Content area
Aim
The paper examined the current evidence on the impact of virtual simulation compared with mannequin-based simulation learning on undergraduate nursing students’ ability to recognise and manage clinical deterioration.
Background
Simulation-based learning is widely used in nursing education to enhance clinical decision-making. Mannequin-based simulation has been the standard, as emerging virtual simulation technologies offer new opportunities for experiential learning. However, the comparative effectiveness of these approaches in preparing students for clinical deterioration remains unclear.
Design
Systematic review and narrative synthesis on the outcomes of using mannequin-based and virtual simulation among undergraduate nursing students in the context of clinical deterioration were conducted.
Methods
A comprehensive search was performed following PRISMA guidelines across multiple databases, including PubMed, CINAHL, EMBASE, PsycINFO, Web of Series and ProQuest. The focus included quantitative studies, such as randomised controlled trials and quasi-experimental trials from 2013 to 2023, that compared virtual simulation to other simulation methods. The methodological quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Tool and a narrative synthesis was conducted.
Results
Fourteen studies met the inclusion criteria. The notable advantages of using virtual simulation include improved clinical performance, enhanced assessment, increased adaptability for larger group practice and knowledge retention. However, limitations included the absence of immediate debriefing, reduced realism and technological challenges that impacted virtual simulation.
Conclusion
This review highlights the strengths of mannequin-based and virtual simulation methods in clinical deterioration management, with marked differential outcomes in realism and anxiety among undergraduate nursing students.
1 Introduction
Simulation is a foundation of clinical education in healthcare, providing invaluable experiential learning opportunities that enhance the effectiveness of training for healthcare professionals. Over the past five decades, mannequin-based simulation (MBS) has been widely used in nursing education to develop knowledge and skills. In recent years, the COVID-19 pandemic has created opportunities to enhance remote learning by incorporating virtual simulation (VS) into nursing curricula ( Haanes et al., 2024). This has led to a surge in simulation-based learning (SBL) and increased technological integration in nursing education ( Cobbett and Snelgrove-Clarke, 2016). Adopting remote learning with technology has driven the development and enhancements of virtual simulation and blended learning approaches ( Haslam, 2021). Understandably, nursing education has swiftly incorporated these changes immediately into the curricula to better prepare nursing students for managing complex illness and critical clinical deterioration situations ( Cobbett and Snelgrove-Clarke, 2016; Eyikara and Baykara, 2018).
Increasing challenges in the complexity of medical conditions require nurses to manage critical clinical emergencies efficiently. Developing competence in recognising and responding to clinical deterioration is a critical learning outcome of undergraduate nursing education ( Haddeland et al., 2018). However, clinical placements often do not guarantee exposure to acute deterioration events, making simulation a crucial substitute while learning in a safe and effective learning environment ( Jarvelainen et al., 2018).
Simulation enables nursing students to practice essential clinical reasoning skills, early warning recognition, patient comprehensive assessment, escalation of care and handover communication, all within a controlled environment ( Anstey et al., 2019; Haddeland et al., 2018; Yuan et al., 2012). Despite its importance, undergraduate nursing students frequently report low confidence and competence in managing high-stakes clinical deterioration scenarios ( Gillan et al., 2022).
Evidence shows that both MBS and VS significantly improve preparedness for managing deterioration ( Haddeland et al., 2018; Gillan et al., 2022; Liu et al., 2023). Despite the increasing integration of both MBS and VS in nursing curricula, there is a lack of systematic reviews comparing their impact on undergraduate nursing students’ ability to recognise and manage clinical deterioration. In this review, the term virtual simulation is used, which also encompasses interventions in the literature as virtual reality (VR). This review aims to synthesise current evidence on MBS and VS to evaluate their relative effectiveness and provide insights for the future development of simulation-based nursing education focused on clinical deterioration management.
2 Background
2.1 Clinical deterioration and early recognition of deterioration
Healthcare facilities worldwide face increasingly higher acuity levels of patients who present at the services and an increased number of patients at risk of experiencing clinical deterioration while hospitalised ( Anstey et al., 2019). The Australian Commission on Safety and Quality in Healthcare (ACSQHC) defines clinical deterioration as an acute physiological, psychological or cognitive changes that indicate a worsening of a patient’s health status, which may occur over hours or days ( ACSQHC, 2024). Physiological changes such as fluctuating vital signs and other complications are often early indicators of deterioration. Hence, early detection is key to timely patient care ( Brekke et al., 2019). To address this challenge, the healthcare system has implemented various strategies, protocols and frameworks such as Early Warning Scoring (EWS) systems, which support improving early recognition of clinical deterioration and escalation of care ( La Cerra et al., 2019; McGaughey et al., 2017). Significant emphasis has been placed on the healthcare system to support nursing professionals in immediate proximity to the patient population in recognising and responding to clinical deterioration ( Odell, 2015; Wood et al., 2019). Despite various strategies implemented, significant unreported physiological abnormalities and lack of escalation resulted in a 4 % annual increase in ICU bed crashes in the UK, Intensive Care National Audit and Research Centre (ICNARC).
Evidence suggests that qualified registered nurses are frequently underprepared to identify and manage clinical deterioration, which underscores a gap in nursing education ( Sapiano et al., 2018). Undeniably, the consequences of this lack of ability to recognise early signs of clinical deterioration can lead to delay and failure to rescue deteriorating patients, resulting in adverse health outcomes for hospital patients ( Subbe and Welch, 2013). To ensure undergraduate nursing students are well equipped with the knowledge and skills to manage acute clinical settings efficiently, nursing schools must prioritise preparing them with the knowledge, skills and confidence to manage acute clinical deterioration effectively ( Liaw et al., 2011).
2.2 Simulation-based learning modalities (Mannequin and Virtual)
2.2.1 Definitions
2.2.1.1 Mannequin-based simulation
Mannequin simulation refers to “The use of manikins to represent a patient using heart and lung sounds, palpable pulses, voice interaction, movement (e.g., seizures, eye blinking), bleeding and other human capabilities that may be controlled by a simulation using computers and software”. This definition of simulation refers to mannequin simulation found in the Healthcare Simulation Dictionary ( Lioce, 2020, p. 22); various part-task trainer modalities may also be considered mannequin-based simulation. This review includes MBS delivered through patient simulators, part-task trainers and role-play scenarios.
2.2.1.2 Virtual reality simulation
Virtual reality simulations are defined as the “use of a variety of immersive, highly visual, 3D characteristics to replicate real-life situations and health care procedures; virtual reality simulation is distinguished from computer-based simulation in that it generally incorporates physical or other interfaces such as a computer keyboard, a mouse, speech and voice recognition, motion sensors, or haptic devices” (American Society for Surgery of the Hand [ASSH], Lioce, 2020.p.56).
2.2.2 Evolution of simulation in nursing education
Early simulation approaches in nursing (1960s – 1990s) were focused on task trainers to teach fundamental skills such as Resusci Anne and vital signs assessment ( Bienstock and Heuer, 2022). Introduction of high-fidelity simulation in the 2000s made a shift towards immersive clinical scenarios, which enabled nursing students to integrate psychomotor, cognitive and affective skills in a safe environment ( Aebersold, 2016). The establishment of the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice and the Society for Simulation in Healthcare (SSH) standards provided frameworks to guide simulation design and ensure educational rigour ( Watts et al., 2021). A landmark study by the National Council of State Board of Nursing (NCSBN) in 2010 demonstrated that up to 50 % of traditional clinical hours could be effectively replaced by high-fidelity simulation without compromising clinical hours ( Alexander, 2015).
2.2.3 Pedagogical value of simulation
Simulation is recognised as a pedagogical strategy that enhances clinical reasoning, decision-making and critical thinking in nursing students ( Chua et al., 2021). It enables students to engage in unpredictable clinical scenarios in a safe environment, promoting experiential and reflective learning ( Liaw et al., 2021; Shorey and Ng, 2021). Standard simulation methods for preparing nursing students' decision-making and applying clinical reasoning skills often include high-fidelity simulators, computer-based or screen-based simulations, standard patients and role-playing scenarios ( Connell et al., 2016; Guo et al., 2019). Research has shown that simulation-based training enhances nursing students’ knowledge, performance, critical thinking and cognitive and affective competencies in a safe environment that allows them to learn from mistakes without real-world consequences ( Jans et al., 2023).
2.2.4 Rise of virtual simulation
Virtual simulation has gained attention to deliver an interactive, conversational avatar-based experience in 3D environments, where learners engage with a realistic experience ( Foronda et al., 2020; Ghanbarzadeh et al., 2014). Evidence supports that VS promotes repetitive practice, clinical decision-making and self-paced learning, which makes it particularly effective for managing complex scenarios ( Levett-Jones et al., 2019; Sapiano et al., 2018). Although virtual simulation is increasingly used in healthcare education, uncertainty remains about fully understanding this evolving and potentially valuable learning tool ( Foronda et al., 2020). Continued research is needed to understand how best to leverage VS and VR for clinical reasoning and deterioration management.
2.3 Gaps in current literature
Existing literature on SBL has primarily focused on its effectiveness among registered nurses and healthcare professionals, with limited emphasis on undergraduate nursing students, particularly in the context of early recognition of deterioration ( Elder, 2017; Hart et al., 2014). Nevertheless, it is essential that nursing students develop the ability to identify and respond to physiological signs of clinical deterioration during their undergraduate nursing education.
A recent systematic review by ( Wei et al., 2024) obtained results from various simulation modalities such as high-fidelity simulation, role play and standardised patients and found SBL to be effective in enhancing decision-making, knowledge, skills and clinical decision-making. However, the review did not explore other critical outcomes such as clinical confidence, teamwork, or emotional resilience, limiting the comprehensiveness of findings.
Similarly, Jans et al. (2023) conducted an integrated review on the effects of VR simulation on critical thinking, clinical reasoning and judgement among undergraduate nursing students, highlighting positive effects on cognitive skills. However, its scope was limited to clinical reasoning and did not address broader competencies ( Jans et al., 2023). Although both Wei et al. (2024) and Jans et al. (2023) demonstrated positive effects of SBL, their reviews primarily focused on graduate nurses and specific cognitive domains, reducing their applicability to undergraduate nursing education ( Jans et al., 2023; Wei et al., 2024). Furthermore, studies by Gillan et al. (2022) and Liu et al. (2023) lacked empirical depth in evaluating simulation outcomes on undergraduate nursing students ( Gillan et al., 2022; Liu et al., 2023).
To address these gaps, this review aims to systematically synthesises and compare the effectiveness of MBS and VS in preparing undergraduate nursing students to recognise and manage clinical deterioration. This comparison will provide insights into the pedagogical value of each modality and inform future curriculum development.
2.4 Research aims
This review explores and gathers evidence on how VS has an impact on undergraduate nursing students’ confidence level, knowledge, skill and communication compared with MBS in managing clinical deterioration. This review has three research questions:
I. How effective is the VS compared with MBS in recognising the early clinical deterioration among undergraduate nursing students?
II. Did the intervention group display higher confidence levels in recognising, responding to and reporting clinical deterioration than the control group exposed to MBS alone?
III. What are the comparative effects of VS and MBS on undergraduate nursing students’ level of communication and acquisition of knowledge in the context of early recognition of clinical deterioration?
3 Methods
3.1 Search strategy and screening
This systematic review followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) framework ( Page et al., 2021). Although the protocol was not registered in PROSPERO, the methods were prespecified and applied consistently throughout the review process.
An initial search was conducted through the MEDLINE (Ovid) database in compliance with the pre-defined inclusion and exclusion criteria. The final search was conducted in September 2023 by two independent reviewers. The search strategy incorporated both controlled vocabulary (MeSH terms) and keywords, combined with Boolean operators. Search terms included combinations such as (“nursing students” [MeSH] OR “undergraduate nursing” OR “student nurse*”) AND (“clinical deterioration” OR “patient deterioration” [MeSH] AND (‘simulation” [MeSH] OR “virtual simulation” OR “mannequin-based simulation”), randomised control trial*, quasi-experimental*. Redundant terms were removed to streamline the strategy. Abstracts and titles were analysed to refine the search terms. Boolean operators were applied across databases to ensure comprehensive coverage, including: CINAHL, MEDLINE (Ovid), EBSCO, EMCARE (Ovid), EMBASE (Elsevier), Web of Series (Clarivate), ProQuest and Google Scholar. Additionally, the reference lists of relevant articles were reviewed to identify potential high-quality studies that were missing from the database searches.
All citations were managed using EndNote v.20 and duplicates were removed. Relevant articles were then uploaded to Covidence (
Vertis Health Innovation, n.d.) for further screening. Title and abstracts were independently reviewed by two reviewers using the inclusion and exclusion criteria
The PRISMA 2020 flow diagram in (
3.2 Critical appraisal
The quality of the selected studies was assessed using the Joann Briggs Institute (JBI) Critical Appraisal Tools (Joanna Briggs Institution, 2020), integrated with the Covidence platform to complete the appraisal process. Two JBI checklists were used for the study designs identified in the review for quasi-experimental studies and randomised controlled trials (RCTs). Two independent reviewers conducted the appraisal using the JBI tool embedded in Covidence. Each study was evaluated against the relevant checklist and appraisal scores were generated within the platform. Any discrepancies were discussed via Microsoft Teams, and a consensus was reached through collaborative discussion. This rigorous process ensured that only quality studies were included in the final synthesis.
3.3 Data extraction
Data extraction was conducted by two independent reviewers using a standardised data extraction form, which included the following elements: a) Author/year; b) simulation type; c) simulation scenario; d) study design; e) population; f) sample size; g) experimental; h) control interventions; i) outcome variables; and j) results respectively. The combination of RCT, mixed-methods pre- and post-tests and quasi-experimental designs was included. For mixed-methods studies, only the quantitative findings relevant to undergraduate nursing students’ recognition and management of clinical deterioration were extracted, synthesised and described in
3.4 Risk of bias assessment
The risk of bias in the included studies was assessed by incorporating the combination of CASP (Critical Appraisal Skills Programme) and JBI (Joanna Briggs Institute) RCT and Quasi-Experimental pre- and post-checklists embedded in Covidence and the table is generated from the Covidence. The interpreted and generated outcomes in (
3.5 Data analysis
Due to the heterogeneity in study designs, including RCTs, quasi-experimental studies and mixed methods, as well as variations in outcome measures and instruments, conducting a meta-analysis or calculating pooled effect sizes was not feasible. Instead, a narrative synthesis approach was adopted to summarise findings across three key domains: cognitive, affective and performance Table 2. Relevant outcomes and results were identified according to the quality emphasised in the study findings. Statistical values such as p-values and effect sizes were reported as presented in the original studies; however, no secondary statistical analysis or meta-analysis was conducted. Findings deemed relevant to the review objectives were highlighted in the results and further discussed in the discussion and recommendations sections.
4 Results
4.1 Characteristics of the studies
A total of 14 studies were included in this review conducted across several established countries: Australia, Hong Kong, Singapore, Canada, the UK, South Korea and England. The characteristics of these studies were summarised in Table 2. Six studies were randomised controlled trials (RCTs), four were mixed methods and four were quasi-experimental pre- and post-studies of quantitative and qualitative studies. Participants in these studies were undergraduate nursing students, as seen in studies by ( Adhikari et al., 2021; Cobbett and Snelgrove-Clarke, 2016; Goldsworthy et al., 2022, 2019; Haerling et al., 2023; Havola et al., 2021; Liaw et al., 2014; Padilha et al., 2019). Some studies included a combination of undergraduate nursing and medical students ( Chua et al., 2022; Liaw et al., 2023), while others involved undergraduate and diploma nursing students ( Bogossian et al., 2015; Kiegaldie and Shaw, 2023; Sapiano et al., 2018). Where available, p-values and effect sizes are reported directly from the included studies to demonstrate statistical significance. These results are integrated into the narrative synthesis to provide a comprehensive summary across the evidence base.
4.2 Intervention characteristics and simulation scenario
The presented studies explored a range of simulation-based interventions, incorporating both MBS and VS modalities. These interventions were designed to address diverse clinical scenarios, focusing on the early recognition and management of clinical deterioration. ( Adhikari et al., 2021) used an immersive virtual reality (IVR) simulation focused on the sepsis game, while ( Bogossian et al., 2015) applied an e-simulation (eVRS) targeting cardiac, respiratory and shock scenarios. ( Padilha et al., 2019) and ( Liaw et al., 2014) used virtual clinical simulation (VCS) and virtual patient simulation (VPS), respectively, both targeted respiratory, sepsis and shock conditions. ( Cobbett and Snelgrove-Clarke, 2016; Goldsworthy et al., 2022, 2019; Haerling et al., 2023) engaged in virtual simulation (vSim) incorporating postoperative shortness of breath and myocardial infarction, COPD and other emergencies such as angina and preeclampsia, Group B streptococcus. Other studies include ( Cooper et al., 2015) used a web-based simulation for shock and respiratory conditions; ( Chua et al., 2022) used virtual telesimulation for septic shock; while ( Liaw et al., 2023) used desktop VR for sepsis and septic shock scenarios. Two others, ( Sapiano et al., 2018) and ( Havola et al., 2021) focused on cardiac and chest pain scenarios. ( Kiegaldie and Shaw, 2023) employed JasperVR to simulate deteriorating patient scenarios. These diverse simulation interventions are summarised in Table 2. Across the studies, the simulations addressed both cognitive (knowledge, skills and clinical judgement) and affective (confidence, anxiety and communication), providing a comprehensive approach to preparing students for real-world clinical deterioration scenarios.
5 Findings
A review of 14 studies on virtual simulation, both VR and VS compared with MBS, face-to-face (F2F) simulation, desktop VR and web-based e-simulation for undergraduate nursing students, highlights the impact of SBL on confidence, performance, skills, knowledge and communication in the context of early recognition of clinical deterioration.
5.1 Affective domain: confidence, anxiety and communication
Several studies demonstrated that VS significantly enhances affective outcomes among nursing students. ( Adhikari et al., 2021) reported a 26.1 % increase in confidence and a 23.4 % reduction in anxiety following an immersive VR sepsis simulation (p < 0.001), indicating substantial emotional benefits of VR-based learning. ( Goldsworthy et al., 2019) found significant improvement in confidence (p < 0.05) using vSim* scenarios focused on myocardial infarction and paediatric asthma emergency. ( Cobbett and Snelgrove-Clarke, 2016) observed that VS significantly reduced anxiety and also showed mixed results in confidence. ( Liaw et al., 2023) supported these findings as their study reported a significant increase in confidence levels (p < 0.01) with desktop VR, whereas standardised patient (SP) showed no changes in confidence. ( Chua et al., 2022) observed improved team communication following team-based telesimulation on sepsis education (p < 0.001). ( Haerling et al., 2023) also reported significant improvements in communication skills (p = 0.04), suggesting that VS environments effectively support the development of collaborative communication in the critical care team.
5.2 Cognitive domain: knowledge and performance
Several studies determined that VS significantly enhances cognitive outcomes, particularly in knowledge acquisition and clinical performance. ( Bogossian et al., 2015) reported a statistically significant improvement in knowledge following eVRS, with participants demonstrating a clear understanding of cardiac, respiratory and shock scenarios (t = 15.845, p < 0.001). The same study also found a significant increase in clinical performance across different scenarios (1, n = 367) = 16.09, p = 0.000). ( Haerling et al., 2023) identified that VS improved clinical judgment, knowledge and communication in post-operative scenarios, with a significant statistical improvement in knowledge (p < 0.01). ( Padilha et al., 2019) found sustained knowledge retention over a two-month follow-up post-intervention (p = .02), showing long-term benefits in a clinical setting. ( Liaw et al., 2014) and ( Cooper et al., 2015) also reported significant improvements in performance scores through virtual and web-based simulations, reinforcing the effectiveness of these modalities in enhancing cognitive skills related to clinical deterioration.
5.3 Confidence and self-efficacy outcomes
Five studies identified significant improvements in confidence and self-efficacy among nursing students exposed to VS and VR interventions. ( Adhikari et al., 2021) identified an increase in mean confidence scores among participants following a VR sepsis game simulation, indicating enhanced preparedness for managing clinical deterioration. ( Kiegaldie and Shaw, 2023) reported that students using immersive VR demonstrated higher self-perceived confidence in managing deteriorating patient scenarios. Participants also expressed feeling more prepared for clinical placement. ( Goldsworthy et al., 2022) identified increased confidence in clinical practice following VS exposure. This outcome was derived from the qualitative component of a mixed-method study. Conversely, ( Cobbett and Snelgrove-Clarke, 2016) reported that self-confidence levels remained consistent regardless of whether the VCS or F2F MBS was used. However, the anxiety levels were higher in the VCS group. ( Liaw et al., 2023) reported a significant negative correlation between anxiety and confidence. Their findings showed that higher psychological stress was associated with lower confidence levels in both the VR intervention and SP control groups. No significant differences were found in confidence and clinical performance between the two modalities. These findings suggest that while VR and VS can effectively improve confidence and self-efficacy, the choice of simulation scenarios may impact the outcomes.
5.4 Knowledge acquisition and retention outcomes
VR was often associated with improvements in knowledge acquisition and retention among undergraduate nursing students. Eight studies identified knowledge-related outcomes in both VR and MBS with clinical deterioration scenarios. ( Padilha et al., 2019) identified improved knowledge retention following a VCS. However, the short follow-up limited the generalisability of long-term retention outcomes. ( Bogossian et al., 2015; Cooper et al., 2015), found that exposure to the e-simulation program FIRST2ACT WEB™ enhanced students’ knowledge of managing clinical deterioration. Cooper et al. further emphasised that web-based simulation led to greater improvements in knowledge cores compared with F2F simulation. ( Sapiano et al., 2018) observed a significant improvement in knowledge following the VS of the deterioration scenario. However, the study lacked a comparison group using MBS, which limited conclusions about the modality-specific effectiveness. ( Goldsworthy et al., 2019) reported significant knowledge improvement in a treatment group involving both hybrid high-fidelity simulation and vSim (Wolters Kluwer) for scenarios involving myocardial infarction, septic shock and paediatric asthma. However, the control group did not receive an equivalent 16-hour simulation intervention and comparison based on baseline and post-intervention changes. ( Haerling et al., 2023) found no significant differences in cognitive learning outcomes across three groups: screen-based VS, MBS and clinical experience, suggesting comparable effectiveness. ( Chua et al., 2022), demonstrated immediate post improvements in sepsis knowledge following a virtual patient telesimulation. However, the absence of a control group limited the ability to assess the specific impact of VR compared with other modalities. ( Liaw et al., 2014) reported that both the virtual patient simulation (VPS) and MBS groups improved performance, with the MBS group outperforming in skill retention. These findings suggest that both VS and VR and MBS are effective in enhancing knowledge acquisition, with each modality offering unique strengths. While VR may support immediate learning and engagement, MBS may contribute more to long-term skill retention.
5.5 Skills and performance outcomes
Four studies evaluated the impact of VS and VR on clinical skills and performance, comparing it with MBS and clinical experience. ( Haerling et al., 2023) compared three different modalities of screen-based VS, MBS and clinical experience to assess the response, assessment, patient safety and communication in handling clinical deterioration. This study found MBS outperformed screen-based VS in clinical judgment and competency assessments. However, the study was limited to screen-based VS and did not explore more immersive technologies such as augmented reality or VR. ( Sapiano et al., 2018) and ( Cooper et al., 2015) identified that students using the web-based FIRST 2ACT simulation program attained a higher average performance score of 69 % compared with F2F patient simulation scenarios involving cardiac, shock and respiratory deterioration. ( Liaw et al., 2014) found that both VPS and MBS groups showed improved performance in managing clinical deterioration. However, MBS outperformed in specific areas, as it was associated with deeper learning and hands-on experience, compared with the self-directed nature of VPS. These findings suggest that VR and VS are effective in developing clinical skills and MBS may offer advantages in skill retention and deeper learning.
5.6 Effective communication outcomes
Two studies evaluated the effectiveness of communication outcomes in managing clinical deterioration with simulation modalities such as telesimulation, screen-based VS and MBS. ( Chua et al., 2022) found significant improvements in team communication in interprofessional telesimulation on sepsis among the undergraduate nursing and medical students. However, the study lacks a control group for comparison to assess the specific impact of VR on MBS or other modalities. ( Haerling et al., 2023) identified that the screen-based VS group scored 0.45 points higher in communication efficiency than those who participated in clinical practice during an emergency scenario. These findings suggest that VS and VR simulation provides a better modality in enhancing communication skills in a controlled virtual environment.
5.7 Anxiety outcomes
Some studies identified that anxiety levels were higher among participants exposed to VS compared with MBS. ( Cobbett and Snelgrove-Clarke, 2016) identified that students participating in VCS experienced higher anxiety levels than those in F2F MBS. However, this may have been influenced by the lack of pre-simulation orientation provided to the VS group, suggesting that methodological differences could have contributed to the elevated anxiety. ( Liaw et al., 2023) further informed that VS can induce physiological and psychological stress responses equal to MBS. Their study indicated a negative correlation between anxiety and confidence. These results suggest that VS and MBS can both simulate realistic emotional responses to clinical scenarios; adequate preparation and orientation may play a critical role in mitigating anxiety and enhancing the learning experience.
6 Discussion
This systematic review highlights the effectiveness of virtual simulation in enhancing learning outcomes among undergraduate nursing students in the context of preparation and managing clinical deterioration. The findings align with an emerging body of literature that supports the value of SBL in promoting both cognitive and experiential learning.
Quantitative evidence from this review supports the benefits of virtual simulation in improving knowledge, clinical performance and confidence. These outcomes are consistent with previous studies demonstrating the cognitive advantages of simulation modalities ( Foronda et al., 2020; Haddeland et al., 2018; Sim et al., 2022; Wei et al., 2024). However, the quality of experiential learning is closely tied to reflective practice, which requires robust instructional strategies to optimise learning in virtual environments ( Edelbring, 2013). VS enhances realism and contextualisation by mimicking clinical settings to engage students and enhance immersion, which are key factors in preparing students for real-world clinical practice ( Bayram and Caliskan, 2020). To cultivate critical thinking and decision-making skills, VR scenarios should be designed with increasing complexity ( Liaw et al., 2014). Despite these strengths, MBS remains superior in skill retention and clinical judgement due to its tactile, hands-on nature. Studies have shown that students often prefer MBS for its perceived realism and physical interaction, especially in complex clinical scenarios ( Cobbett and Snelgrove-Clarke, 2016; Liaw et al., 2014).
While VRS enhances knowledge acquisition, confidence and replicating the experiential learning depth of MBS remains challenging. Accurate mimic of real-life scenario reproduction within high-fidelity simulation also requires an attentive focus on confounding variables ( Cheng et al., 2014) and ( Haddeland et al., 2018). Although immersive VR technologies are advancing, a few studies have adequately addressed realism and competency in managing clinical deterioration through VR alone. Future research should explore these dimensions more deeply in the evolving landscape of SBL in nursing education.
The review also identified that VR improves knowledge acquisition, clinical judgement and communication with some evidence of sustained performance benefits over time. These are supported by ( Sim et al., 2022) and ( Liu et al., 2023), who emphasised VR’s role in enhancing learner satisfaction and cognitive preparedness. However, ( Liu et al., 2023) also highlight that VR has limitations in fostering critical thinking and decision-making abilities. In contrast, subgroup analysis by ( Rababa et al., 2022; Wei et al., 2024), suggested that both VR and MBS can improve clinical decision-making. However, outcomes varied depending on the complexity of scenarios and contextual factors, indicating that decision-making performance is not uniformly improved across all simulation types. These findings urge the need for continued robust research to refine the VR interventions that support higher-order cognitive skills, especially in clinical deterioration.
( Qiao et al., 2023) highlighted that MBS significantly enhances knowledge, self-efficacy and performance, while also indicating that variability in simulation effectiveness exists. This underscores the need for a balanced approach that considers the unique strengths of both VR and MBS. Despite the promising potential use of VR and MBS simulations, ( Tamilselvan et al., 2023) raised concerns about the challenges of translating simulation experiences into real-world clinical practice. Similarly ( Shorey and Ng, 2021) argued that while VR enhances theoretical knowledge, it may fall short in addressing affective learning outcomes, such as emotional responses. However, this review specifies that VR simulations can induce heightened engagement by authentically replicating real-life clinical scenarios, including their emotional intensity. Exposure to such pressured situations is crucial for preparing students to manage clinical deterioration events.
Preparing nursing students for high-pressure clinical deterioration scenarios remains a significant challenge due to the unpredictable and chaotic nature of these events, as highlighted by ( Gillan et al., 2022). While ( Haddeland et al., 2018) found that high-fidelity simulation (HFS) effectively enhances knowledge and skills, their findings do not significantly improve students’ self-confidence in managing real-world emergencies. This review reinforces the role of VR in developing situational awareness and teamwork, which are critical for managing complex critical emergencies. Integrating VR into nursing curricula may improve readiness for real-world clinical practice.
Despite its promise, VR simulation presents challenges such as a perceived lack of realism. Addressing these challenges by enhancing realism and incorporating immediate feedback mechanisms could benefit and increase effectiveness. ( Chavez and Bayona, 2018) identified that VR technology elevated student engagement by creating a more immersive and realistic learning experience. However, reviews by ( Liaw et al., 2018; Tamilselvan et al., 2023) and ( Shorey and Ng, 2021) suggest that VR still falls short of accomplishing realism. This review reflects these contrasting findings, underscoring the need for more research to justify VR's effectiveness in enhancing realism and immediate feedback mechanisms, particularly in clinical deterioration.
Several researchers support the integration of VR and MBS in nursing education ( Liaw et al., 2017; Shorey and Ng, 2021; Wei et al., 2024). While VR has been shown to enhance knowledge acquisition and learner satisfaction, this review indicates that it may not achieve comparable outcomes in areas such as communication, hands-on skills, or cognitive load when compared with MBS. To address these limitations, it is recommended that MBS complement VR to ensure mastery of specific skills and long-term retention ( Chen et al., 2020; Liaw et al., 2018; Liu et al., 2023; Sim et al., 2022). A hybrid simulation approach, combining the strengths of both modalities, could provide undergraduate nursing students with the most achievable comprehensive simulation education experience in managing clinical deterioration.
Integrating both MBS and VR offers a comprehensive framework for near education. MBS provides foundational hands-on experiences, while VR can reinforce critical clinical concepts through repeated and cost-effective practice to support undergraduate nursing students’ preparedness and competency in managing clinical deterioration. Future research should focus on improving familiarity with virtual environments and expanding diverse scenarios, particularly in resource-limited or remote settings, where the scalability of VR offers a distinct advantage over MBS. Moving forward with emerging technologies such as artificial intelligence (AI) integrated into VS platforms may enable adaptive learning that personalises scenarios to the learner’s performance. This could enhance engagement, reduce cognitive overload and provide real-time tailored feedback ( Benfatah et al., 2024). Given VR’s scalability, further exploration into its use for interprofessional education is warranted. VR can facilitate collaborative learning across disciplines, preparing students for team-based responses to clinical deterioration ( Liaw et al., 2014). However, significant gaps remain, particularly in longitudinal data on knowledge and skill retention and how VR impacts learner anxiety and engagement over time. Overall, the findings of this review suggest that VR is valuable for cognitive preparedness, while MBS retains a distinct advantage in developing hands-on clinical skills. In summary, both MBS and VR are effective in preparing nursing students for clinical deterioration.
7 Limitations
This review has several limitations. First, while eight studies were rated as low risk of bias, five studies were rated high risk and two were unclear, which may reduce confidence in some of the findings. Second, heterogeneity in study design, simulation modalities and outcome measures precluded meta-analysis and limited generalisability. Third, only English-language publications from 2013 to 2023, potentially introducing language and publication bias. Finally, this review was not registered in PROSPERO and while some included studies used mixed-method designs, only the quantitative findings were extracted for analysis. This may have excluded valuable insights from qualitative data, which could be addressed in future reviews.
8 Conclusion
This review demonstrated that both MBS and VS enhance undergraduate nursing students’ preparedness for clinical deterioration. However, each modality contributes in distinct ways: MBS excels in realism, hands-on skills and performance retention, while VS or VR enhances knowledge acquisition, confidence and scalability. Given the complementary strengths of both approaches, a hybrid simulation model that integrates MBS and VR is recommended to provide a comprehensive experience in managing clinical deterioration. Addressing challenges such as learner anxiety, realism and long-term skill retention will be essential for optimising future simulation-based education. This study underscores the importance of combining cognitive and practical learning strategies through integrated simulation modalities. As healthcare environments become increasingly complex and technology continues to evolve, nursing education must adapt quickly to ensure students develop confident clinical competencies and are well-prepared to manage critical clinical deterioration effectively.
Funding Source
This review received no grant from funding sources in the public, commercial, or not-for-profit sectors.
Author contribution statement
Provided on the title page
CRediT authorship contribution statement
Sonja Cleary: Writing – review & editing, Supervision. Lin Zhao: Writing – review & editing, Supervision, Investigation, Data curation. James Harland: Writing – review & editing, Supervision. Rajarajeswari Rajasekaran: Writing – review & editing, Writing – original draft, Validation, Software, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.
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
Appendix A Supplementary material
Supplementary material
Table 1
| Inclusion Criteria | Exclusion Criteria |
| Randomised controlled trials or experimental studies with intervention and comparisons, cohort or case-control studies.
Experimental studies focus on recognizing and managing clinical deterioration. |
Studies other than RCT, experimental studies
without intervention or comparison, cohort and case control studies are not included |
| Participants consisted of only undergraduate nursing students or bachelor of nursing students. | Participants not consisting of nursing students
such as allied health students, medical students, registered nurses, or PG specialty training. |
| The study intervention or comparison must have used virtual simulation and/or virtual reality. | Study intervention that did not utilise virtual
simulation and/or virtual reality simulation, mannequin-based simulation, face-to-face, high fidelity simulation, or computer/desktop assisted learning in their intervention. |
| Published reports in English from a database from 2013 to 2023 | Studies that are not in English |
| Studies with outcome measure knowledge and performance communication specific to recognising clinical deterioration. | Studies that are not peer-reviewed, such as
dissertations and thesis |
Table 2
| Participants | Intervention | ||||||||
| Author/Year | Simulation Type | Simulation Scenario | Study Design | Population | Sample size | Experimental | Control | Outcome Variables | Results |
| ( Adhikari et al., 2021) | Immersive virtual reality) sepsis game (IVR) | Sepsis game | Sequential mixed method design (pre-post) | Undergraduate nursing students (third year) | IG:19 CG: 0 | Immersive
Virtual Reality (IVR) sepsis game. In the first stage, pre-registration nurses' self-efficacy was assessed using the Nursing Anxiety and Self-confidence in Clinical Decision Making (NASC-CDM©) scale before and after engaging with the immersive virtual reality sepsis game. |
No mention a
group |
1. Confidence score
2. Anxiety score |
Significant increase
in mean confidence score and a decrease in anxiety score post-intervention engaged with IVR sepsis game. |
| ( Bogossian et al., 2015) | e-sim clinical simulation (eVRS) | Cardiac, respiratory, shock | A quasi-
experimental study |
Undergraduate
nursing students (final year), TAFE diploma nursing students |
RN: 330; EN: 37
IG: 367 CG: 0 |
The intervention involved three interactive e-sim clinical scenarios: video recordings of patients with deteriorating conditions, interactive clinical tasks, pop-up responses to tasks, and timed performance assessments. | No mention a
group |
1. Knowledge
Improvement 2. Virtual Clinical Performance 3. Engagement and completion rates 4. self-assessed knowledge, skills, confidence and competence 5. Predictors of performance |
The proportion of
students achieving a satisfactory knowledge score increased from 78.5 % pre-e-simulation to 91.6 % post-e-simulation. The e-simulation program resulted in improvements in virtual clinical performance scores. The study reported a high engagement level among final-year nursing students, with a completion rate of 89.7 % (367 out of 409 students) for the e-simulation program. |
| ( Padilha et al., 2019) | Clinical virtual simulation (CVS)- (Body Interact) | Respiratory (hypoxia) | RCT | Undergraduate
nursing students (second year) |
IG: 21 CG: 21 | participated in a clinical virtual
simulation session, exposure to a variety of clinical scenarios through a virtual platform, aimed to enhance clinical reasoning skills |
received a lab class of
45 mins that utilised a low-fidelity simulator in realistic environment |
1. Learning Satisfaction
2. Knowledge retention 3. Self-efficacy 4. Clinical Reasoning |
1. Knowledge retention:
After intervention (A1): P = .001 Follow-up (A2, 2 months later): P = .02 2. Learning Satisfaction After intervention: P < .001 3. Self-efficacy: No significant difference was found P = .9 |
| ( Liaw et al., 2014) | Virtual patient simulation (VPS); RAPIDS | Sepsis and septic shock | RCT | Undergraduate nursing students (third year) | IC: 31, CG: 30 | Intervention
group students interacted with 2 hr automated virtual patient software received real-time feedback based on their nursing actions and engaged in active learning. The effectiveness of the intervention group was evaluated post-test conducted one day and 2.5 months after the intervention to assess improvement in clinical performance in assessing and managing clinical deterioration. |
The CG underwent a 2-hour facilitator-led mannequin-
based simulation training. The scenario designed with models ABCDE and SBAR mnemonics to perform the assessment and call for help. The evaluation of this CG was through post test conducted one day and 2.5 months after the intervention to assess improvement. |
1. Improved clinical performance in both IG and CG. Indicated that both simulations are practical.
2. Retention of skills in MBS showed deeper learning and better retention skills than in CG. 3. Virtual patient simulation rated the learning experience positively. 4. Clinical performance is no different in IG and CG. 5. MBS requires higher resources, while VRS offers more practical resource efficiency. |
1. Improvement in clinical performance in both IG and CG indicated that both simulations are practical.
IG: P < .001 CG: P < .05 2. Sustained Improvement: Retention of skills in MBS showed deeper learning and better retention of CG. IG: P < .05 CG: P = .94 3. Comparison between groups over time: No significant difference P = .17 |
| ( Haerling et al., 2023) | Screen-based virtual simulation | Postoperative patient discharge, postoperative patient re-admission to ED for shortness of breath | RCT | Undergraduate nursing students,
associate nursing degree students |
IC: 31, CG: 30 | The study included
different intervention groups that experienced different types of learning activities, such as traditional clinical experience, mannequin-based simulation, screen based virtual simulation. By comparing outcomes across these intervention groups, the study evaluated each type of activity. |
CG has been the
group that underwent traditional clinical experience first, experimental learning. |
1. Cognitive Learning: 3 groups (traditional
clinical experience, MBS and screen-based virtual simulation). 2. Clinical judgement: There is a significant difference; the students in the MBS group performed better in this area. P < 0.01 3. Competency: Significant difference p < 0.01 that type of experiential learning activity affected overall competency performance. |
Cognitive learning: No significant difference.
Clinical judgment: Significant difference in responding favouring MBS Competency: Significant difference in assessment, communication, patient safety, and total scores. Self-reported perception: Preferred for traditional clinical experience and MBS or screen-based virtual simulation. |
| ( Goldsworthy et al., 2019) | Virtual simulation, vSim* (Wolters Kluwer) | Paediatric asthma, myocardial infarction, septic shock, COPD, seizure, | A quasi-experimental
study |
Undergraduate
nursing students, (third year) |
IG: 20, CG: 23 | IG Group attended
two eight-hour simulation in scenarios aimed at confidence, competence in responding deteriorating Patients. |
CG group as
comparison group filed out a baseline survey and second survey aligned with the completion of simulation intervention in the treatment group. By not receiving the intervention, the CG group served as a baseline to determine the changes. |
1. Clinical self-efficacy improvement: The IG showed significant improvements in clinical self-efficacy.
2. Knowledge gains: The IG exhibited significant increases in knowledge in three of the six domains assessed (MI, paediatric asthma, septic shock) 3. Sustained self-efficacy: The levels of self-efficacy sustained over time, as measured by a follow-up assessment conducted eight weeks after intervention. 4. Participants satisfaction: IG reported high satisfaction |
The results indicated
that the IG experienced significant improvements compared to the CG, reinforcing the effectiveness of simulation intervention |
| ( Cooper et al., 2015) | Web-based simulation (WBS) | Cardiac, shock, respiratory distress | A quasi-experimental
study |
Final year
preregistration nursing students |
IG: 97, CG: 330 | IG group participated
in F2F simulation with simulated patient 3 scenarios on recognition management of patients. |
CG group completed
web-based simulation with 3 scenarios |
1. Clinical knowledge: The web-based group showed significant improvement in knowledge.
2. Clinical performance: The web-based group scored higher. |
Both F2F simulation
and e-simulation are effective education strategies of enhancing skills and knowledge related to deterioration, with F2F simulation showing slightly greater benefits in skill and satisfaction. |
| ( Chua et al., 2022) | Virtual patient telesimulation (Sepsis interprofessional education program) | Postoperative patient with early manifestation of sepsis, septic shock | A quasi-experimental
study |
Undergraduate nursing students (third year)
Medical students (fourth year) |
IC: 415, CG:0 | IG group, all participants
were participated in sepsis interprofessional education program using virtual patient telesimulation |
No control group | 1. Sepsis knowledge:
demonstrated significant improvements in sepsis knowledge and team communication skills after attending the sepsis interprofessional education program 2. Team communication skills: pretest: Medical students have significantly higher scores in sepsis knowledge and communication skills. Post-test: both MN groups showed significant improvement. |
Virtual telesimulation
program effectively enhanced sepsis knowledge and team communication skills among nursing and medical students. |
| ( Sapiano et al., 2018) | Virtual simulation program (FIRST2ACTWebTM) | Cardiac, shock, respiratory | Mixed method study, pre and post-design | Undergraduate nursing
students (second & third) year, diploma in nursing students |
IG: 166, CG:0
participants: 166 |
No intervention group | No control group | 1. Knowledge: Significant improvement in the students' post-scenario knowledge of virtual simulation
2. Performance: Students improved their performance in the scenario progression 3. Knowledge is not a predictor of performance: In the scenario, knowledge alone was not a predictor of student performance. |
Virtual simulation is
an effective learning tool for nursing students, significantly improving their knowledge and performance in rapid patient deterioration. |
| ( Havola et al., 2021) | Virtual reality simulation (VRS) and computer-based simulation (CBS) | Chest pain | Mixed method study, pre- and post-design | Undergraduate
nursing students |
IG: 40; CG: 0
participants 40 |
No intervention group | No control group | 1. Improvement in
self-evaluated clinical reasoning skills: It increased after engaging in both the CBS and VRS games. 2. Increased Engagement in VR Simulation: The students spent more time in the VR environment, indicating a higher level of engagement with the VR simulation. |
The study demonstrated
both CBD and VRS can be effective tools for improving nursing students' clinical reasoning skills, with VRS showing high engagement and performance outcomes. |
| ( Goldsworthy et al., 2022) | Virtual simulation, vSim* (Wolters Kluwer Publisher, Laerdal Medical) | angina/cardiac arrest; anaphylaxis; acute exacerbation of asthma; COPD/pneumothorax, pulmonary embolism; and blood transfusion reaction | RCT | Undergraduate nursing students | IG: 54, CG: 34 | IG was involved in six virtual simulation scenarios focusing on recognising and responding to rapid deterioration. Pre and post-tests measured clinical self-efficacy and knowledge. | CG involved in
regular nursing program, traditional classroom and clinical environment. Pre and post-tests to assess their knowledge, self- efficacy, for comparison with IG and CG |
1. Clinical self-efficacy: IG showed a significant increase in CSE post-study.
CG showed some improvement but not as IG. 2. Knowledge Improvement: IG showed significant improvement in knowledge in the post-study period, while CG showed a slight decrease. |
The study concluded
VRS is an effective education strategy for improving nursing students' knowledge and self-efficacy, and it is a valuable tool in nursing education. |
| ( Kiegaldie and Shaw, 2023) | Virtual Reality simulation, JasperVR | Verbal aggressive patient, deteriorating patient, (module 2) cognitive impairment, palliative and end-of-life care | Mixed method study, pre and post-design | Bachelor and
Diploma Nursing student |
IG: 393, CG: 282 | IG involved with Jasper VR provided immersive
simulation learning experiences at their own pace. IG group interacted with scenarios involving deteriorating patients, assessed clinical skills, decision-making skills |
CG followed
traditional nursing education served as a comparison to assess the impact of VRS |
1. Knowledge: Post-test, improved knowledge compared to the CG
2. Confidence: IG reported higher self-perceived knowledge and prepared for clinical placement 3. Self-efficacy: IG showed greater self-efficacy in learning specific modules related to deterioration |
The study suggested
that VRS can enhance knowledge and self-perceived confidence in nursing students; however, long-term retention of these benefits could be limited. |
| ( Cobbett and Snelgrove-Clarke, 2016) | Virtual simulation, vSim* (Wolters Kluwer Publisher, Laerdal Medical) | Preeclampsia, Group B Streptococcus | RCT | Undergraduate nursing students | IG: 28, CG:28 | IG received vSim* virtual clinical simulation for a maternal emergency scenario. | CG involved F2F
simulation |
1. Knowledge: There is no significant difference in post-simulation participants who underwent F2F simulation. This suggests that the simulation mode did not impact students' knowledge about caring for pregnant women.
2. Self-confidence: Did not show any difference. Both IG and CG show similar effects. 3. Anxiety levels: Students in the IG reported significantly higher anxiety levels compared to CG |
The study found there were no significant
difference in students' knowledge and self- confidence between F2F and VCS. However, anxiety levels were higher in the VCS group. Student preferences showed F2F simulation due to its perceived realism and debriefing. |
| ( Liaw et al., 2023) | Desktop virtual reality (DVR) | Sepsis, septic shock | RCT | Undergraduate
medical and nursing students |
IG: 60, CG: 60 | IG received desktop
virtual reality (VR), engaged in 2-hour simulation training with clinical deterioration scenarios. |
CG received 2-hr training.
Through F2F simulation with simulated patients. |
1. Physiological stress:
2. Psychological stress: 3. Confidence levels: 4. Performance: |
The study concluded
that desktop VR could induce physiological and psychological stress responses and performance outcomes as traditional F2F simulation, highlighting VR's potential effectiveness as a training modality. |
Table 3
| Study ID | Clear “Cause & Effect” | Similar participants in comparisons | Similar treatment across groups | Control group present | Multiple pre/post
measurements |
Complete follow-up described | Consistent outcome measurement | Reliable outcome measurement | Appropriate
statistical analysis |
Other sources of bias |
| ( Kiegaldie and Shaw, 2023) | high | low | low | low | low | high | low | low | low | low |
| ( Goldsworthy et al., 2022) | low | low | low | low | low | low | low | low | low | low |
| ( Liaw et al., 2014) | low | low | low | low | low | high | low | low | low | low |
| ( Liaw et al., 2023) | low | low | low | low | low | high | low | low | low | low |
| ( Padilha et al., 2019) | low | low | low | low | low | low | low | low | low | low |
| ( Cooper et al., 2015) | high | low | low | high | low | high | low | low | low | low |
| ( Havola et al., 2021) | low | high | high | high | low | high | high | low | low | low |
| ( Sapiano et al., 2018) | high | high | low | high | high | high | low | low | low | low |
| ( Cobbett and Snelgrove-Clarke, 2016) | low | low | low | low | low | high | low | low | low | low |
| ( Goldsworthy et al., 2019) | low | low | low | low | low | high | low | low | low | low |
| ( Adhikari et al., 2021) | high | high | high | high | low | high | low | low | low | low |
| ( Haerling et al., 2023) | low | low | low | high | low | unclear | low | low | low | low |
| ( Bogossian et al., 2015) | low | low | low | high | low | unclear | low | low | low | low |
| ( Chua et al., 2022) | low | low | low | high | low | low | low | low | low | low |
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