The use of portable simulation technology in complex medical units for nursing and medical staff: Scoping review

Most studies were conducted in the United States (n = 18) and South Korea (n = 11). Seven studies were undertaken in Taiwan, seven in China, and four in Canada. The remaining studies were distributed across Europe, including Germany (n = 2), the United Kingdom (n = 2), Sweden (n = 2), Italy (n = 1), France (n = 1), South Africa (n = 1), Saudi Arabia (n = 1), Iran (n = 1), Singapore (n = 1), Singapore and Malaysia (n = 1), Israel (n = 1), Colombia (n = 1), Australia (n = 1), and Japan (n = 2), demonstrating broad international interest in portable simulation-based education.

Study designs were heterogeneous and included randomized controlled trials (n = 16), quasi-experimental (n = 13), mixed-methods (n = 9), and pre-post-test studies (n = 8). The remaining studies included qualitative (n = 5), quantitative (n = 4), descriptive (n = 2), framework-based design (n = 4), cohort study (n = 1), post-test observation (n = 1), time-series, prospective pilot study (n = 1), and non-randomized controlled design (n = 1).

Across the 65 included studies, the majority focused on nurses, who were the primary population in 37 studies. Physicians were the sole participants in 4 studies. The remaining 24 studies involved mixed healthcare professional groups, including combinations of nurses, physicians, nursing assistants, nurse practitioners, pharmacists, medical trainees, allied health professionals, and students. Overall, participants represented a broad spectrum of healthcare roles, with nurses being the most frequently studied group (see Appendix 2).

Among the 65 included studies, VR-only simulations were the most frequent education medium (n = 21), followed by hybrid simulations (n = 11). Traditional low- and high-fidelity simulations (n = 4) were described, utilizing manikins and task trainers to support hands-on practice. Other mediums included computer-based simulations (n = 6), web-based simulations (n = 5), game-based or mobile simulations (n = 5), AR-only simulations (n = 4), virtual patient simulations (non-VR, non-game) (n = 3), mobile or travelling simulation carts (n = 2), and other educational interventions and learning mediums (n = 4).

Most VR (n = 19),^{[15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]} computer-based/web-based (n = 11),^{[34,35,36,37,38,39,40,41,42,43,44]} game-based and mobile (n = 5),^{[45,46,47,48,49]} and virtual patient simulations (n = 3)^[50,51,52] were fully portable and usable across multiple learning environments. Some VR simulations were semi- or potentially portable due to manikin integration or PC-tethering (n = 2).^{[53, 54]} Of 11 hybrid simulations,^{[55,56,57,58,59,60,61,62,63,64,65]} seven were fully portable,^{[55,56,57,58,59,60,61]} one was semi-portable due to blended online and hands-on training,^[62] and three were portable but required significant set-up due to physical and mechanical components.^[63,64,65] All AR simulations (n = 4) were portable, using standalone headsets or mobile devices.^{[66,67,68,69]}

High-fidelity simulations varied: two were portable^{[70, 71]} and deployable on laptops with task trainers, while two were portable but required significant set-up considerations due to reliance on manikins and specific hospital environment requirements.^{[72, 73]} Some structured interventions required significant set-up (n = 3).^[74,75,76] These included high-fidelity manikins and unit-based simulation setups, though one study promoted portability, combining high-fidelity, virtual, and case-based simulations.^[77] Mobile carts and in situ models (n = 2) were fully transportable, enabling context-specific clinical training.^{[78, 79]}

1) Virtual Reality Simulation

VR offers an immersive, computer-generated environment that supports experiential learning and reflective practice 12. Across the studies, VR simulations were frequently described as engaging, realistic, and acceptable to healthcare learners, with reported benefits across cognitive and affective learning domains. For instance, Kai et al.^[23] reported that VR simulation enhanced understanding of clinical procedures, while Gillespie et al.^[19] found that VR facilitated better understanding of the social determinants of health and patient complexity. Similarly, Beverly et al.^[15] reported increased awareness of disability-related discrimination and improved confidence in recognizing and reporting abuse. Forgiarini et al.^[18] found VR simulation engaging, challenging, and useful for improving self-confidence, though participants required time to adapt to the technology. In a quasi-experimental study, Kim et al.^[24] observed significant improvements in knowledge, self-efficacy, and learning satisfaction in the VR group compared with conventional learning. Comparable results were reported by Rowlands et al.,^[27] Jeon et al.,^[21] and Gunther et al.,^[20] who identified enhanced motivation, empathy, and performance following VR-based interventions. Other studies noted improvements in diagnostic performance, dementia–care practices, clinical reasoning, and learner confidence.^{[17, 30, 31, 54]} Learner satisfaction was consistently high,^{[25, 53]} although some studies highlighted limitations such as headset discomfort, technological adaptation,^[28] and preferences for blended approaches combining VR with in-person training.^[33] Jung et al.^[22] observed improved knowledge, self-efficacy, and perceptions of accessibility. Similarly, Chiang et al.^[16] demonstrated that VR training materials substantially improve trainees’ self-efficacy by boosting their familiarity, confidence, and comfort, while increasing satisfaction with the learning experience and motivating them to apply the skills and knowledge in clinical practice. Notably, Zhang et al.^[32] found no significant differences in theoretical or performance scores compared with traditional methods; participants still regarded VR as a realistic and safe environment for practice.

Overall, VR simulation has demonstrated strong potential as a flexible educational modality that supports experiential learning, confidence development, and skills application, while acknowledging ongoing technological and implementation challenges.

2) Hybrid Simulations

Hybrid simulations combine two or more simulation modalities, such as manikins, standardized patients, and digital or virtual tools, to create a more comprehensive and realistic learning experience. This blended approach improved both technical and communication skills, bridging the gap between traditional and technology-enhanced learning.^[1] Across studies, hybrid approaches were associated with improvements in technical skills, communication, and clinical performance. For example, Guerrero et al.^[64] reported gains in knowledge and clinical examination performance following combined VR and high-fidelity training, while Hung et al.^[57] observed improvements in attitudes, knowledge-related outcomes, and self-efficacy using integrated VR and AR simulations for oral care education.

Several studies highlighted the adaptability and practicality of hybrid models. Dwyer et al.^[56] described a portable hybrid simulation combining high-fidelity elements with humanistic role-play, which enhanced recognition of patient deterioration in settings without access to simulation centers. Similarly, Huang et al.^[62] and Zhang et al.^[61] reported increased confidence, familiarity with decision-making, and disaster preparedness through blended VR and hands-on training approaches. Reece et al.^[60] demonstrated improvements in teamwork and clinical performance, including a 36.6% reduction in PPE breaches, using VR simulations and standardized patients or manikins.

Other studies reported positive learner perceptions and performance-related outcomes using hybrid delivery, including mobile education programs,^[59] smartphone-based MCI training,^[55] and web-based applications with AR components for end-of-life care education.^[58] In a comparative study, New et al.^[65] found that manikin-based simulation was more realistic and emotionally engaging than VR for hemoptysis management, while Covington et al.^[63] demonstrated improvements in emergency airway management knowledge and self-efficacy following combined online and in-situ simulation.

Overall, hybrid simulations demonstrated versatility across healthcare contexts and were associated with technical, interpersonal, and teamwork-related learning. By combining physical and digital components, hybrid approaches offer adaptable and resource-efficient strategies for clinical education.

3) Computer-based and Web-based Simulations

Computer- and web-based simulations are increasingly used in nursing education to provide safe, interactive, and accessible learning environments, supporting knowledge acquisition, clinical skill development, and decision-making through flexible virtual scenarios.^{[36, 38]} Evidence from the reviewed studies demonstrates positive educational outcomes across multiple domains. For example, Marsack et al.^[36] reported sustained improvements in knowledge and confidence in early sepsis recognition immediately after training and at three-month follow-up, while Parchami et al.^[37] observed higher moral sensitivity in intervention groups two months post-training. Simulation tools such as Urecath^[35] and Visual Blood^[39] were associated with improved confidence, diagnostic accuracy, and performance, alongside high usability and willingness to integrate these tools into practice.

Similarly, web-based interactive simulations demonstrated significant improvements in knowledge, accuracy, compliance, and self-efficacy, as reported by Hung et al.^[40] in personal protective equipment training. Liaw et al.^[42] found enhanced clinical performance and learner satisfaction in acute care education, and Moule et al.^[44] observed increased knowledge in oncology training using virtual patient simulations. During the COVID-19 pandemic, Mastoras et al.^[43] reported that fully online critical care triage simulations improved confidence, knowledge, comfort, and attitudes toward practice. Ko et al.^[41] also demonstrated significant gains in disaster mental health competence, problem-solving, self-leadership, self-efficacy, and motivation following web- and mobile-based training.

Overall, computer- and web-based simulation modalities were consistently associated with positive learning and competency-related outcomes, with effectiveness varying according to learning objectives, technological features, and instructional design.

4) Game-based and Mobile Simulations

Game-based and mobile simulations use interactive digital platforms, including smartphone applications and serious games, to support engagement, self-paced learning, and clinical decision-making.^{[45, 46, 48]} These mediums were associated with improvements in knowledge-related outcomes, confidence, and performance while offering flexible and accessible training options across all studies examining these mediums. Wang et al.^[48] reported improved skill performance and reduced procedural errors following a game-based mobile intervention. Similarly, Albright et al. (2013) observed increases in knowledge, skill, behavioural intent, with participants describing the training as realistic and satisfactory. Wang et al.^[49] found significant improvements in theoretical test scores and procedural performance using a game-based ECMO training application, while Chang et al.^[46] reported enhanced attitudes, communication competence, and decision-making accuracy following smartphone-based virtual simulation. Lim et al.^[47] also demonstrated improved preparedness for nursing delegation after completion of a mobile simulation program.

Overall, game-based and mobile simulations were associated with positive educational outcomes and represent engaging, scalable approaches for delivering clinical education across diverse healthcare settings.

5) Augmented Reality Simulations

AR enhances education by overlaying virtual elements onto the real world, allowing interaction with both physical and digital objects.^[80] AR has been shown to improve the understanding of complex clinical procedures and skills. Leary et al.^[68] found that learners using an AR CPR application demonstrated better engagement and reported more realistic patient presence compared with those using a standard audiovisual manikin. Similarly, Balian et al.^[66] reported that AR-based CPR training was feasible and well-received, while Heo et al.^[67] showed AR effectively guided ventilator setup using holographic prompts. Sun et al.^[69] demonstrated improved nurses’ knowledge and performance in ACLS scenarios through AR applications.

Overall, AR provides flexible, safe, and effective platforms for learning complex procedures, particularly beneficial for remote or resource-limited settings, though challenges such as equipment requirements and cognitive load remain.

6) Virtual Patient (non-VR) Simulations

Virtual simulation is an interactive, computer-based learning approach that presents realistic patient scenarios through mobile devices or desktop browsers. These simulations provide engaging, self-directed learning opportunities that enhance knowledge, clinical reasoning, and technical skills. Studies have shown that virtual simulations effectively build learners’ confidence and competence while supporting the application of theory to practice.^[50,51,52] The flexibility of these simulations allows healthcare providers to engage in training at their own pace and setting, making virtual simulation an efficient, scalable, and accessible tool for ongoing professional development.

7) Low- and high-fidelity Simulations

Low- and high-fidelity simulation modalities have both been used to support clinical training with outcomes varying learning objectives and context.^{[70, 73]} Arnold et al.^[70] found no significant differences in knowledge, confidence, or performance when comparing low-fidelity, computer-based, and full-scale simulations for emergency response training. In contrast, Carpico et al.^[72] reported improved adherence to ACLS algorithms following in-situ resuscitation review training among nursing staff, and Sok et al.^[73] observed increased knowledge and performance and reduced stress using low-fidelity simulation in CPR training. Wang et al.^[71] found that participants trained with high-fidelity simulation demonstrated higher performance scores, fewer medication errors, and better teamwork and communication compared with computer-based simulation. Together, both low- and high-fidelity simulations were associated with improved clinical preparedness, while high-fidelity models offered added value for complex decision-making and team-based skills.

8) Educational Intervention and Learning Modalities

Simulation-based educational interventions can improve clinicians’ competence, confidence, and performance by providing realistic, practice-based learning experiences.^{[75, 76]} Structured interventions consistently demonstrated positive impacts on decision-making, diagnostic skills, and clinical performance. Fernández-Avila et al.^[74] found that focused learning activities enhanced diagnostic reasoning. Luo et al.^[77] reported that interactive, case-based exercises improved clinical judgement in complex scenarios. Page et al.^[76] further showed that simulation-based central-line care training increased competency and reduced bloodstream infection rates. Han et al.^[75] demonstrated improvements in ICU nurses’ self-efficacy and emergency airway management. Together, these studies indicate that well-designed simulation-based interventions effectively strengthen clinical reasoning, decision-making, and patient care outcomes across healthcare settings.^{[74, 77]}

9) Mobile/Travelling Cart Simulations

Portable simulation brings training directly to healthcare providers in their workplace, reducing interruptions to clinical responsibilities and eliminating the need for travel.^{[78, 79]} Using self-contained mobile carts, learners engaged in realistic, hands-on practice across a variety of settings, building technical skills, critical thinking, and confidence while enabling immediate application of knowledge. Studies consistently reported that portable simulation was practical, valuable, and effective for integrating learning into daily practice, improving skills, competence, and self-confidence.^{[78, 79]} This approach provides an adaptable, efficient, and safe model for high-quality clinical education in real-world environments.

10) Thematic Analysis of Portable Simulation-Based Education

The studies found that portable simulation technologies were the main educational method used. Examples include mobile simulation carts, virtual reality platforms, and web-based tools that help with clinical training in different settings. In general, portable simulation helped learners improve their clinical skills by allowing them to practice procedures and decision-making in a safe, low-risk environment.

A consistent theme across the reviewed studies was the improvement of learner confidence and engagement following simulation-based training. Participants often indicated improvements in self-efficacy, clinical task performance, and readiness to engage in patient care. These outcomes were most evident in immersive modalities such as virtual and augmented reality, which provided realistic scenarios that promoted active participation and experiential learning.

Improved clinical reasoning and decision-making were another major theme identified in the literature. Learners across different simulation types demonstrated stronger skills in assessing patients, selecting appropriate interventions, and applying clinical judgment in complex cases. Simulation-based activities enabled participants to practice responding to urgent, high-risk, or infrequently encountered scenarios in a controlled environment, thereby strengthening situational awareness and facilitating the transfer of knowledge to clinical practice.

Accessibility and portability were also identified as important advantages of portable simulation-based education. Unlike traditional simulation centres, portable technologies can be implemented directly within clinical environments, reducing barriers related to scheduling, travel, and access to specialized facilities. This flexibility enables healthcare providers to participate in training closer to the point of care and may support greater participation in continuing professional development activities. In summary, the findings show that portable simulation helps improve professional learning outcomes, such as clinical skills, confidence, and readiness for clinical practice.

Figure 2 summarizes the four major thematic areas identified across the reviewed literature and their contribution to professional learning outcomes in portable simulation-based healthcare education.

Figure 2.

Major Themes Identified in Portable Simulation-Based Education Literature