Effectiveness of extended reality‑based cardiopulmonary resuscitation training for healthcare students: A systematic review

Abstract

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a lifesaving intervention where timely, effective actions improve survival. However, traditional Basic and Advanced Life Support (BLS and ALS) training often lacks realism, limiting preparedness among healthcare students. Extended Reality (XR) technologies, including Virtual, Augmented, and Mixed Reality, offer promising tools to enhance CPR training. The aim is to assess the effects of XR on CPR training outcomes among healthcare students.

METHODOLOGY: Following the Preferred Reporting Items for Systematic Reviews and Meta Analysis Protocols guidelines, PubMed/MEDLINE, EMBASE, CINAHL, Cochrane, Web of Science, and Scopus were searched for randomized controlled trials and quasi experimental studies. Two reviewers independently extracted data, with disagreements resolved by a third. Risk of bias was evaluated using Cochrane ROB 2 and ROBINS I. Due to heterogeneity, findings were synthesized narratively.

RESULTS: Eight studies from six countries were included. Evidence showed mixed outcomes: XR improved confidence and reduced anxiety in Basic Life Support and ALS training, but results on technical performance, including CPR knowledge and quality, were inconsistent. Variability in study design and concerns about bias limited generalizability.

CONCLUSION: XR shows potential as a valuable complement to traditional CPR training, particularly in blended learning approaches aligned with modern pedagogy. However, inconsistent findings highlight the need for standardized assessments, evaluation of long term outcomes, and integration of haptic torso simulators to improve technical skills and clarify XR’s role in resuscitation education.

Introduction

Sudden cardiac arrest (SCA) is responsible for approximately 20% of deaths in North America and Western Europe,[1,2] highlighting the importance of effective cardiopulmonary resuscitation (CPR) in improving survival rates.[3] Despite widespread Basic Life Support(BLS) and Advanced Cardiac Life Support(ACLS) training, SCA remains a leading cause of death, with a resuscitation success rate of around 10%,[4,5] emphasizing the need for improved educational strategies.[6,7]

Healthcare professionals must be skilled in performing CPR promptly, yet studies suggest that CPR proficiency is not always guaranteed after undergraduate education.[8] A common misconception is that healthcare professionals are fully capable of performing CPR after completing undergraduate education.[6] However, global studies have raised concerns about the CPR competencies of medical and healthcare students.[9,10] In Europe, for instance, a lack of BLS courses in medical students’ undergraduate education has been linked to insufficient CPR competencies.[6] Additionally, many students fail to master the necessary knowledge and skills for CPR despite BLS training.[11]

Traditional manikin based CPR training has limitations, including its inability to replicate real life resuscitation scenarios, which reduces confidence in performing CPR.[12] Furthermore, it faces scalability challenges, such as costs and resource constraints related to time, personnel, and equipment.[13] This training method also has drawbacks, such as physical risks to participants and repeatability in training, limiting its effectiveness.[14] Manikin based training struggles to simulate the stress and complexity of real cardiac arrest situations,[7] often emphasizing didactic learning over hands on skill development[15] and failing to provide immediate, objective feedback on CPR quality metrics like compression depth and rate.[7] Additionally, it does not adequately prepare students for the team dynamics of actual resuscitation efforts.[16] As a result, many students experience a deterioration in knowledge and skills within 3 6 months.[7]

In response to these challenges, extended reality (XR) technologies – such as virtual reality (VR), augmented reality (AR), and mixed reality (MR) – have emerged as innovative solutions in medical education, offering immersive, scalable, and cost effective alternatives to traditional training.[17] VR based resuscitation training has proven valuable in compensating for face to face teaching disruptions during the COVID 19 pandemic.[18] Research has shown that VR simulations provide a safe environment for practicing procedural skills and developing soft skills, such as stress management, which are crucial in real life emergencies.[5] The immersive nature of VR also helps users feel actively engaged, similar to real life scenarios, enhancing learning outcomes.[19]

Despite growing interest in XR based CPR training, its effectiveness in enhancing student competence remains insufficiently examined. Existing research has predominantly focused on laypersons or professionals, leaving its effectiveness among healthcare students understudied. Notably, no prior synthesis has systematically evaluated how XR interventions influence key CPR training outcomes within this specific population. This study addresses this gap by presenting the first systematic review dedicated to the use of extended reality (XR) for CPR training among healthcare students. It would consolidate available evidence, outline the reported advantages and limitations of XR based approaches, and identify areas requiring methodological and outcome standardization. By assessing the impact of XR technologies on CPR related competencies in this group, the review offers direction for future research and guidance for educators considering XR enhanced training strategies. If XR proves effective, its adoption may support wider implementation and contribute to the development of a more standardized CPR curriculum. Thus, the objective of this study is to evaluate the effects of extended reality (XR) technologies on CPR training outcomes among healthcare students.

Material and Methods

Study design

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analysis Protocols (PRISMA) guidelines [Supplementary Table 1].[20] For transparency and completeness, the details of the protocol for the study were registered in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42024528709 on April 19, 2024.

Data collection

Literature searches were conducted in PubMed/ MEDLINE, EMBASE, CINAHL, Cochrane, Web of Science, and Scopus. The search strategy combined MeSH and free text terms related to “cardiopulmonary resuscitation,” “augmented reality,” “virtual reality,” and “students.” The search strategy and retrieval counts are provided in Table 1. All searches were performed on May 8, 2024, covering all records from database inception up to that date. References from included studies were also examined.

Table 1. Search strategy used to conduct the review (Search date: May 8, 2024)

Table 1. Contd...

Eligibility criteria

Eligible studies were peer reviewed full text articles on extended reality in CPR training for healthcare students, based on the Population, Intervention/Exposure, Comparison, and Outcome (PICO) framework [Table 2]. CPR quality is a focused outcome as it is a standardized measure, while other technical and nontechnical skills were included to capture the full range of competencies needed for effective CPR, including procedural proficiency, confidence, and team behaviors.

Table 2. Details of the inclusion criteria of the systematic review

The research did not include studies where XR technology is not used as an intervention in CPR training. Additionally, studies involving lay persons and healthcare professionals, including those undergoing postgraduate education, were excluded. There were no restrictions concerning the language, year of publication, publication status, or the locale of the study’s conduct.

Search outcome

An initial systematic search was conducted across various databases, followed by manual selection. All studies were uploaded to the Rayyan QCRI tool for study selection, and duplicates were removed.[21] In the first screening phase, two reviewers (JRS and IDP) independently assessed article relevance based on titles and abstracts. The same reviewers then read the full texts to determine eligibility, excluding studies that did not meet the inclusion criteria or fell under the exclusion criteria. Discrepancies were resolved with the help of a third reviewer (MPR).

Quality appraisal

Quality appraisal of eligible studies was performed using established tools: The Cochrane Risk of Bias version 2 (ROB 2) for randomized trials[22] and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS I) for nonrandomized and quasi experimental studies with a control group.[23] Studies were categorized based on predefined criteria, including low, some concerns, or high risk of bias.

Data abstraction

Data extraction was carried out independently by two reviewers using an adapted version of the Cochrane Extraction form.[24] Extracted information included study identification, participant characteristics (sex, age, course, and year), intervention details (XR technology, simulation type), and outcomes (CPR quality, knowledge, skills retention, perception). Authors were contacted for missing data, and any unreceived information was excluded from analysis, with this limitation addressed in the discussion.

Synthesis

A narrative synthesis approach was used to present results, emphasizing study characteristics and key findings. Due to significant heterogeneity, a meta analysis was not performed. Dichotomous outcomes were presented as risk ratios with 95% confidence intervals (CI), and continuous outcomes as mean differences with 95% CI. The P value of the results was also evaluated. For proportions, data conversion was performed by calculating the total correct answers divided by the possible correct answers. Data were summarized in tables, detailing study characteristics and results.

Results

Selection of articles

The selection process from six different databases initially identified 614 articles. After the removal of duplicates, 347 articles underwent title and abstract screening based on the predefined inclusion and exclusion criteria. Twenty three articles eventually underwent review in full text. In the end, eight articles were deemed suitable for inclusion in this systematic review [Figure 1].

Figure 1. Article selection flow based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Study characteristics

This study reviewed eight articles published between 2022 and 2024, reflecting a recent increase in research on XR technologies for CPR training in healthcare students. Geographically, the studies were conducted in six countries, predominantly in high income settings, with Türkiye as the only upper middle income country represented. Spain and Germany contributed the most studies, with two articles each.

Sample sizes ranged from 29 to 241 participants, with a predominance of female participants (average 70% across six studies specifying sex distribution). Half of the studies involved first year healthcare students, though two did not specify the participants’ year level. The focus was largely on nursing (3 articles; 37.5%) and medical students (3 articles; 37.5%), with two studies (25%) including mixed disciplines such as nursing, medicine, psychology, and health sciences.

Most studies (75%) were randomized controlled trials, while 25% were quasi experimental. Outcomes predominantly assessed both technical and nontechnical skills. Table 3 summarizes the study characteristics of the included articles, with extended details in Supplementary Table 2.

Table 3. Summary of study characteristics, interventions, and key outcomes of articles included in the systematic review

Quality assessment of articles

The risks of bias (ROB 2) of the included articles and their outcomes are summarized in Table 4 and Figure 2. Overall, 59.4% of the study outcomes were deemed to have some concerns, and 40.6% were categorized as high risk, indicating susceptibility to biases that could affect the validity of the findings. These results suggest that although many studies attempted to follow robust methodologies, limitations in randomization and outcome reporting may compromise the reliability of the reported effects.

Table 4. Risk‑of‑bias summary of included articles (D1 Randomisation process, D2 Deviations from the intended interventions, D3 Missing outcome data, D4 Measurement of the outcome, D5 Selection of the reported result)

Figure 2. Risk of Bias 2 graph of included articles

Similarly, the summarized results of ROBINS I are presented in Table 5. Among the nonrandomized studies, Yang et al. displays notable methodological consistency and a low risk of bias,[25] whereas those by Rushton et al. reveal considerable concerns,[26] as several domains were not reported, reducing certainty in their outcomes. Overall, the prevalence of high risk and some concern outcomes implies that the findings of this review should be interpreted with caution.

Table 5. Risk of bias in nonrandomized studies of interventions (Mod: Moderate, NR: Not reported summary)

Effect of extended reality

The studies reviewed various forms of XR technologies to train CPR among healthcare students. VR was the most common, used in five (62.5%) of the articles.[18,19,25,27,28] Augmented reality(AR) was utilized in two studies (25%), while one combined VR and MR.[26] No studies exclusively utilized MR technology. Most studies employed smart glasses or headsets for BLS or multiple scenarios, often incorporating feedback mannequins,[18,19,26,28] except for one that used an immersive simulation room with video technology.[26]

Due to substantial heterogeneity in outcome definitions, measurement tools, and statistical reporting across the included studies, a meta analysis was not conducted. Although several studies assessed similar outcomes (e.g., CPR quality, technical skills, knowledge, confidence, and BLS performance), they used different measurement tools, scoring systems, and scales. In addition, comparable outcomes were analyzed using varying statistical approaches (e.g.,means vs. medians, raw scores vs. change scores, nonparametric tests vs. ANCOVA/GLM), making effect sizes noncomparable and preventing calculation of statistical heterogeneity. Given these inconsistencies, the results were synthesized narratively.

Effect on technical skills

Cardiopulmonary resuscitation knowledge

The results regarding CPR knowledge were varied. Two studies reported nonsignificant decrease,[27,29] while two others demonstrated higher scores among the XR group,[25,28] including a significant improvement in neonatal CPR knowledge with VR.[25] Regarding BLS performance, the results were similarly contradictory. One study noted a nonsignificant decline in the XR group,[27] while another observed a significant improvement.[18]

Cardiopulmonary resuscitation knowledge Quality

The findings related to various components of CPR quality were also inconsistent across studies. Regarding hand positioning, results ranged from no difference[30] to lower scores in the XR group, with one study showing a significant difference.[26,28] Compression depth findings were mixed, with some studies reporting nonsignificant lower scores[28,30] and others significantly higher scores.[26] Similarly, chest recoil results ranged from nonsignificant decreases[28] to significant improvements.[30] Ventilation outcomes were inconclusive.[26]

For no flow time, one study showed a significant decrease in the VR group,[18] while another reported an increase.[19] In the overall assessment of technical skills, two studies reported declines in XR groups,[19,28] including a significant decrease in one,[27] whereas another study noted a significant improvement.[26]

Effect on nontechnical Skills

Confidence and anxiety

Majority of the studies made assessments on the impact of XR on nontechnical skills in CPR. Assessing the level of confidence was a recurring theme among the studies. The majority reported higher confidence in the intervention group compared to controls.[18,19,25,26] One study noted significantly higher confidence in the VR group compared to high fidelity simulation and lecture groups.[25] Another study comparing MR, VR, and control groups found lower confidence in the VR group but higher confidence in the MR group compared to controls.[26]

Anxiety reduction showed mixed results. One study reported a minimal but significant decrease in the VR group, though the high fidelity simulation group showed greater anxiety reduction.[25]

Other nontechnical skills

No significant difference was observed in crew resource management between the VR group and the control.[27]

In terms of overall practical skills, one study indicated that the XR group scored significantly lower in overall practical skills compared to other groups.[28] Summary results on the different nontechnical skills outcomes are presented in Supplementary Table 3.

Discussion

This systematic review aimed to assess the effects of XR technologies on CPR training outcomes among healthcare students. The review highlighted that VR is the most used XR technology for CPR training, with most participants being female first year students. However, many of the studies included in this review were susceptible to bias, which compromised the validity and reliability of their reported outcomes. Additionally, the findings showed considerable variability in both technical and nontechnical skills outcomes, further limiting the ability to draw definitive conclusions about the overall effectiveness of XR in CPR training.

Effect on technical skills

Cardiopulmonary resuscitation knowledge

The review yielded mixed results for CPR knowledge. Some studies reported improvements in posttraining CPR knowledge,[25,28] while others did not,[27,29] creating contradictory findings. These findings partially align with recent systematic reviews reporting that VR training improves CPR knowledge among healthcare professionals and adolescents.[31-34] One study even showed good retention of CPR knowledge 6 months after XR training.[12] A major issue in this domain is the lack of standardized knowledge assessment tools. In this review, only the study by Yang et al. used a standardized questionnaire, which focused on neonatal CPR.[25] This highlights the need for validated, standardized questionnaires to enable reliable comparisons across studies.

Cardiopulmonary resuscitation quality

Findings on CPR quality were inconsistent, aligning with prior reviews. Recent studies focusing on laypersons and another on healthcare professionals showed VR improved chest compression rate and depth, suggesting its potential for skill enhancement.[34,35] However, another review showed that XR often failed to achieve the guideline recommended compression depth of 50–60 mm.[12] A meta analysis examining XR among mixed populations found no significant differences in chest compression quality.[33] These outcomes suggest XR simulations, while valuable, lack the physical feedback critical for mastering manual CPR skills.[35] The immediate correction and personalized feedback provided by instructors during traditional training also appear to play a role in improving learning outcomes.[32] With this, it is recommended to incorporate the presence of an instructor and the use of haptic torso mannequins in XR simulations.

Ventilation skills

Ventilation quality was another area where findings were inconclusive. One study included in the review lacked clear results,[26] but prior research indicated that XR with real time feedback helps maintain appropriate ventilation rates.[36] Given the persistent challenges in achieving the necessary compression and ventilation parameters, regular refresher training is advised as long term XR effects remain uncertain.[32]

Overall, the findings on CPR quality were contradictory, mirroring inconsistencies in previous reviews on XR’s effectiveness compared to face to face training.[32,33,35] There is a need for further research to establish more reliable conclusions regarding XR’s impact on CPR quality.

Effect on nontechnical skills

Confidence and anxiety

Enhancing confidence was a recurring theme in many of the included studies,[18,19,25,26] with mixed reality (MR) showing greater confidence boosts than VR or traditional methods.[26] This aligns with recent reviews noting that VR training positively impacts CPR confidence[36] and willingness to perform CPR.[12] However, current evidence is limited to short term outcomes, necessitating further research on the longevity of these effects.

Extended reality technologies also showed potential in reducing anxiety, though with minimal effects.[25] High fidelity simulations were more effective in alleviating anxiety, likely due to their ability to better replicate real life emergency pressures.[25] Prior studies support this, noting less positive emotional responses, including anxiety, with XR.[37] This finding points to the potential benefit of integrating XR with high fidelity simulations to achieve optimal training outcomes for CPR.

Other nontechnical skills

In terms of other nontechnical skills, XR’s impact on rapid decision making and team building under pressure remains underexplored.[34] These skills are crucial in real world CPR scenarios, limiting the current applicability of XR in this aspect. On usability, however, XR technology in CPR training received a positive reception, indicating its potential as a viable training tool.[12]

Considerations and implications

This review did not address potential side effects of XR technology, but prior studies have noted temporary issues such as dizziness, blurred vision, and headaches, which may disrupt training sessions.[33] Additionally, inexperienced users may require extra time to adapt to XR environments, potentially affecting early training efficiency.[33] These challenges highlight the need for careful implementation to maximize XR’s benefits.

While cost effectiveness was outside this study’s scope, prior research indicates that XR systems, though initially expensive, may be more economical than traditional CPR training at the organizational level.[34] The scalability of XR also supports more frequent and accessible training sessions, particularly where physical resources and instructors are limited.[33]

Strengths and limitations

To the best of our knowledge, this review is the first systematic assessment of XR technologies in CPR training for healthcare students. It followed a robust methodological framework adhering to PRISMA guidelines, capturing a broad range of studies from various databases, which enhances the comprehensiveness and generalizability of the findings. The absence of temporal or geographic limits allowed for a global perspective. However, several limitations should be considered when interpreting the findings.

The included studies revealed outcomes rated as high risk or having some concerns, indicating methodological weaknesses in randomization, outcome reporting, and bias control. Additionally, the overall certainty of the evidence was not assessed using the GRADE approach, which could have strengthened the interpretation of findings given the proportion of studies with methodological concerns. Furthermore, the heterogeneity in XR technologies and outcome measures across studies posed challenges in data synthesis, limiting the ability to draw definitive conclusions about XR’s effectiveness. Although this heterogeneity prevented a meta analysis, alternative strategies such as calculating Standardized Mean Differences or applying the Synthesis Without Meta analysis guidelines were not used and may have provided a more structured synthesis. Several XR specific sources of bias may also have influenced study results. The novelty effect may have temporarily enhanced engagement, while unfamiliarity with XR devices could have hindered skill execution initially. These issues, combined with generally small sample sizes, reduce confidence in the reported effects of XR on CPR outcomes. Additionally, language limitations and the exclusion of grey literature may introduce publication bias.

Despite these limitations, the review highlights critical gaps in evidence and underscores the potential of XR as a complementary tool in CPR training. Future research should prioritize larger, rigorously designed trials, standardized outcome measurement, and structured orientation periods to address device unfamiliarity. Strengthening these areas will be essential for developing robust, evidence informed XR enhanced CPR training programs for healthcare learners.

Conclusion

This systematic review analyzed eight studies on the impact of extended reality (XR) technologies in CPR training for healthcare students, conducted across six countries. Key findings include:

• Virtual reality (VR) was the most used XR technology for CPR training

• The effect of XR on technical CPR skills was mixed, with studies showing both improvements and declines in outcomes

• Some evidence suggested XR could boost learners’ confidence and reduce anxiety, though findings on other nontechnical skills were inconsistent

• Outcome variability and bias concerns highlight the need for caution in generalizing these results.

Given these mixed outcomes, XR appears to be a useful tool within a blended learning methodology, aligning with current pedagogical trends, but should not be considered a standalone method. Its strengths appear most relevant for enhancing engagement, and supplementing hands on practice rather than replacing traditional methods. Future research should strengthen methodological consistency by using standardized assessment tools for technical CPR skills, conduct long term follow up studies to determine retention of skills acquired through XR, and investigate the role of haptic torsos to enhance technical skill acquisition. These efforts will help clarify XR’s educational value in CPR training and guide evidence based implementation into healthcare education.

Supp. T. 1. Preferred Reporting Items for Systematic Reviews and Meta‑Analysis Checklist for the systematic review

Supp. T. 1. Contd...

Supp. T. 2. Characteristics of the articles included in the systematic review

Supp. T. 2. Contd...

Supp. T. 2. Contd...

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Supp. T. 3. Summary of key cardiopulmonary resuscitation outcome findings in the reviewed articles

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How to cite this article: Suazo JR , Piuvezam G, Pimenta ID, Ferrándiz LL, Ríos MP, Castro‑Delgado R. Effectiveness of extended reality‑based cardiopulmonary resuscitation training for healthcare students: A systematic review. Turk J Emerg Med 2026;26:223-33.

This study examines previously published studies that do not contain personally identifiable information about participants, rendering ethical approval unnecessary from a research committee.

JRS: Conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, writing – review and editing; GP: Data curation, formal analysis, investigation, methodology, validation, writing – review and editing; IDP: Data curation, formal analysis, investigation, methodology, validation, writing – review and editing; LLF: Data curation, formal analysis, investigation, validation, writing – review and editing; MPR: Conceptualization, investigation, project administration, resources, supervision, validation, writing – review and editing; RC: Conceptualization, funding acquisition, investigation, project administration, resources, supervision, validation, writing – review and editing.

None Declared.

Jhon Raymundo Suazo was awarded and scholarship from the European Education and Culture Executive Agency for the Erasmus Mundus Master in Public Health in Disasters.

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