User experience)/Two fire fighters and seven paramedics	MIC (a large building fire and a chemical accident with hazardous materials)	Multi player role playing interactive environment/MR:the Magic Leap One (ML1) MR glasses, a GPS antenna, mobile phone for outdoor tracking, virtual manikins	MCI training	The results showed that the system was generally well received, with positive intention to use and ease of use.Improvements are needed in perceived usefulness and work relevance.
( Athanasopoulou et al.,2024) USA	To identify and measure practice deviation from current guidelines. The second objective was to measure learner and facilitator satisfaction with the simulation intervention and to improve prehospital provider self-reported knowledge, skills, and attitudes	A prospective observational cohort study	Simulation satisfaction, learners' performance, knowledge, skills, attitudes/33 facilitator and 55 learner surveys. The learners were prehospital clinicians(n = 55), Eligible participants were paramedics, EMTs(n = 33)	Undefined	Video-Augmented: SimBox is a PC-based software.	Prehospital pediatric resuscitation training	open-access simulation resources like SimBox can be used to identify and measure the gap between actual practice and clinical guidelines.
( Arif et al., 2023) USA	To examine the added benefit of an immersive VR hemorrhage control training experience on tourniquet performance skills in EMT students	A prospective open-blinded endpoint design (A Pilot Study)	Ratings of mock tourniquet application tests/40 EMT students	Real-World (a simulated environment)	Single player, guided step-by-step intervention/VR: Oculus Quest 2. The VR program was created by Train XR, LLC (Las Vegas, NV)	Tourniquet application training	Using a VR headset did not improve the efficacy and retention of tourniquet placement skills. Participants who received the VR intervention were more likely to have errors relating to haptics.
( Mills et al.,2020) Australian	To compare the simulation efficacy of a bespoke VR MCI triage training simulation against a comparable live simulation scenario	A mixed-methods approach (A within-subject comparison trial)	Degree of immersion satisfaction cost analysis clinical decision-making/Twenty-nine students enrolled in a Bachelor of Science (Paramedical Science)	Accident scene(ten injured patients resulting from a police car chase and shooting)	Single player interactive environment/VR: an Oculus Rift (Oculus, Irvine, USA) or HTC Vive headset (HTC Corporation, New Taipei City, Taiwan, China)	Disaster triage training	The VR simulation provided near identical simulation efficacy for paramedicine students compared to the live simulation.
( Shujuan et al.,2022) China	To assess the impact of VR scenarios on disaster preparedness among nursing students	A two-arm RCT	Disaster Preparedness Questionnaire (DPQ), confidence, performance/106 nursing students(VR groups:49, the control group:52)	MCI (earthquake and fire)	Single player, guided step-by-step intervention/VR: the head-mounted displays was HTC Vive	Disaster preparedness training	The VR simulation can enhance disaster preparedness, confidence, and performance among nursing students.Some students had motion sickness and dizziness during the VR experience.
( Farra et al.,2015) USA	To examine the use of virtual reality simulation (VRS) to teach the disaster-specific skill of decontamination	A quasi-experimental design; control-group design (treatment group (VRS); control group)	Self-efficacy, cognitive tests, performance of decontamination capacity/106 senior nursing students	Undefined (an emergency department (ED) room, a survivor, a stretcher)	Single player, guided step-by-step intervention/VRS using a computer and a monitor connected to a Microsoft Kinect. The Kinect is a video gaming control device	Decontamination capacity training	Students in the VRS treatment group reported high levels of satisfaction with VRS. VRS may provide a means for nurses to learn this important disaster skill in a safe and realistic environment.
( Ulrich et al.,2014) USA	To explore the experience of students participating in a VRS for the disaster competency of decontamination	A mixed-methods approach (in focus groups)/treatment (VRS): 53, control (written instructions) group: 54	Usage feedback (feeling, experience, performance)/107 senior baccalaureate nursing students	Undefined	Single player, guided step-by-step intervention/VRS using a computer and a monitor connected to a Microsoft Kinect. The Kinect is a video gaming control device	Decontamination capacity training	Students were very enthusiastic about an interactive VRS experience and strongly endorsed VRS as a learning method for this disaster-specific skill.
( Chang et al.,2022) China	To examine effectiveness of a “360◦ VR chemical disaster training program” on disaster preparedness and self-efficacy in ER nurses	A quasi- experimental study with two-group repeated measures	Self-preparedness for chemical disasters, self-efficacy/77 emergency room (ER) nurses. the experimental group (n = 32) and the control group (n = 35)	A VR simulated disaster environment	Single player, multiple role plays perform operations/VR: the VIRTI platform which is made by HTC Corporation (360◦VR)	Chemical disaster training	VR could be used for nurses without prior disaster response experiences/ drills, whereas tabletop drills were more suitable for nurses with prior experiences. Both methods may effectively promote nurses' learning effectiveness and self-efficacy in chemical disaster preparedness.
( Cicero et al.,2022) USA	To examine the experiences of prehospital providers after completing pediatric SimBox simulations.	A cross-sectional study	Satisfaction and performance/103 (87 %) were paramedics, and 18 (13 %) were EMTs	Undefined	Single player/SimBox simulations, a low-fidelity manikin	Pre-hospital first aid training for children	SimBox simulations are associated with improved self-efficacy of prehospital care providers for care of acutely ill or injured children.