Virtual Reality in Critical Care Nursing Education: A Scoping Review

Abstract

The provision of care to critically ill patients demands specialized training. Virtual reality (VR) has emerged as an effective tool in nursing education, promoting active learning and fostering the development of essential care competencies. Therefore, this study aimed to map the existing literature on the content related to the teaching of adult critical care nursing practices that have been modeled in VR environments. This study employed a scoping review methodology, guided by the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A comprehensive search was conducted across 13 data sources, including grey literature. A total of 27 studies were included, highlighting key content areas such as cardiopulmonary resuscitation, tracheostomy care, and mechanical ventilation. The findings indicate that VR has a positive impact on knowledge acquisition, technical skill development, critical thinking, and the enhancement of student and professional confidence and safety. VR demonstrates considerable promise as a pedagogical tool for nursing education in complex clinical settings. However, methodological and technical limitations persist and require further attention. This review contributes to the scientific advancement by systematically organizing the evidence on the use of immersive technologies in health education.

1. Introduction

Nursing care for critically ill patients requires a high level of technical and scientific competence. In this context, nurses play a vital role in both meeting patient needs and upholding their dignity (Branco et al., 2020; Faria et al., 2018). Accordingly, this level of care necessitates specialized training, the use of complex technologies, and pedagogical strategies that promote safe clinical decision-making (García-Pazo et al., 2023).

The intensive care environment requires nurses to perform clinical decision-making rapidly and effectively, as the unit’s work context presents unique characteristics, such as the simultaneous operation of multiple devices and the need for continuous monitoring of various physiological parameters. Furthermore, numerous decisions must be made under significant time pressure due to the imminent risk to patients’ lives, demanding agility, accuracy, and competence in prioritizing clinical interventions (Yee, 2023). However, comprehending the complexity of critical care presents a significant challenge for students without prior clinical experience in an intensive care unit (ICU). This reality underscores the importance of educational strategies that foster the development of clinical competencies from the outset of their training (García-Pazo et al., 2023).

Nursing education is a complex process aimed at developing the ability of future nurses to make precise clinical judgments and informed decisions, thereby ensuring safe and effective care (Marques et al., 2022; Banville et al., 2023). Clinical training serves as the indispensable cornerstone, preparing students to achieve competence and ensure patient safety within the healthcare system (Babaita et al., 2024). Consequently, to provide students with the foundational experiences necessary to consolidate knowledge into action, innovative pedagogical approaches are required (Junior et al., 2020).

Virtual reality (VR) is an immersive technology that enables users to experience realistic scenarios through artificial sensory stimulation. The immersive and interactive characteristics of VR-based clinical settings promote engagement, facilitate procedural repetition, and enhance learning. By simulating realistic clinical environments, VR allows for safe, repetitive training without any risk to patients, thereby maximizing the learning experience and allowing students to develop skills at their own pace (Fleming et al., 2020; Filho et al., 2020; Lee & Han, 2022; García-Pazo et al., 2023; Trevi et al., 2024).

VR-based simulation supports active and experiential learning, aligning with the principles of student-centered, constructivist pedagogy (Rim & Shin, 2021). The educational potential of virtual worlds is substantial, offering learners opportunities that align with the pedagogical requirements for intensive care training, including improved task performance, enhanced experiential learning, greater engagement and motivation, and more contextualized, collaborative learning experiences (Brown et al., 2012). Furthermore, it contributes to the development of critical thinking, problem-solving, and psychomotor skills; while also making the learning process more meaningful, it enhances student interactivity with the content covered and enables experiential learning, where it becomes possible to test behaviors, receive immediate feedback, and correct errors in a safe environment (Hall et al., 2024; Araújo et al., 2024).

VR can serve as a tool for inclusion by facilitating learning for individuals with specific needs and offering alternative means of interaction and content mastery. Furthermore, due to its ability to adapt to different learning styles, VR benefits both visual and non-verbal learners, owing to its highly visual nature, as well as those who prefer active exploration over passive deduction. In this sense, by providing interactive environments that allow direct manipulation of elements and immediate feedback, VR expands the possibilities for personalized and accessible learning (Aguiar et al., 2021). Thus, the benefits of VR are significant, and its integration into education should be considered a necessity (Banville et al., 2023).

Given its potential, it is essential to investigate how VR has been employed to teach specific content pertinent to intensive care unit practices, with the aim of supporting the cognitive, psychomotor, and affective domains of student learning and the continuing professional development of practitioners. The use of VR as a complementary pedagogical strategy can enhance the quality of nursing education, drive innovation in health training, and contribute to the inclusion of diverse learners (García-Pazo et al., 2023; Tamilselvan et al., 2023).

In this context, it is crucial to map the evidence on the use of VR for teaching content related to critical care nursing. Such an effort can inform the development of innovative educational strategies that are aligned with the demands of professional practice in complex settings. Despite the increasing use of VR in health education, there is a scarcity of studies that systematically catalog the specific critical care nursing topics being modeled in virtual environments. This gap highlights the need to map what has been developed and validated in the scientific literature to support the creation of effective educational strategies for high-complexity environments like the intensive care unit. Therefore, this study aimed to map the literature to identify the content related to the teaching of adult critical care nursing practices that has been modeled for virtual reality.

2. Materials and Methods

This study is a scoping review conducted following the nine-step methodological framework developed by the Joanna Briggs Institute (JBI) (Peters et al., 2024). The reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist (Page et al., 2021). This alignment ensures clarity, rigor, and reliability in the methodological procedures (Peters et al., 2022).

The research question was formulated using the Population, Concept, and Context (PCC) mnemonic, as recommended by JBI, with the following components: P (Population): Nursing care for critically ill patients; C (Concept): Content modeled in virtual reality; and C (Context): Intensive care unit. The guiding research question established for the literature search was: What content related to the practice of nursing care for adult critically ill patients has been modeled in virtual reality?

Subsequently, search terms were defined using the Health Sciences Descriptors (DeCS) for Portuguese and the National Library of Medicine’s Medical Subject Headings (MeSH) for English. The primary English search string was “Nursing care” AND “Virtual Reality” AND “Intensive care units,” utilizing the Boolean operator AND. To prevent duplication, a preliminary search for existing or ongoing reviews with the same objective was conducted on the following platforms: International Prospective Register of Systematic Reviews (PROSPERO), Open Science Framework (OSF), The Cochrane Library, and the Database of Abstracts of Reviews of Effects (DARE). The study protocol was prospectively registered with the OSF (registration DOI: https://doi.org/10.17605/OSF.IO/H6B4P).

The search strategy was applied to the following electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PubMed, SciELO, Web of Science, Scopus, ScienceDirect, Virtual Health Library (VHL), and Embase. Grey literature was searched through the CAPES Thesis and Dissertation Catalog, the Brazilian Digital Library of Theses and Dissertations (BDTD), the Scientific Open Access Repository of Portugal (RCAAP), and the DART-Europe E-theses Portal. The specific search strategy applied to each information source is detailed in

Table 1. Search strategies applied to the information sources.

Data Sources	Search Query
Cumulative Index to Nursing and Allied Health Literature (CINAHL)	Nursing care AND Virtual Reality AND Intensive Care Units
Cochrane Library	“nursing care” in Title Abstract Keyword AND “virtual reality” in Title Abstract Keyword AND “intensive care unit” in Title Abstract Keyword
PubMed	((“nursing care”[All Fields] OR “nursing care”[MeSH Terms]) AND (“virtual reality”[MeSH Terms] OR (“virtual reality”[All Fields]) AND (“intensive care units”[MeSH Terms] OR (“intensive care units”[All Fields]))
SciELO	((TS = (Nursing care)) AND TS = (Virtual Reality)) AND TS = (Intensive Care Units)
Web of Science	((ALL = (Nursing care)) AND ALL = (Virtual Reality)) AND ALL = (Intensive Care Units)
SCOPUS	(TITLE-ABS-KEY (Nursing care) AND TITLE-ABS-KEY (Virtual Reality) AND TITLE-ABS-KEY (Intensive Care Units))
Science Direct	Nursing care AND Virtual Reality AND Intensive Care Units
CAPES Thesis and Dissertation Catalog	Nursing care AND Virtual Reality AND Intensive Care Units
Virtual Health Library (VHL)	(Nursing care) AND (Virtual Reality) AND (Intensive Care Units)
Embase	(“nursing”/exp OR nursing) AND virtual AND (“reality”/exp OR reality) AND intensive AND (“care”/exp OR care) AND units
Brazilian Digital Library of Theses and Dissertations (BDTD)	(All fields: Nursing care AND All fields: Virtual Reality AND All fields: Intensive Care Units)
Scientific Open Access Repository of Portugal (RCAAP)	Nursing care AND Virtual Reality AND Intensive Care Units
DART-Europe E-theses Portal	Nursing care AND Virtual Reality AND Intensive Care Units

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Inclusion criteria comprised full-text scientific articles, dissertations, and theses, with no time restrictions on publication, accessed via institutional subscriptions. Studies were excluded if they did not address the research question, focused on neonatal intensive care units, or were abstracts, reviews, letters to the editor, or book chapters. Duplicate records were removed and considered only once.

The study selection process was conducted in two stages. The first stage involved screening the titles and abstracts of records imported into the Rayyan^® platform (Ouzzani et al., 2016). Microsoft Word^® was used to manage records that could not be processed by Rayyan. Subsequently, the full texts of the records selected from this initial screening were assessed against the established eligibility criteria to determine their final inclusion. Each stage was performed independently by two researchers. Any disagreements were resolved through discussion or, if necessary, by consulting a third researcher for a final decision. Backward citation searching (reviewing the reference lists of included articles) was also performed to identify additional relevant studies. Figure 1 will present the flow of identification, screening, eligibility, and inclusion of studies, following the PRISMA-ScR (Tricco et al., 2018) recommendations.

For data extraction and synthesis, a data-charting form was developed in Microsoft Excel^®. Information was extracted from the selected articles according to the following variables: author, year, country, study design, sample size, population, interface used, content addressed, and main findings. The extracted data were analyzed descriptively and thematically categorized. Furthermore, to enhance the quality and clarity of this report, the PAGER (Patterns, Advances, Gaps, Evidence for Practice, and Research Recommendations) framework was used to structure the analysis and reporting of the findings from the selected articles (Bradbury-Jones et al., 2021).

Ethical approval was not required for this study, as it involved the analysis of publicly available secondary data. However, all original sources have been appropriately cited and referenced to respect intellectual property rights.

3. Results

The initial search identified 2180 records. After the removal of duplicates, 1716 titles and abstracts were screened, of which 1664 did not meet the eligibility criteria. Consequently, the 52 remaining records were selected for full-text reading. Of these, 7 were excluded because the full text could not be accessed, and 28 were excluded for not addressing the research question. The remaining 17 studies were included in this review. Additionally, the backward citation search identified 14 potential studies, from which 4 were excluded for not aligning with the research question. The remaining 10 studies were included, resulting in a total of 27 studies composing the final sample for this review, as illustrated in Figure 1.

The analyzed studies were published between 2012 and 2024, with the highest concentration in 2021 and 2024 (7 studies each, 25.93%), followed by 2022 (5 studies, 18.52%) and 2023 (3 studies, 11.11%). The remaining years each had 1 publication (3.70%).

Regarding the country of origin, Australia and the United States were the most prominent, with 4 studies each (14.81%), followed by Canada, the Republic of Korea, the United Kingdom, and Taiwan, with 2 studies each (7.41%). The remaining countries each contributed 1 study (3.70%). In terms of study design, 6 (22.22%) were mixed-methods studies, 4 (14.81%) were randomized controlled trials, 3 (11.11%) were systematic reviews, and 2 (7.41%) were methodological studies and scoping reviews, respectively. Other designs each accounted for 1 study (3.70%). A detailed distribution of the publications by country, design, and main findings can be observed in

Table 2. Characteristics of the included studies, 2025.

(Author, Year)/Country	Study Design	Sample Size/Population	Interface Used	Content Addressed	Main Evidence
(Trevi et al., 2024)/Italy	Systematic Review	1042 records identified, 15 included in the final sample/Not applicable (N/A)	3D virtual scenario with a viewer	Cardiopulmonary resuscitation (CPR) training	High usability and participant satisfaction, improved skill performance, and knowledge retention. Reduced response time to the procedure and lower teaching costs.
(Wood et al., 2022)/Australia	Integrative Review	859 articles identified, 5 included in the review (N/A)	Multi-user virtual world (MUVW) and vSim (avatars), virtual patients, head-mounted displays (HMDs)	Resuscitation	Development of leadership skills, team-based learning, and a positive impact on self-confidence were evident in resuscitation training.
(Bayram & Caliskan, 2019)/Turkey	Randomized Controlled Trial	Initial population of 238 students, with 86 remaining in the study/First-year nursing students	Game-based mobile VR application	Tracheostomy care	The experimental group showed higher performance in internal cannula cleaning and peristomal skin care skills, as well as a shorter time in the first execution.
(Brown et al., 2012)/Australia	Methodological Study—Prototype Application	(N/A)/ICU nurses	Virtual world with avatars + viewer (Open Simulator)	Patient handover during the first hour of an ICU shift	Pedagogical benefits included the development of listening skills, verbal articulation, synthesis and prioritization abilities, and acting with thoroughness in a complex environment. The prototype may also improve training quality, reduce costs, support teamwork training, and allow for contextualized scenarios.
(Babaita et al., 2024)/Japan	Randomized Clinical Trial	62 students participated in the randomization/Third-year nursing students	360° VR video and HMDs	Closed tracheal suctioning procedure (including oral suction)	Good usability, more interesting learning, immersion, and realism; allows students to reuse videos. No statistically significant difference between groups in psychomotor skill development, knowledge acquisition, or self-confidence. Over half of the participants reported motion sickness symptoms.
(Banville et al., 2023)/Canada	Descriptive Qualitative	13 participants/Final-year nursing students	Virtual Care Unit (VCU) + viewer	Clinical surveillance competencies in critical care	Provided students with a sense of presence, allowing them to mentally anticipate care. Contributed to reduced stress levels, allowed for mistakes in a controlled environment, and stimulated increased concentration.
(Yang et al., 2024)/China	Mixed Methods	All 122 invited students participated/Third-year nursing students	vSim for Nursing (avatars)—Integrated Program	Enhancing clinical judgment in the ICU (acute pulmonary embolism)	Potential to enhance discovery and identification of critical learning points. Fosters interpretation, reflection, evaluation, and appropriate classification. The combination of vSim and in-person simulation improved clinical judgment, communication skills, operational interventions, and self-confidence.
(Tamilselvan et al., 2023)/Singapore	Systematic Review and Meta-synthesis	5550 studies identified, 14 included/(N/A)	Viewer	Learning nursing care with VR	Promotes self-assessment of knowledge, motivates, and makes learning more effective and independent. Improves psychomotor competencies, decision-making, and self-confidence. Makes practice more memorable and allows for repeated practice without risk.
(Cheng et al., 2024)/Canada	Systematic Review	1807 records identified, 13 included/(N/A)	3D computer-simulated space	Basic and advanced life support training	Observed knowledge acquisition and retention, the opportunity to apply clinical reasoning and decision-making in scenarios, and promotion of training support.
(Plotzky et al., 2021)/Germany	Systematic Review	13,945 records identified, 22 included in the final sample/(N/A)	3D head-mounted displays (HMDs)	Auscultation, endotracheal suctioning, urinary catheterization, empathy, and emergency response	Studies identified the potential for procedure and skill training and providing immersion in situations difficult to replicate in traditional simulation. Makes teaching less stressful, increases self-efficacy, self-confidence, resilience, and enhances empathy.
(Kim & Seo, 2024)/Republic of Korea	Mixed Methods	46 participants/Third-year nursing students	VIRTI application + 360-degree camera with HMDs	Intravenous (IV) therapy training with an infusion pump	Improved motivation to transfer learning, self-efficacy, confidence, and skills. Enabled repetitive training in an autonomous, proactive, and psychologically safe environment. Reported a sense of presence, immersion, and expectations of enhanced long-term memory. Physical side effects were noted.
(Harmon et al., 2021)/Australia	Scoping Review	2841 articles identified, 4 included/(N/A)	Serious gaming and avatars	Pain education	Promotes decision-making in a realistic and safe environment and the ability to progress and improve knowledge. VR can lead to stress, eye strain, and cybersickness.
(Samosorn et al., 2020)/United States	Pilot Study	31 participants/Nursing faculty and students	Virtual Oculus Rift + Touch	Airway management of an apneic and unresponsive patient	Increased knowledge and its effective transmission and the possibility of self-guided learning. VR can be positive across clinical disciplines but is not suggested to replace clinical encounters. Participants did not experience significant motion sickness.
(Hall et al., 2024)/Australia	Single-arm Repeated Measures Study	79 students participated out of 219/Nursing students	VirtualU End of Life Care + 360° Video + VR goggles	Communication skills in “end-of-life care”	Improved self-assessment of knowledge, skills, and behaviors. Promoted highly beneficial and unique learning with effective engagement. Provided psychological safety for making mistakes and open discussions. Some reported discomfort, dizziness, and anxiety.
(Perez et al., 2022)/United States	Mixed Methods	105 participants/Master’s and doctoral nursing students	Mursion (virtual environment and avatars)	Managing difficult conversations	Enabled management of difficult conversations and increased communication confidence. Anxiety and nervousness before the simulation were reported.
(Rim & Shin, 2021)/Republic of Korea	Methodological Study	16 students participated/Nursing students	Unity 3D and Second Life platforms (avatars)	Neonatal apnea, hypoglycemia, and transfusion	Allows multiple practice attempts, independent knowledge construction, and emotional adaptation and self-regulation in unfamiliar situations.
(García-Pazo et al., 2023)/Spain	Cross-sectional Study	Purposive sample of 175 students/Third-year nursing students	360° video + HMDs	Assessment of critical patients	Good usability that allows for scenario review and improves students’ perception of their skill acquisition, as well as understanding of the ICU environment and required technology. Observed learning in skin/mucous hygiene, patient mobilization, and empathy.
(Chao et al., 2021)/Taiwan	Randomized Clinical Trial	47 participants recruited, 45 participated/Nursing students > 20 years with no prior nasogastric tube feeding skills	HMDs + immersive 3D video + VIVEPAPER	Nasogastric tube feeding	Improved knowledge, confidence, and satisfaction with the learning method. Exam scores in the intervention group were higher. Mild dizziness was reported but did not affect learning.
(Botha et al., 2021)/South Africa	Not Specified	34 students volunteered, 6 in pilot test, 28 in final analysis/Nursing students	HMDs + Oculus Rift	Management of a patient with a foreign body airway obstruction	The system was genuinely usable with no task failures. Students had a very positive and satisfying experience, finding the system realistic and interactive with good usability. However, some reported dizziness and nausea.
(Y. M. Chang & Lai, 2021)/Republic of China	Qualitative research design and focus group interview	60 students selected from 90 potential participants/Nursing students	HMD, motion sensors, and hand controls (HTC VIVE)	Nasogastric tube feeding	Good adaptation and usability of the virtual environment, though it required time. Students could learn from their mistakes and manage their own learning progress without stress. VR offers cost savings and the possibility of repeated practice.
(Kuyt et al., 2021)/United Kingdom	Scoping Review	696 articles identified, 42 selected for the final sample/(N/A)	Not specified	CPR	Great potential as a blended learning strategy, useful for training and increasing confidence. No improvement in skill was noted, but there was greater knowledge application and engagement. No studies addressed the influence of training on patient outcomes.
(Hubail et al., 2022)/United Kingdom	Randomized Controlled Trial	42 participants contacted, 26 attended, 7 withdrew/Adults > 18 with no prior CPR course or one taken >1 year ago	VR headset and hand sensors (HTC Vive)	CPR	CPR skill acquisition was comparable in both groups. Participants indicated a preference for hands-on training. The traditional group had a greater gain in knowledge and confidence. The VR content had clear instructions and useful feedback, leading to a positive experience.
(Butt et al., 2018)/United States	Mixed Methods	20 students participated out of 36 recruited/Fifth- and sixth-semester nursing students	3D helmets (Oculus Rift) and haptic devices (interactive glove)	Urinary catheterization	Good usability, opportunity for repeated practice, and stimulation of practice and self-confidence. Assisted in correct catheter insertion and memorization of procedural steps. The ability to demonstrate sterile technique was equal for both groups.
(Y. Y. Chang et al., 2024)/Taiwan	Mixed Methods	35 students in Phase I; 128 participants in Phase II (out of 146)/Second-year nursing students	Oculus Rift headset	IV injection	Increased knowledge, motivation, memorization of skills and processes, and a sense of realism. Some steps were challenging, including smoothness of the VR, needle positioning, and patient communication.
(Ulrich et al., 2014)/United States	Mixed Methods	107 students participated/Senior baccalaureate nursing students, >18 years, English-speaking	Computer monitor + Microsoft Kinect webcam	Decontamination	Sense of realism, ability to make mistakes without patient harm, and feeling of safety from contamination. Improved memory.
(Al-Mugheed et al., 2022)/Cyprus	Experimental	126 students met the inclusion criteria out of 135/Third- and fourth-level nursing students	Not specified	Standard precautions	More significant results in knowledge, attitude, and compliance with standard precautions. Provided the opportunity to repeat practice multiple times, translating knowledge into practice, and preparing for professional life.
(Lee & Han, 2022)/South Korea	Quasi-experiment	66 students selected, 60 participated/Nursing students with no prior VR simulation experience with mechanical ventilation	VR goggles	Mechanical ventilation	No significant difference in knowledge between groups. Greater immersion and learning satisfaction, improved clinical decision-making, critical thinking, perception, and effective for increasing self-efficacy.

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Upon evaluating the sample sizes, it was observed that the 20 empirical studies included a total of 1376 participants, of whom 1340 (97.38%) were nursing students. The remaining 7 secondary studies analyzed a total of 115 articles in their respective samples.

Regarding the interfaces used, head-mounted displays (HMDs) were the most frequent means of interaction, appearing in 18 (66.66%) of the studies, followed by multi-user virtual worlds with avatars in 6 (22.22%) and 360° videos in 4 (14.81%). It should be noted that many studies combined different interfaces in their interventions; therefore, the quantitative count of devices reflects the frequency of their use rather than the total number of included studies.

Among the content areas modeled in virtual reality, CPR was the most prominent, featured in 5 (18.52%) of the studies. This was followed by tracheostomy care in 3 (11.11%) and auscultation, communication, airway management, and nasogastric tube insertion each in 2 (7.41%) of the studies. The remaining nursing care topics, such as IV therapy with an infusion pump, urinary catheterization, standard precautions, and mechanical ventilation, were each the focus of one publication (3.70%).

Although the primary objective of this study was to map the content related to critical care nursing education modeled in virtual reality, the analysis of the included studies also consistently revealed relevant impacts of this technology on the teaching-learning process. These impacts emerged as significant findings and reinforced the potential of VR for the development of cognitive, psychomotor, and affective competencies in nursing education.

Table 3. PAGER framework based on the analyzed studies.

Pattern (Type of Impact)	Advances	Gaps	Evidence for Practice	Research Recommendations
Increased knowledge	The use of VR led to greater knowledge acquisition, effectively linking theory with practice.	Lack of real-world interaction and absence of authentic emotional elements in clinical contexts; dependency on connectivity and need for technological adaptation.	Studies show increased knowledge retention, better comprehension of content, and greater student motivation in virtual environments.	Conduct longitudinal research to assess the long-term impact of continuous VR use on learning and develop technological solutions that increase realism and accessibility.
Improved self-confidence	Virtual environments allow for errors without risk to the patient, promoting psychological safety and self-confidence in skill performance.	Difficulty in initial adaptation to technological interfaces and simulation-related anxiety, especially among students with less digital familiarity.	Reports indicate increased self-confidence in procedure execution and a greater willingness to face practical challenges after VR training.	Implement emotional support and pre-training strategies to reduce barriers and facilitate student adaptation to VR; evaluate the impact on different student profiles.
Development of critical thinking	VR fosters reflection, evaluation, and classification of complex situations, stimulating decision-making and clinical judgment.	Need for more realistic and interactive scenarios to better simulate critical situations and enhance the development of clinical reasoning.	Significant improvement in analytical and problem-solving abilities, with immediate feedback that potentiates the development of critical thinking.	Develop more complex and realistic scenarios; evaluate the impact of VR on critical thinking development in different clinical contexts and on a larger scale.
Enhancement of technical skills	Provides repetitive practical training, development of psychomotor skills, leadership, and communication.	Few simulations with haptic devices; limitations in reproducing advanced psychomotor skills; insufficient time provided to learn the VR technology beforehand.	Proven effectiveness in technical skill acquisition, with performance similar to or superior to traditional methods in certain procedures.	Invest in haptic technologies, improve simulator fidelity to broaden the development of technical skills in virtual environments, and provide more time for users to familiarize themselves with the technology.
Strengthening of practice safety	The controlled environment reduces physical and emotional risks during learning and promotes safety for practice and error-making.	Absence of the psychological pressure typical of real scenarios, which can impact preparation for high-risk situations. Additionally, physical symptoms like nausea and dizziness can compromise user safety.	Studies indicate that VR contributes to learning safety by reducing risks associated with traditional practical training, thereby increasing students’ confidence in performing procedures.	Deepen research on the impact of physical symptoms on user safety and develop strategies to minimize these adverse effects. Explore ways to incorporate elements of emotional realism and psychological pressure to better prepare students for real-world scenarios.

presents the PAGER framework, which organizes the identified results into five dimensions: Patterns, Advances, Gaps, Evidence for Practice, and Research Recommendations. During the review of the selected articles, consistent patterns of VR’s impact on nursing education were identified, most notably, increased knowledge (40.74%), improved self-confidence (37.04%), development of critical thinking (29.63%), enhancement of technical skills (25.93%), and strengthening of practice safety (22.22%).

4. Discussion

The objective of this study was to map the literature on content related to the teaching of critical care nursing practices that have been modeled in virtual reality. In doing so, beyond identifying the specific content areas, it was also possible to characterize relevant aspects of the included studies, such as their temporal and geographical distribution, methodological designs, participant profiles, technological interfaces used, simulated themes, and associated pedagogical impacts.

Analysis of the temporal distribution of the studies revealed a predominance in the years 2024 and 2021, which together accounted for the largest number of articles (14 total, with 7 in each year). This landscape indicates a growing academic and scientific interest in the use of virtual reality for teaching nursing content applicable to the intensive care unit. This field, which previously had few studies on its educational application, has now seen VR emerge as a valued technology for its potential in nursing skills training (García-Pazo et al., 2023; Ma et al., 2024; Hong & Wang, 2023).

Regarding geographical distribution, a prevalence of publications from Australia and the United States was evident, comprising 8 articles in total (4 from each country). This finding aligns with the study by Hong and Wang (2023), which identified the United States as the country with the most scientific contributions to VR-based nursing skills training, with Australia ranking fourth. Similarly, a systematic review by Shorey and Ng (2021) on randomized controlled trials and quasi-experimental studies found that VR research in nursing was primarily conducted in developed countries, noting that the initial implementation costs of VR are high. That review also identified the United States as the country with the most publications, whereas Australia, in that specific analysis, had none. This context suggests a growing interest in this topic in developed nations, yet concerns about high implementation costs remain, as pointed out by Shorey and Ng (2021). This highlights the need to explore lower-cost strategies and solutions to broaden access to pedagogical innovations in contexts with less infrastructure.

Regarding the profile of the study populations, it was observed that in the 20 articles that detailed their participants, the majority were nursing students, representing 97.38% of the 1376 individuals. A study assessing the perceptions of nurse educators on the application of VR in nursing education found that this technology is a teaching methodology that promotes reflection for assertive decision-making and student engagement (Serpa & Netto, 2024). In this vein, Marques et al. (2022) describe nursing education as a complex process. It is therefore apparent that VR, as a pedagogical resource, has been solidifying its role as a promising and necessary tool for enhancing academic training in nursing.

With respect to the technological interfaces employed in the analyzed studies, head-mounted displays (also referred to as viewers, HMDs, headsets, and helmets) were the most frequently used means of interaction, appearing in 66.66% of the 27 studies. This predominance is likely due to the benefits these devices offer in terms of flexibility, accessibility, and portability, as well as their ability to promote deep immersion in the created scenario, facilitating their adoption in academic settings (Lau et al., 2023).

4.1. Nursing Skills

As highlighted in this review, a wide variety of critical care nursing skills have been modeled in virtual reality for educational purposes. Among these, the most frequent were CPR, tracheostomy care, auscultation, communication, airway management, and nasogastric tube care. Other skills were also addressed, albeit less frequently, such as intravenous therapy with an infusion pump, urinary catheterization, standard precautions, and mechanical ventilation.

4.1.1. Cardiopulmonary Resuscitation

The effective execution of CPR is one of the most critical skills in healthcare (Wood et al., 2022). An observational cohort study using a national readmissions database found that among 4,610,154 patients admitted to ICUs, 426,564 (9.25%) required CPR during hospitalization (Mir et al., 2024). This indicates that CPR is a recurrent need in the ICU, making it imperative for students to receive training that prepares them to provide qualified and effective care. In support of this, a systematic review by Trevi et al. (2024) concluded that the available evidence on the use of VR for CPR training is promising. Likewise, Cheng et al. (2024), in another systematic review, found that VR can support this training, although they emphasize that more in-depth research is needed. Furthermore, a randomized pilot study identified that the use of VR for CPR skill acquisition is non-inferior when compared to traditional teaching methods (Hubail et al., 2022). Thus, the use of VR in teaching CPR should not be overlooked; it merits recognition not only as a teaching support but also as a technology deserving of continuous refinement and development.

4.1.2. Tracheostomy

Tracheostomy care was another nursing procedure that featured prominently among the content modeled in virtual reality. Tracheostomy management is a crucial skill for nurses, who are considered essential members of the care team (Alotaibi et al., 2022). A point-prevalence, cross-sectional observational study conducted in 8 Italian ICUs reported a total of 475 tracheostomies performed in 2022, with an annual prevalence of 9.1% (Merola et al., 2025). This underscores the importance of refining skills related to this care and the need for educational scenarios that allow for its practice. Studies highlight the potential of VR in teaching tracheostomy care. Bayram and Caliskan (2019) demonstrated that a game-based application contributed to the development of knowledge and psychomotor skills in nursing students. Complementarily, Plotzky et al. (2021) noted in a systematic review that VR makes teaching this procedure more efficient and engaging. In a recent study in Japan, Babaita et al. (2024) observed that 42.3% of students who used a 360° VR video found the technology useful for learning the technique. These findings reinforce that VR, when combined with traditional methods, can foster mastery of procedures critical to patient safety and comfort.

4.1.3. Nasogastric

Nasogastric tube care was another skill taught via virtual reality. The study by Y. M. Chang and Lai (2021) with nursing students found that VR applied to this topic is a tool that supports self-directed learning and the creation of student experiences. Similarly, a randomized clinical trial by Chao et al. (2021) showed that this technology enables an interactive learning process, representing an alternative strategy for developing skills related to nasogastric tube care. Therefore, VR can contribute to enhancing competencies for this procedure, strengthening clinical practice, and engaging students in their academic journey.

4.1.4. Mechanical Ventilation

Mechanical ventilation also emerged as a practice suitable for VR modeling. In this context, Lee and Han (2022), through the development and evaluation of a VR simulation program on mechanical ventilation for nursing students, found that this methodology develops students’ competencies for safer practice and promotes learning unconstrained by time or space. Given that nursing care for mechanically ventilated patients is a complex and dynamic process requiring both knowledge and skills, it is important to build this foundation throughout academic training, and VR serves as a bridge to this end.

4.1.5. Other Nursing Skills

Other nursing content, such as auscultation, communication, urinary catheterization, and others mentioned previously, were also covered in the analyzed studies. This variety of critical care skills that can be modeled in VR demonstrates not only the technology’s potential but also the need to promote its continuous implementation and address the gaps that hinder its applicability. As VR simulation can be adapted to various scenarios in nursing education and facilitates authentic learning, its importance as a strategic resource for qualified care is clear (Kiegaldie & Shaw, 2023).

4.2. Impact on Teaching and Learning

In addition to identifying the scenarios modeled in VR, this study detected the impacts of this tool on the teaching-learning process, as well as the challenges associated with its use. Several studies highlighted the impact of this teaching methodology on knowledge. According to Al-Mugheed et al. (2022), combining online education with game-based VR applications significantly contributes to translating theoretical knowledge into practice, preparing students for their professional roles. Furthermore, students are able to apply the knowledge gained during VR training sessions, which enhances their learning (Kuyt et al., 2021; Chao et al., 2021). Complementing this, Hall et al. (2024) identified statistically significant improvements in students’ knowledge after using VR as an educational approach, thereby boosting their academic development.

Another impact of VR noted in the studies was on student self-confidence. In the study by Perez et al. (2022), participants reported that the virtual simulation was effective and promoted greater confidence in handling similar situations in the future. Similarly, Kim and Seo (2024) found a significant improvement in student self-confidence after VR training. Consistent with these findings, Tamilselvan et al. (2023) also highlighted that students expressed a notable increase in confidence when using immersive technology as an educational tool. These data reinforce the relevance of VR not only as a teaching instrument but also as a means of fostering autonomy and security in future nursing professionals.

Another important aspect identified was the development of critical thinking. The study by Lee and Han (2022) found that clinical decision-making was significantly enhanced, accompanied by improvements in critical thinking, and suggests that VR experiences can be effective for developing clinical reasoning competency. Complementing this perspective, García-Pazo et al. (2023) noted that students perceived VR as a tool that helped them identify priority problems or diagnoses and contributed to more assertive care planning.

Beyond the impacts, studies also found that the use of this technology fosters the development of technical skills and enhances student safety in practice settings, as evidenced in the studies by Bayram and Caliskan (2019) and Ulrich et al. (2014), respectively. In this light, the use of VR in nursing education extends beyond the transmission of theoretical knowledge, promoting significant impacts on the development of competencies essential for professional practice.

4.3. Challenges in VR

Although the application of virtual reality enhances the teaching-learning process, challenges related to its use are also present. One of the main challenges is the lack of realism in scenarios, especially in critical environments such as resuscitation, given that both emotional and relational aspects, like the stress of the situation, communication, team decision-making, and the difficulty in re-creating this environment’s complexity, can compromise the simulation experience (Trevi et al., 2024; Wood et al., 2022). Added to this is the scarcity of simulations involving psychomotor skills with haptic devices, which are essential for developing manual dexterity and providing a faithful sense of touch (Plotzky et al., 2021; Y. M. Chang & Lai, 2021). On the other hand, Al-Mugheed et al. (2022) observed that their simulation was able to provide a very close scenario to the real environment.

Another recurring point in the findings is the presence of technical limitations, which can affect presence, immersion, and the learning process. These include operational failures, difficulty interacting with the environment, lack of real-time communication during the simulation, and the need for prior preparation to use the technology effectively (Rim & Shin, 2021; Banville et al., 2023; Yang et al., 2024; Ulrich et al., 2014).

Furthermore, discomfort during VR use was observed in several studies. Participants reported dizziness, motion sickness, a “feeling of intoxication,” nausea, and stress (Babaita et al., 2024; Tamilselvan et al., 2023; Kim & Seo, 2024; Botha et al., 2021; Harmon et al., 2021). Conversely, the study by Samosorn et al. (2020) did not report significant motion sickness. Additionally, some studies associate technology use with anxiety and nervousness (Perez et al., 2022; Hall et al., 2024). In contrast, it was also noted that in some cases, these discomforts did not compromise learning (Chao et al., 2021).

It is therefore evident that the adverse effects and limitations associated with VR can vary depending on the type of technology employed, exposure time, students’ familiarity with the resource, and the complexity of the content. This methodological diversity limits the generalization of results but also points to the need for standardizing practices and developing specific guidelines for the safe and effective use of VR.

4.4. Limitations of the Review

This study has some limitations that must be considered. The exclusion of studies focusing on the pediatric population restricts the applicability of the findings and prevents generalization to this specific group. Another limitation is the potential for selection bias, as the choice of search terms may have influenced the results and the scope of the final sample. The insufficient reporting of methodological components in some of the analyzed articles is also a limitation; for example, two studies did not specify the VR interface used or evaluated, and one did not state its methodological design. Finally, it is worth emphasizing that no assessment of the level of evidence of the included studies was conducted, as this is not an objective of scoping reviews.

4.5. Future Research Implications

Based on the findings of this review, it is recommended that future studies broaden their inclusion criteria to different populations to assess the applicability of VR in varied nursing care contexts. Furthermore, it is essential that research adopts methodologies with greater transparency in describing components such as the type of interface and study design. It is also suggested that new approaches explore the application of VR for psychomotor skills using haptic devices, as the absence of this feature was identified as a relevant limitation. For greater methodological rigor, comparative studies with control groups and long-term evaluation of VR’s effects on learning should be encouraged.

Additionally, it is recommended that preliminary tests be conducted with students before the definitive implementation of the technology, along with active participation from instructors during the process, to minimize reported discomforts such as dizziness, anxiety, and operational difficulties. Finally, it is important for future research to investigate the application of VR for specific nursing content areas in isolation to allow for a more rigorous evaluation of the technology’s effectiveness in each thematic area.

5. Conclusions

This study revealed that the application of virtual reality in nursing education is a promising strategy for competency development. It was found that a diverse range of critical care nursing practices have been modeled in virtual reality, including cardiopulmonary resuscitation, tracheostomy care, nasogastric tube insertion, and mechanical ventilation, among other topics addressed in this review. These findings demonstrate that virtual reality can be used versatilely to address relevant professional themes, exposing students to complex and challenging clinical scenarios.

Furthermore, this review identified evidence pointing to the potential of virtual reality in the teaching-learning process, highlighting its contribution to knowledge acquisition, the strengthening of critical thinking, the improvement of technical skills, and an increase in student self-confidence. Moreover, immersive resources provide a safe and controlled environment for training, allowing for the repetition of procedures without risk to patients. However, significant gaps remain to be addressed. The included studies exhibit heterogeneity in their methodologies, descriptions of technological interfaces, and target populations, which hinders the generalization of the findings. Additionally, challenges such as physical discomfort, technical limitations, and the absence of simulations involving psychomotor skills reveal the need for improvements in the available tools.

Therefore, the findings of this review contribute to the strengthening of evidence-based practices in nursing education, especially in the context of intensive care and critical patient care. These insights have the potential to transform nursing practice, as the use of virtual reality to supplement traditional instruction can improve the quality of learning, making education more practical and effective.