Neher et al.

BMC Medical Education (2025) 25:292 BMC Medical Education

https://doi.org/10.1186/s12909-025-06867-8

RESEARCH Open Access

Virtual reality for assessment

in undergraduate nursing and medical
education – a systematic review
Andrea N. Neher1,2* , Florian Bühlmann1 , Martin Müller1 , Christoph Berendonk3 , Thomas C. Sauter1† and
Tanja Birrenbach1†

Abstract
Background Virtual reality (VR) is increasingly used in healthcare education, offering immersive training experiences
that are as effective as conventional methods, with benefits like cost-effectiveness, replicating complex scenarios,
and reduced need for physical resources. However, the use of VR as an assessment tool is still emerging, particularly
in nursing and medical education. The aim of this systematic review was to examine how immersive VR is used as an
assessment tool for nursing and medical students.
Methods Embase, PubMed, PsycINFO, Cochrane, CINAHL, and ERIC were searched for articles that assessed nursing
and/or medical students using immersive/HMD VR. The data was extracted, and content analysis was performed.
Results Twenty-six studies met the inclusion criteria, investigating VR assessments in various settings mostly
emergencies. Assessments focused on core competencies Patient Care such as first triage, Interpersonal and
Communication Skills (e.g., interprofessional communication), and Medical Knowledge (e.g., about coma), utilizing
a range of assessment methods from knowledge to performance levels. VR was used either as an automated or
supporting assessment tool. Practical considerations in VR implementation were also examined, such as hardware and
software.
Conclusion The use of VR in medical education assessment shows promise, particularly for emergency scenarios and
performance-based tasks related to core competencies such as Patient Care, Interpersonal and Communication Skills,
and Medical Knowledge. While this technology offers opportunities to automate assessments and reduce examiner
workload, challenges related to software, costs, and feasibility must be addressed. Additionally, aligning learning
objectives, teaching methods, and VR assessments through constructive alignment is essential to ensure effective
implementation as both a teaching and evaluation tool.
Keywords Medical education, Virtual reality, Performance assessment, Nursing

1
†
Thomas C. Sauter and Tanja Birrenbach contributed equally to this Department of Emergency Medicine, Inselspital, Bern University Hospital,
work. University of Bern, Rosenbühlgasse 27, Bern CH-3010, Switzerland
2
Graduate School for Health Sciences, University of Bern, Bern,
*Correspondence: Switzerland
Andrea N. Neher 3
Institute for Medical Education, University of Bern, Bern, Switzerland
[email protected]

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Neher et al. BMC Medical Education (2025) 25:292 Page 2 of 11

Introduction Specifically, this review explored the settings and com-

In health care education, virtual reality (VR) has become petencies assessed by or through VR and the taxonomic
widely available. It refers to an entirely virtual experi- level of the assessments, as well as the practical consider-
ence that encompasses everything one sees, moves, or ations associated with implementing VR in assessments.
interacts with. It exists in multiple forms, ranging from
screen-based applications to highly immersive systems. Materials and methods
These varying levels of immersion seem to have an This preregistered systematic review (PROSPERO,
impact on learning outcomes and should therefore be CRD42023490861) is reported according to the Preferred
examined separately [1, 2]. In this study, we focus specifi- Reporting Items for Systematic Review and Meta-Analy-
cally on immersive VR, delivered through head-mounted sis (PRISMA) guideline.
displays (HMDs), to achieve the highest possible level of
realism and immersion. Eligibility criteria
The training of medical students with immersive VR To reflect the broad application of VR for assessment
has been well-researched and has several advantages and purposes (e.g., evaluating skills or knowledge) among
disadvantages. Training covers everything from knowl- nursing and or medical students, the following inclusion
edge [3] and basic skills [4] to complex procedures [5], criteria were established:
and full clinical scenarios [6]. Reviews suggest that VR All studies that conducted assessments of nursing and
is at least as effective as conventional training meth- or medical students while they were using immersive VR,
ods, particularly in skills training and knowledge [7, 8]. defined strictly as VR facilitated through an HMD (VR
Compared to traditional methods, VR can be more cost- headset) were included, regardless of the original study’s
effective [9]; it requires less space and fewer additional defined outcomes. These assessments could involve
resources, such as standardized patients or simulation either virtual environments or 360° video-based experi-
manikins, medical supplies, or even supervisors. Situ- ences, provided they included some form of evaluation of
ations that are difficult to recreate in real life, such as the students—whether conducted by a human examiner
emergency scenarios [10, 11] can be replicated with VR or the VR system itself.
without posing safety risks to patients and can be used The exclusion criteria were as follows: (1) other health-
location-independently [12]. However, users must first care students, (2) other forms of VR, not facilitated by an
become familiar with VR technology before they can HMD, such as screen-based, or (3) other technologies
effectively operate it [13]. Additionally, there is a risk of such as Mixed Reality (MR) or Augmented Reality (AR).
discomfort or even cybersickness associated with VR (4) Reviews, trial protocols, conference papers or letters,
usage [14] and the development of VR simulations is and (5) all reports in languages other than English or
complex and requires trained staff [15]. German were also excluded.
While VR has become widely adopted as a training tool
in medicine, its use as an assessment instrument is just Search strategy
emerging. It is plausible that the benefits of VR in train- A librarian specialized in systematic literature searches
ing also apply when it is used for assessment purposes. was involved in initiating and reviewing the search string
Moreover, the high scalability of VR and its potential for (See Additional File 1). The search strategy involved com-
objectivity, as seen in VR simulator assessments in sur- bining multiple terms, as well as MeSH terms, related to
gery with performance metrics [16], could offer addi- nursing or medical education, immersive/HMD VR, and
tional advantages. assessment using the Boolean operator OR. These indi-
Given the evident advantages of VR, integrating it vidual search strings were then conducted separately and
into routine assessments—particularly in undergraduate subsequently combined using the operator AND. The
nursing and medical education—appears highly promis- systematic literature search was performed in Decem-
ing. This study seeks to investigate the potential of VR ber 2023 in Embase, PubMed, PsycINFO, Cochrane,
assessments, defined here as a broad range of evaluative CINAHL, and ERIC. Additionally, Google Scholar was
methods conducted within or supported by HMD VR used as a supplementary search. Manual searches were
environments. An example includes practical exams with conducted by screening the reference lists of included
a virtual patient, where students diagnose and manage studies as well as identified reviews that appeared eligible
conditions in real time. The focus was not on outcome during the initial screening process.
assessments for research purposes, but rather on practi- The search was restricted to articles published after
cal assessments intended for direct use with nursing and/ 2015, given the widespread availability of commercially
or medical students. Therefore, the aim of this system- accessible, all-in-one HMDs that operate independently
atic review was to explore how HMD VR is being used as without external devices since 2016 [17].
an assessment tool for nursing and/or medical students.
Neher et al. BMC Medical Education (2025) 25:292 Page 3 of 11

Study selection and data extraction process was carried out using MAXQDA (Release 22.8.0)
The platform Rayyan (http://rayyan.qcri.org) was ​u​t​i​l​ by a single reviewer (AN), after which the categories were
i​z​e​d to identify duplicates and efficiently search for rel- discussed within the author team.
evant studies. To determine if a study met the review’s
inclusion criteria, two independent reviewers (AN, Results
FB) initially screened title and abstract. After the ini- Study selection
tial screening, all studies not directly excluded by both A total of 2528 studies were initially found, with 888
reviewers underwent full-text screening and were tested duplicates removed (Fig. 1). Following exclusion based
for inclusion by the same reviewers (AN, FB). Any dis- on title and abstract (1181 studies), 459 full-text studies
agreements between reviewers were resolved through were assessed, resulting in the inclusion of 25 studies. An
discussions to reach a consensus. additional search yielded 161 studies, with one meeting
The data extraction was subsequently carried out by a the inclusion criteria. In total, 26 studies were included
single reviewer (AN), followed by independent double- in the final analysis (details about the fulfillment of the
checking by another reviewer (FB). inclusion criteria are shown in Additional File 2).

Data items Study characteristics and quality

For the data extraction, information about the following One study was conducted in 2017 [23]; while the remain-
topics was gathered: title, author, publication date and der were conducted in 2020 or later (see Table 1). Studies
journal, design, country, objective, population, effective were conducted in Europe (n = 9) [11, 23–30], Asia (n = 9)
participants (only VR Intervention), inclusion and exclu- [31–39], North America (n = 7) [40–46], and Australia
sion criteria, intervention, hardware and software, intro- (n = 1) [47]. Eight studies (31%) used the VR assessment
duction to VR, VR assessment methods and the nature of as a primary or secondary outcome [11, 28, 30, 32, 40, 42,
competencies being assessed. The results were discussed 44, 46]. The number of participating students in the stud-
among the author team. ies (only VR intervention) varied from 10 to 207 (mean
59, SD 49.9, median 38.5, IQR 26.5–73.8). The quality
Quality assessment of the studies varied with a MERSQI score range from
To assess the quality of the included studies, the Medical 7 to 15.5 (mean 12.4, SD 2.6). Eight studies (31%) had a
Education Research Study Quality Instrument (MERSQI) MERSQI score over 14 indicating high quality. Please
was used, which is a useful and reliable tool to assess the refer to the Additional File 3 for the detailed informa-
quality of medical education research [18]. The MERSQI tion regarding the MERSQI. We also included studies
has a total of ten items over six domains: Study design, with lower quality, as our primary focus was on the VR
sampling, type of data, validity of evaluation instrument, assessment. In studies where VR was compared to other
data analysis and outcomes. The scale allows a maximum modalities, assessments of learning outcomes were often
of 18 points. Analogous to Goldenberg et al., this work conducted in different formats, such as on mannequins
used a score of 14 or higher as an indicator of high qual- [e.g., 24] or through pre/post-tests [e.g., 41]. Additionally,
ity [19]. The studies were independently rated by two some studies did not focus on performance but instead
reviewers (AN, FB), and discrepancies in every item were evaluated factors such as workload, or usability [e.g.,
addressed through discussion. 30,36]. The inclusion of these studies was therefore not
based on their quality but rather on their relevance to our
Synthesis method exploration of VR as an assessment tool.
Content analysis was employed to synthesize the data,
utilizing a deductive approach [20]. All studies were Settings and competencies
coded for settings and competencies including tasks, tax- Fourteen studies (54%) examined emergency settings [25,
onomic level, and practical considerations. Competencies 26, 28–30, 35, 45, 46], including five (19%) that focused
were additionally coded according to the Accreditation on pediatric emergencies [11, 31, 40, 41, 47] and one on
Council for Graduate Medical Education (ACGME) core prehospital emergencies with mass casualty incidents
competencies framework including Interpersonal and [34]. In addition, three studies (12%) were conducted in
Communication Skills, Patient Care, Medical Knowledge, the operating room, two of which specifically addressed
Practice-Based Learning and Improvement, Profession- surgery [27, 32], while one covered general perioperative
alism, and Systems-based Practice [21]. The taxonomic practice such as sterile procedures [33]. Furthermore,
level of assessments was coded following the well-known two assessments (8%) were related to mental health [36,
framework from Miller, which progresses from knowl- 42], one explored genetics [44], one on disaster education
edge (Knows) to competence (Knows how), performance [43], and one on ophthalmology [23]. The four remaining
(Shows how), and finally, action (Does) [22]. The coding
Neher et al. BMC Medical Education (2025) 25:292 Page 4 of 11

Fig. 1 PRISMA flow diagram

studies (15%) did not specify a particular setting (see improvement, professionalism, and systems-based prac-
Table 1 or Fig. 2) [24, 37–39]. tice were either not assessed or not explicitly addressed
The VR assessments targeted three of the six ACGME in these studies.
core competencies: Patient Care (62%), Interpersonal
and Communication Skills (50%), and Medical Knowl- Taxonomic level of assessment
edge (42%). For an overview, see Fig. 2. Patient care was The taxonomic level of the VR assessment according to
assessed to varying degrees, ranging from individual Miller’s pyramid is shown in Table 1; Fig. 2. Three of the
skills such as peripheral venous catheter placement [24], four studies that tested knowledge (15%) used multiple-
performing retinal examination [23], subcutaneous injec- choice questions (MCQs) or quizzes [35, 39, 43]. The
tion, and intravenous therapy [37] or first triage [34] to questions were presented to the participants in VR and
entire procedures such as history taking and clinical had to be answered by using the hand-held controllers.
assessment as well as treatments (e.g., pediatric seizure Anbro et al. used verbal checkbacks instead [45]. In the
or respiratory management) [11, 25, 26, 28, 29, 31, 40, three studies (12%) that assessed competence, also mul-
41, 46] and cardiopulmonary resuscitation [47], or entire tiple-choice questions (MCQs) were used [30, 33, 36].
surgical procedures [27, 32]. Interpersonal and commu- However, additional methods such as matching quiz-
nication skills were examined, through the evaluation of zes, like matching the correct labels, as well as tasks like
interactions with (anxious) patients [38, 42, 44], family “rearrangement of sequences” and scenario-based assess-
members [11, 31], or inter-professional communication ments, were also employed to assess not only knowledge
[11, 29, 36, 40, 41, 45, 46]. Medical knowledge assess- but also to evaluate whether the knowledge was under-
ments covered a variety of topics, including knowledge stood and could be applied in this specific context. The
about coma [35], nasogastric tube feeding [39], decon- remaining 19 performance level studies (73%) used clini-
tamination [43], ophthalmology [23] and others [28, 30, cal cases such as Objective Structured Clinical Examina-
31, 33, 36, 40, 41, 44, 47], as detailed in Table 1. Some tions (OSCE) or surgical procedures [11, 23–29, 31, 32,
studies also assessed multiple competencies simulta- 34, 37, 38, 40–42, 44, 46, 47]. The action level, was absent,
neously [11, 23, 28, 29, 31, 36, 40, 41, 44, 46, 47]. Nota- as it would ideally occur during clinical practice [22].
bly, competencies such as practice-based learning and All VR assessments were assumed to be formative (low
stakes), even though seven studies (27%) integrated VR
interventions into courses or curricula [25, 26, 29, 31, 40,
Neher et al. BMC Medical Education (2025) 25:292 Page 5 of 11

Table 1 Overview of included studies

Author, year Setting Competencies Task Taxonomic Auto- MERSQI
Students (n in VR) level* mated
yes/no
Anbro et al., 2020 [45] Emergency IC 360° Video: Serve as a recorder of the event Knowledge No 12.5
Med. and nurs. (105) setting by providing verbal checkbacks (i.e., verbal
confirmation of procedural steps)
Andersen et al., 2021 Not specified PC Skill: Ultrasound-guided peripheral venous Performance Yes 13.5
[24] cannulation
Med. (10)
Azher et al., 2023 [46] Emergency PC, IC Clinical scenario: Management patient with Performance Yes 13.5
Nurs. (29) setting acute anxiety
Berg & Steinsbekk, Emergency PC Clinical scenario: assess patient according to Performance Yes 15.5
2020 [25] setting ABCDE scheme (e.g. airway, breathing, cir-
Med. and nurs. (149) culation, disability, environment), document
observations (Single-player)
Berg & Steinsbekk, Emergency PC Clinical scenario: assess patient according to Performance Yes 15.5
2021 [26] setting ABCDE scheme (e.g. airway, breathing, circu-
Med. and nurs. (146) lation, disability, environment, document the
observations. (Multi-player)
Chao et al., 2021 [39] Not specified MK 360° Video; MCQ: Nasogastric tube feeding Knowledge Yes 15.5
Nurs. (22)
Chou et al., 2023 [38] Not specified IC Clinical scenario: Nurse-patient commu- Performance Yes 13.5
Nurs. (42) nication: self-introduction, nurse–patient
relationship establishment, interaction, and
medical history collection
Feeley et al., 2022 (Orthopedic) PC Procedure: Total knee replacement Performance Yes 13.5
[27] Surgery
Med. (28)
Hollister et al., 2022 Genetics MK, IC Clinical scenario: Responding to patient’s Performance No 15.5
[44] medical concerns and questions (e.g.
Med. (81) explanation of genetic test results, causes of
fatigue); verbal reflections
Jacobs et al., 2023 Emergency PC, MK Clinical scenario: Sepsis identification and Performance Yes 10
[28] setting management
Med. (14)
Knudsen et al., 2023 Emergency MK 360° videos: 5 emergency medicine scenari- Competence Unclear 12.5
[30] setting os; MCQ: e.g. Procedure– what to do next
Med. (59)
Lau et al., 2023 [37] Not specified PC Skill: subcutaneous injection and intrave- Performance Yes 8
Nurs. (29) nous therapy
Lee et al., 2020 [36] Mental health MK, IC 360° videos: 5 schizophrenia scenarios; Quiz: Competence Unclear 9
Nurs. (60) (schizophrenia) adequate scenario-based reaction (e.g.
identify harmful objects)
Lietz et al., 2023 [11] Pediatric emer- PC, IC Clinical scenario: Management of a pediatric Performance Yes 14.5
Med. (35) gency setting patient with hypovolemic shock; communi-
cation with mother / assistant
Mahling et al., 2023 Emergency PC, IC Clinical scenario: 4 emergencies (e.g. per- Performance Yes 11
[29] setting forming examinations, lab tests, adequate
Med. (129) communication with VP/support staff )
Mansoory et al., 2021 Emergency MK MCQ: Coma (e.g. provide initial diagnosis– Knowledge Unclear 11.5
[35] setting Glasgow coma scale)
Med. (50)
Park & Kim, 2023 [34] (Prehospital) PC Clinical scenario: perform first triage in a Performance Unclear 9
Nurs. (30) Emergency mass casualty incident (20 casualties)
setting
Perron et al., 2021 Pediatric emer- PC, MK Clinical scenario: Pediatric cardiopulmonary Performance Unclear 8
[47] gency setting resuscitation (e.g. check for a response,
Med. (23) performing adequate chest compressions
and defibrillation)
Neher et al. BMC Medical Education (2025) 25:292 Page 6 of 11

Table 1 (continued)
Author, year Setting Competencies Task Taxonomic Auto- MERSQI
Students (n in VR) level* mated
yes/no
Siah et al., 2022 [33] Perioperative MK Clinical scenario: Handling in/with sterile Competence Yes 9.5
Nurs. (207) setting environment and sharp instruments (e.g.
passing of sterile instruments; management
of sharps injury); Quiz
Smith et al., 2021 [43] Disaster MK Skill: decontamination (e.g. donning appro- Knowledge Yes 12.5
Nurs. (61) education priate PPE, decontaminating patient); MCQ
Traister, 2023 [42] Mental health IC Clinical scenario: Communication with Performance Yes 13
Nurs. (33) (Anxiety) anxious patient (e.g. determining the cause
of patient’s acute anxiety, therapeutic com-
munication techniques)
Wan et al., 2024 [32] (Maxillofacial) PC Procedure: Bimaxillary orthognathic surgery Performance Yes 14.5
Med. (20) Surgery
Wilson et al., 2017 Ophthalmology PC, MK Skill: Performing retinal examination; MCQ: Performance Yes 7
[23] identify abnormalities in images
Med. (15)
Wu et al., 2022 [31] Pediatric emer- PC, MK, IC Clinical scenario: Managing pediatric seizure Performance Yes 14.5
Nurs. (53) gency setting (e.g. check vital sign, provide family educa-
tion); MCQ: select correct seizure type
Zackoff et al., 2020 Pediatric emer- PC, MK, IC Clinical scenario: Managing pediatric bron- Performance No 14.5
[40] gency setting chiolitis in three simulations (1) no distress,
Med. (78) (2) respiratory distress, (3) impending respira-
tory failure
Zackoff et al., 2021 Pediatric emer- PC, MK, IC Clinical scenario: Managing pediatric viral Performance No 12.5
[41] gency setting bronchiolitis (e.g. clinical assessment and
Med. (26) examination, therapeutic steps)
Note. Med.: medical; Nurs.: nursing; VR: Virtual Reality; MERSQI: Medical Education Research Study Quality Instrument; IC: Interpersonal and Communication Skills;
PC: Patient Care; MK: Medical Knowledge; ABCDE: Airway, Breathing, Circulation, Disability, Exposure; MCQ: multiple choice questions; VP: virtual patient; PPE:
personal protective equipment
*According to Miller [22]

Fig. 2 Summary of results: Settings, competencies and taxonomic levels. On the left, a pie chart illustrates the distribution of study settings. In the center,
the Accreditation Council for Graduate Medical Education (ACGME) competencies are presented, with the size of the bars indicating the frequency with
which each competency was assessed. On the right, a pyramid diagram displays the taxonomic levels, with the shape and size reflecting the frequency
of their application. Additionally, examples of tasks associated with each competency are provided, as well as examples of how the different taxonomic
levels were applied in the studies

45, 46]. However, participation in these studies was vol- Practical considerations
untary, suggesting formative assessment. A detailed over- Two different ways were used to implement VR: in 17
view of the key findings from the chapters on settings studies (65%) as an automated and independent assess-
and competencies, and taxonomic levels, can be found in ment tool, meaning it performed the evaluation without
Fig. 2. human intervention [11, 23–29, 31–33, 37–39, 42, 43,
46], and four times (15%) as a supporting assessment tool
[40, 41, 44, 45], where the assessment took place in VR
Neher et al. BMC Medical Education (2025) 25:292 Page 7 of 11

but the evaluation was carried out by human examiners voice recognition [31]. Two studies (8%) explicitly men-
instead (see Table 1). This could not be determined in tioned implementing haptic feedback through vibration
the other studies, as it was not clearly described whether in hand controllers, allowing users to feel the pulse on the
the evaluation was conducted by the VR system itself or wrist and respiratory intake, when placing the hand on
by an external examiner. An example of a VR automated the chest [25, 26]. This feedback might have been present
assessment is described by Traister, the software used in other studies but was not explicitly described.
a dashboard that provides feedback ranging from 0 to All studies except for three (12%) mentioned a form of
100%, showing the individual’s average score, percent- VR-tutorial or orientation in VR [35, 40, 47]. The intro-
ages related to skill performance across technical skills, ductions to the VR experiences showed a lot of variation,
communication, teamwork, and timing [42]. The calcu- from verbal instructions, slideshows, pre-recorded videos
lation method for the feedback was not always explicitly or tutorials directly in VR. One study further described
described. When VR was used as a supporting tool, the that they explained cybersickness and safety manage-
VR scenarios were evaluated by an external evaluator ment purposes [34].
either directly or via recording and transcription using a Technical challenges were scarcely reported, but sev-
checklist. eral studies noted that an assistant supervised the VR
Regarding hardware, five studies (19%) did not specify simulation to intervene in case of potential technical
the HMDs used [27, 33–35, 42], 14 studies (54%) utilized issues. Some studies have also investigated potential side
Oculus (Meta, California, United States of America) [11, effects of VR. Three studies (12%) indicated no to mini-
25, 26, 28–31, 36, 37, 40, 41, 43, 46, 47] and six (23%) used mal side effects such as cybersickness [31, 38, 39], while
HTC devices (HTC Corporation, Taoyuan City, Taiwan) two (8%) mentioned that cybersickness and physical dis-
[24, 32, 38, 39, 44, 45]. In the oldest study two HMDs comfort occurred, but did not specify their severity [29,
were used, both requiring a smartphone for functionality 37]. The side effect reported the most appeared to be diz-
[23]. Subsequent studies utilized all-in-one HMDs, elimi- ziness. Additionally, specific exclusion criteria were men-
nating the need for smartphones or laptops. The neces- tioned (e.g. epilepsy, vestibular disorders, pregnancy, or
sity of an external computer with all-in-one HMDs varied adverse effects such as nausea after using VR equipment)
based on the software. Three studies (12%) mentioned [29, 31, 33, 38, 39, 44].
the use of gaming laptops [24, 29, 47], while others did
not report or utilize them. For additional analyses, one Discussion
study incorporated eye trackers [45]. This systematic review outlines a variety of VR assess-
The software used in most studies was custom-made, ments used in nursing and medical undergraduate educa-
while six (23%) utilized commercially available options: tion across different settings, mainly in situation that are
VR USGIVA 1.0 (VitaSim, Odense, Denmark) [24], Gog- difficult to replicate such as (pediatric) emergencies. The
glemind Ltd (Cardiff, UK) [30], Precision OS virtual real- studies focused on core competencies, including Patient
ity platform (Vancouver, Canada) [27] and three used the Care, Interpersonal and Communication Skills, and Med-
Oxford Medical Simulation Ltd. (London, UK) [29, 42, ical Knowledge. Taxonomic levels ranged from knowledge
46]. It is assumed that studies not specifying the software (Knows) to performance (Shows how). Additionally, the
used custom-developed software, as commercial soft- review sheds light on the practical considerations sur-
ware would likely be mentioned. However, this remains rounding VR implementation, including hardware and
uncertain. Four studies (15%) utilized 360-degree videos, software variations.
integrating them with interactive elements like multiple- Assessments using VR were primarily employed in sit-
choice questions [30, 36, 39, 45]. See Additional File 4 for uations that are difficult to replicate in real life. This phe-
more information about hardware and software. nomenon is also observed in VR training, highlighting a
In studies focusing on clinical scenarios, virtual patient significant advantage of VR technology [10]. Competen-
(VP) avatars were utilized. Berg and Steinsbekk described cies such as Practice-based Learning and Improvement,
the VP’s visual responses such as eye blinking, head Professionalism, and Systems-based Practice were either
movement, and mouth opening and closing [26]. Addi- not assessed or not explicitly addressed in the included
tionally, dynamic clinical parameters such as blood pres- studies. Assessment should cover all aspects of medical
sure, temperature, and oxygen saturation were simulated. competence. It is acknowledged that competencies such
However, these avatars did not provide vocal responses. as Systems-based Practice are less effectively captured
The VP’s in other studies were capable of communica- using conventional methods too [21]. One study implied,
tion; Interaction with these patients was facilitated, for but did not explicitly assess, Professionalism and System-
instance, through clicking on voice commands [28, 37], based Practice related to different races and genetic test
prerecorded answers prompted by the research assistant reports [44]. Similarly, other studies trained empathy,
[44], or Microsoft Azure (Washington, United States) which could also be considered part of Professionalism,
Neher et al. BMC Medical Education (2025) 25:292 Page 8 of 11

but did not explicitly test it through VR [48]. Therefore, However, commercially available software may be costly
it is worth exploring the extent to which VR can address and lack customization. Creating custom software can
this issue. also be time-consuming, resource-intensive, and expen-
Apart from action, all other taxonomic levels can be sive [58, 59]. Additionally, integrating sophisticated VR
tested in VR. Although one may argue that VR can sim- software alone does not guarantee successful assessment;
ulate high-fidelity clinical scenarios that approximate validity must be carefully considered. The potential of
action to some extent, it would need to assess perfor- VR assessment remains underutilized when, for exam-
mance in real practice rather than in a simulated environ- ple, complex VR scenarios are designed where learners
ment to fully align with Miller’s concept of action, which engage in detailed action sequences, only to be assessed
refers specifically to work-based assessments [22, 49]. It at the end by answering a single multiple-choice question
is notable that some studies conducted VR assessments with a controller click. Simply integrating new technol-
below performance level, although the obvious potential ogy into a training program does not inherently enhance
lies there. This may be due to initial testing purposes, its value; instead, it is crucial to ensure that the technol-
with less attention paid to the pedagogical implications. ogy is thoughtfully integrated into a comprehensive ped-
For further use it should be considered whether the agogical strategy. Close collaboration between clinicians,
effort required to implement MCQs in VR, which can be medical educators and software engineers during devel-
tested in written form, justifies their use in VR [50, 51]. opment is critical to ensure effective assessment tools [6].
Additionally, it is important to determine which learning Technical issues were rarely reported, but having per-
objectives should be assessed in VR and train accordingly sonnel available to address them seems crucial [60].
to achieve alignment between learning objectives, teach- Nearly all studies mentioned introducing students to VR,
ing, and assessment [52, 53]. which is essential, especially for assessments, to ensure
Although some studies have described the integration performance issues are not attributed to unfamiliarity
of VR into the curriculum (e.g [29]), assessments are with the system. Additionally, consideration should be
likely to have remained formative due to the study set- given to exclusion criteria, such as how to accommodate
ting, primarily serving training purposes. Unfortunately, such students especially in summative assessments [61].
little was discussed regarding feasibility, as implement-
ing VR for an entire cohort differs significantly from just Strengths and weaknesses of this review
a limited number of study participants. However, one The role of VR, especially as an assessment tool, is an
study recently integrated VR into an exam for one cohort emerging field covered in this review. The search strategy
and demonstrated its feasibility, both technically and was developed and validated by a specialized librarian,
organizationally, suggesting that such an implementation and the review was conducted with methodological rigor.
could be possible [54]. Additionally, it has an interprofessional author team that
One of the advantages of VR is the automated assess- includes experts from medical education. Categorizing
ment, where the system directly evaluates performance, competencies and assessment methods was occasionally
a concept already applied in the field of surgery [16]. In challenging due to vague descriptions in some studies,
the context of undergraduate studies, automated assess- likely because assessment was not their primary focus.
ment could be employed in the OSCE, addressing the sig- To ensure a comprehensive overview, we included studies
nificant personal demands on clinicians and the intense regardless of whether VR assessments were used as out-
mental effort required of examiners. The implementa- come measures. This approach was chosen to avoid limit-
tion of automated VR assessment could also facilitate the ing the scope to a small number of studies and to better
attainment of objectivity [55, 56]. Tasks, such as accu- align with our aim of capturing the diverse ways in which
rately auscultating the lungs or appropriately selecting VR can be utilized. By doing so, we aimed to highlight the
laboratory results, could be automatically evaluated and broad potential of VR beyond its role as a tool for mea-
marked off by the VR software based on a predefined suring outcomes.
OSCE checklist. This would enable examiners to allocate
their cognitive resources more effectively, allowing them Conclusion and future directions
to focus on higher-order skills, such as communication. This review provides insight into using VR for assess-
The objectivity that automated VR assessments could ment, especially in situations that are difficult to replicate
offer may also benefit students by providing consistent like emergencies. The primary focus of VR assessments is
feedback that is not subject to examiner variability. How- on core competencies such as Patient Care, Interpersonal
ever, it is important to note that students might be skep- Communication, and Medical Knowledge, with a focus
tical about the reliability of such assessments [57]. on performance-level tasks. While VR shows promise in
In recent years, HMDs have undergone significant automating assessments and reducing examiner cognitive
advancements and are now more affordable to purchase. load, there are many technical details such as software,
Neher et al. BMC Medical Education (2025) 25:292 Page 9 of 11

Data availability
costs and feasibility to consider. To maximize its effec- No datasets were generated or analysed during the current study.
tiveness as an educational and evaluative tool, it is crucial
that VR assessments align with learning objectives and Declarations
teaching methods, guided by the principles of construc- This systematic review was registered in PROSPERO (CRD42023490861) and
tive alignment. Automated assessments also hold signifi- utilized the MERSQI Tool instead of the Cochrane Risk-of-Bias-Tool (as initially
registered) for assessing data quality due to the inclusion of a wide range of
cant promise from a practical perspective. A challenge study designs.
in practical exams, such as OSCEs, is the burden placed
on examiners. Future research should explore the poten- Ethics approval and consent to participate
Not applicable.
tial of VR to enable objective, automated assessments.
Additionally, it is essential to investigate how VR assess- Consent for publication
ments can be seamlessly integrated into existing cur- Not applicable.

ricula. Research should also examine the feasibility and Competing interests
cost-effectiveness of scaling VR assessments for larger TCS holds the endowed professorship of emergency telemedicine at the
cohorts. Finally, exploring the integration of VR with University of Bern sponsored by the Touring Club Switzerland. The sponsor
has no influence on the research or decision to publish. All other authors have
advanced technologies, such as Artificial Intelligence, nothing to disclose.
could open new possibilities for enhancing automation
and personalizing assessments to individual learners. Received: 27 June 2024 / Accepted: 12 February 2025

Abbreviations
ABCDE Airway, Breathing, Circulation, Disability, Exposure
ACGME Accreditation Council for Graduate Medical Education
HMD Head-mounted Display References
IC Interpersonal and Communication Skills 1. Farra SL, Smith SJ, Ulrich DL. The student experience with varying immersion
MCQ Multiple Choice Questions levels of virtual reality simulation. Nurs Educ Perspect. 2018;39(2):99.
Med Medical 2. Kardong-Edgren S (Suzie), Farra SL, Alinier G, Young HM, editors. A call to
MK Medical Knowledge unify definitions of virtual reality. Clin Simul Nurs. 2019;31:28–34.
Nurs Nursing 3. Banerjee S, Pham T, Eastaway A, Auffermann WF, Quigley EP III. The use of
OSCE Objective Structured Clinical Examination virtual reality in teaching three-dimensional anatomy and pathology on CT. J
PC Patient Care Digit Imaging. 2023;36(3):1279–84.
PPE Personal Protective Equipment 4. Birrenbach T, Zbinden J, Papagiannakis G, Exadaktylos AK, Müller M, Hautz WE
PRISMA Preferred Reporting Items for Systematic Review and et al. Effectiveness and utility of virtual reality simulation as an educational
Meta-Analysis tool for safe performance of COVID-19 diagnostics: prospective, randomized
VP Virtual Patient pilot trial. JMIR Serious Games. 2021;9(4).
VR Virtual Reality 5. Birrenbach T, Wespi R, Hautz WE, Berger J, Schwab PR, Papagiannakis G, et
al. Development and usability testing of a fully immersive VR simulation for
REBOA training. Int J Emerg Med. 2023;16(1):67.
Supplementary Information 6. Rickenbacher-Frey S, Adam S, Exadaktylos AK, Müller M, Sauter TC, Birrenbach
The online version contains supplementary material available at ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​ T. Development and evaluation of a virtual reality training for emergency
g​/​​1​0​.​​1​1​8​6​​/​s​​1​2​9​0​9​-​0​2​5​-​0​6​8​6​7​-​8. treatment of shortness of breath based on frameworks for serious games.
GMS J Med Educ. 2023;40(2).
Supplementary Material 1: Additional File 1: Search Terms for each data- 7. Abbas JR, Chu MMH, Jeyarajah C, Isba R, Payton A, McGrath B, et al. Virtual
base. reality in simulation-based emergency skills training: a systematic review with
a narrative synthesis. Resusc Plus. 2023;16:100484.
Supplementary Material 2: Additional File 2: Comprehensive justifications 8. Kim HY, Kim EY. Effects of medical education program using virtual reality:
for study inclusion in the systematic review. a systematic review and meta-analysis. Int J Environ Res Public Health.
2023;20(5).
Supplementary Material 3: Additional File 3: MERSQI Scores for each study.
9. Mills B, Dykstra P, Hansen S, Miles A, Rankin T, Hopper L, et al. Virtual reality
Supplementary Material 4: Additional File 4: Overview of used hardware triage training can provide comparable simulation efficacy for paramedicine
and software. students compared to live simulation-based scenarios. Prehosp Emerg Care.
2020;24(4):525–36.
10. Han S, Kim Y, Kong T, Cho J. Virtual reality-based neurological examination
Acknowledgements teaching tool (VRNET) versus standardized patient in teaching neurological
We thank Tania Rivero, medical information specialist at the medical library of examinations for the medical students: a randomized, single-blind study.
the University of Bern, for her support with the systematic literature search. BMC Med Educ. 2021;21(1):493.
11. Lietz A, Kraller J, Hoffelner A, Ritschl V, Berger A, Wagner M. Dose–response of
Author contributions virtual reality training of paediatric emergencies in a randomised simulation-
Study design and conception: ANN, MM, CB, TCS, TB; Search & study selection: based setting. Acta Paediatr. 2023;112(9).
ANN, FB; Data extraction: ANN, FB; Quality assessment: ANN, FB; Data 12. Orser BA, Spadafora SM. Competence-based training and immersion virtual
Interpretation: ANN, FB, CB, TCS, TB; Drafting the manuscript: ANN; Critical reality: paradigm-shifting advances in medical education. Anesth Analg.
revision: ANN, FB, MM, CB, TCS, TB. All authors approved the submitted version. 2022;135(2):220–2.
13. Choi J, Thompson CE, Choi J, Waddill CB, Choi S. Effectiveness of immersive
Funding virtual reality in nursing education: systematic review. Nurse Educ. 2022;47(3).
This study did not receive direct financial support. However, it is associated 14. Saredakis D, Szpak A, Birckhead B, Keage HAD, Rizzo A, Loetscher T. Factors
with a larger project called “Viva VOsCE”, which is funded by Innosuisse. associated with virtual reality sickness in head-mounted displays: a system-
atic review and meta-analysis. Front Hum Neurosci. 2020;14:96.
Neher et al. BMC Medical Education (2025) 25:292 Page 10 of 11

15. Al-Ansi AM, Jaboob M, Garad A, Al-Ansi A. Analyzing augmented reality (AR) 38. Chou CH, Tai HC, Chen SL. The effects of introducing virtual reality com-
and virtual reality (VR) recent development in education. Soc Sci Humanit munication simulation in students’ learning in a fundamentals of nurs-
Open. 2023;8(1):100532. ing practicum: a pragmatic randomized control trials. Nurse Educ Pract.
16. Guerin S, Huaulmé A, Lavoue V, Jannin P, Timoh KN. Review of automated 2023;74:103837.
performance metrics to assess surgical technical skills in robot-assisted 39. Chao YC, Hu SH, Chiu HY, Huang PH, Tsai HT, Chuang YH. The effects of an
laparoscopy. Surg Endosc. 2022;36(2):853–70. immersive 3d interactive video program on improving student nurses’ nurs-
17. Lu Y, Ota K, Dong M. An empirical study of VR Head-mounted displays based ing skill competence: a randomized controlled trial study. Nurse Educ Today.
on VR games Reviews. Games Res Pract. 2024;2(3):1–20. 2021;103:104979.
18. Cook DA, Reed DA. Appraising the quality of medical education research 40. Zackoff MW, Real FJ, Sahay RD, Fei L, Guiot A, Lehmann C, et al. Impact of an
methods: the Medical Education Research Study Quality Instrument and immersive virtual reality curriculum on medical students’ clinical assessment
the Newcastle-Ottawa Scale-Education. Acad Med J Assoc Am Med Coll. of infants with respiratory distress. Pediatr Crit Care Med. 2020;21(5):477–85.
2015;90(8):1067–76. 41. Zackoff MW, Young D, Sahay RD, Fei L, Real FJ, Guiot A, et al. Establishing
19. Goldenberg MG, Garbens A, Szasz P, Hauer T, Grantcharov TP. Systematic objective measures of clinical competence in undergraduate medical educa-
review to establish absolute standards for technical performance in surgery. tion through immersive virtual reality. Acad Pediatr. 2021;21(3):575–9.
Br J Surg. 2017;104(1):13–21. 42. Traister TAA. Virtual reality simulation’s influence on nursing students’ anxiety
20. Gordon M. Are we talking the same paradigm? Considering methodological and communication skills with anxious patients: a pilot study. Clin Simul
choices in health education systematic review. Med Teach. 2016;38(7):746–50. Nurs. 2023;82:101433.
21. Holmboe ES, Iobst WF. ACGME Assessment Guidebook [Internet]. 2020. Avail- 43. Smith S, Farra S, Hodgson E. Evaluation of two simulation methods for teach-
able from: ​h​t​t​p​s​:​​​/​​/​w​w​​w​.​​a​c​g​​m​​e​.​​o​​r​g​​/​m​​i​l​e​s​t​o​n​​e​s​/​r​e​s​o​u​r​c​e​s ing a disaster skill. BMJ Simul Technol Enhanc Learn. 2021;7(2):92–6.
22. Miller GE. The assessment of clinical skills/competence/performance. Acad 44. Hollister B, Schopp E, Telaak S, Buscetta A, Dolwick A, Fortney C, et al.
Med. 1990;65(9):S63–7. Educational considerations based on medical student use of polygenic risk
23. Wilson AS, O’Connor J, Taylor L, Carruthers D. A 3D virtual reality ophthalmos- information and apparent race in a simulated consultation. Genet Med.
copy trainer. Clin Teach. 2017;14(6):427–31. 2022;24(11):2389–98.
24. Andersen NL, Jensen RO, Posth S, Laursen CB, Jørgensen R, Graumann 45. Anbro SJ, Szarko AJ, Houmanfar RA, Maraccini AM, Crosswell LH, Harris FC et
O. Teaching ultrasound-guided peripheral venous catheter placement al. Using virtual simulations to assess situational awareness and communica-
through immersive virtual reality: an explorative pilot study. Med (Baltim). tion in medical and nursing education: a technical feasibility study. J Organ
2021;100(27):1–7. Behav Manag. 2020;40(1–2):129–39.
25. Berg H, Steinsbekk A. Is individual practice in an immersive and interactive 46. Azher S, Cervantes A, Marchionni C, Grewal K, Marchand H, Harley JM.
virtual reality application non-inferior to practicing with traditional equip- Virtual simulation in nursing education: Headset virtual reality and screen-
ment in learning systematic clinical observation? A randomized controlled based virtual simulation offer a comparable experience. Clin Simul Nurs.
trial. BMC Med Educ. 2020;20(1):123. 2023;79:61–74.
26. Berg H, Steinsbekk A. The effect of self-practicing systematic clinical observa- 47. Perron JE, Coffey MJ, Lovell-Simons A, Dominguez L, King ME, Ooi CY. Resusci-
tions in a multiplayer, immersive, interactive virtual reality application versus tating cardiopulmonary resuscitation training in a virtual reality: prospective
physical equipment: a randomized controlled trial. Adv Health Sci Educ. interventional study. J Med Internet Res. 2021;23(7).
2021;26(2):667–82. 48. Barteit S, Lanfermann L, Bärnighausen T, Neuhann F, Beiersmann C. Aug-
27. Feeley A, Feeley I, Lee M, Merghani K, Sheehan E. The specialty mentor effect mented, mixed, and virtual reality-based head-mounted devices for medical
in enhancing surgical experience of medical students: a randomised control education: systematic review. JMIR Serious Games. 2021;9(3).
trial. Surg Elsevier Sci. 2022;20(6):383–8. 49. Norcini JJ. Work based assessment. BMJ. 2003;326(7392):753–5.
28. Jacobs C, Vaidya K, Medwell L, Old T, Joiner R. Case study of virtual reality 50. Curran VR, Xu X, Aydin MY, Meruvia-Pastor O. Use of extended reality in medi-
sepsis management- instructional design and ITEM outcomes. J Vis Commun cal education: an integrative review. Med Sci Educ. 2022;33(1):275–86.
Med. 2023;46(3):168–77. 51. Plotzky C, Lindwedel U, Sorber M, Loessl B, König P, Kunze C et al. Virtual real-
29. Mahling M, Wunderlich R, Steiner D, Gorgati E, Festl-Wietek T, Herrmann- ity simulations in nurse education: a systematic mapping review. Nurse Educ
Werner A. Virtual reality for emergency medicine training in medical school: Today. 2021;101:104868.
prospective, large-cohort implementation study. J Med Internet Res. 52. Davis MH, Harden RM. Competency-based assessment: making it a reality.
2023;25:e43649. Med Teach. 2003;25(6):565–8.
30. Knudsen MH, Breindahl N, Dalsgaard TS, Isbye D, Mølbak AG, Tiwald G et al. 53. Ross S, Hauer KE, Wycliffe-Jones K, Hall AK, Molgaard L, Richardson D, et al.
Using virtual reality head-mounted displays to assess skills in emergency Key considerations in planning and designing programmatic assessment in
medicine: Validity study. J Med Internet Res. 2023;25:e45210. competency-based medical education. Med Teach. 2021;43(7):758–64.
31. Wu ML, Chao LF, Xiao X. A pediatric seizure management virtual reality simu- 54. Mühling T, Schreiner V, Appel M, Leutritz T, König S. Comparing virtual real-
lator for nursing students: a quasi-experimental design. Nurse Educ Today. ity–based and traditional physical objective structured clinical examination
2022;119:105550. (OSCE) stations for clinical competency assessments: Randomized controlled
32. Wan T, Liu K, Li B, Wang X. Effectiveness of immersive virtual reality in trial. J Med Internet Res. 2025;27:e55066.
orthognathic surgical education: a randomized controlled trial. J Dent Educ. 55. Malau-Aduli BS, Hays RB, D’Souza K, Smith AM, Jones K, Turner R, et al. Exam-
2024;88(1):109–17. iners’ decision‐making processes in observation‐based clinical examinations.
33. Siah RCJ, Xu P, Teh CL, Kow AWC. Evaluation of nursing students’ efficacy, Med Educ. 2021;55(3):344–53.
attitude, and confidence level in a perioperative setting using virtual-reality 56. Rodríguez-Matesanz M, Guzmán-García C, Oropesa I, Rubio-Bolivar J,
simulation. Nurs Forum (Auckl). 2022;57(6):1249–57. Quintana-Díaz M, Sánchez-González P. A new immersive virtual reality station
34. Park SK, Kim HJ. Development and evaluation of virtual reality-based simula- for cardiopulmonary resuscitation objective structured clinical exam evalua-
tion content for nursing students regarding emergency triage. J Korean Acad tion. Sensors. 2022;22(13):4913.
Fundam Nurs. 2023;30(2):292–301. 57. Walter S, Speidel R, Hann A, Leitner J, Jerg-Bretzke L, Kropp P, et al. Skepticism
35. Mansoory M, Khazaei M, Azizi S, Niromand E. Comparison of the effectiveness towards advancing VR technology - student acceptance of VR as a teaching
of lecture instruction and virtual reality-based serious gaming instruction on and assessment tool in medicine. GMS J Med Educ. 2021;38(6):Doc100.
the medical students’ learning outcome about approach to coma. BMC Med 58. Farra SL, Gneuhs M, Hodgson E, Kawosa B, Miller ET, Simon A, et al. Compara-
Educ. 2021;21(1):347. tive cost of virtual reality training and live exercises for training hospital
36. Lee Y, Kim SK, Eom MR. Usability of mental illness simulation involving sce- workers for evacuation. Comput Inf Nurs. 2019;37(9):446–54.
narios with patients with schizophrenia via immersive virtual reality: a mixed 59. Coyne E, Calleja P, Forster E, Lin F. A review of virtual-simulation for assessing
methods study. PLoS ONE. 2020;15(9). healthcare students’ clinical competency. Nurse Educ Today. 2021;96:104623.
37. Lau ST, Siah RCJ, Dzakirin Bin Rusli K, Loh WL, Yap JYG, Ang E et al. Design 60. Elston P, Canale GP, Ail G, Fisher N, Mahendran M. Twelve tips for teaching in
and evaluation of using head-mounted virtual reality for learning clinical virtual reality. Med Teach. 2024;46(4):495–9.
procedures: mixed methods study. JMIR Serious Games. 2023;11.
Neher et al. BMC Medical Education (2025) 25:292 Page 11 of 11

61. Cao Y, Ng GW, Ye SS. Design and evaluation for immersive virtual real-
ity learning environment: a systematic literature review. Sustainability. Publisher’s note
2023;15(3):1964. Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.