The effectiveness of immersive virtual reality simulations in improving pediatric clinical skills, diagnostic reasoning, and self-efficacy: a systematic review

Objectives The primary objective of this systematic review is to evaluate the effectiveness of Virtual Reality (VR) simulation compared to conventional teaching methods in nursing students in the pediatric setting. Specifically, the review aims to address the following questions: Clinical Skills: What is the effect of VR simulation on the acquisition and performance of pediatric clinical/procedural skills among nursing students? Clinical Reasoning: Does VR simulation enhance clinical reasoning and decision-making abilities in pediatric care scenarios compared to traditional methods? Self-Efficacy: What is the impact of VR simulation on the level of self-efficacy and confidence of nursing students in providing care within the pediatric domain? Secondary objectives include assessing the impact of VR simulation on students' learning satisfaction and anxiety levels related to clinical practice. Research Question (PICOS Format) In nursing students in pediatric training, what is the effectiveness of Virtual Reality (VR)-based simulations in improving pediatric clinical skills, diagnostic reasoning, and self-efficacy? Participants (Population) Nursing students (Bachelor of Science in Nursing). Intervention Artificial Intelligence simulation (including virtual clinical simulation and Augmented Reality/VR). Comparator Not applicable to an exploratory scoping review. Outcome Development of specific pediatric skills, preparation of future professionals, development of critical thinking, decision making, problem solving. Study design Systematic reviews, quantitative and qualitative primary studies. 3. Systematic Review Methods METHODS (PRISMA-P Items 9-18) 9. Eligibility Criteria Inclusion: Primary studies (RCTs, quasi-experimental) evaluating the effects of simulations integrated with AI/VR/AR on the curriculum of nursing students. Pediatric-specific context. Any publication date, any language. Exclusion: Purely theoretical studies, letters to the editor, scoping/narrative reviews, studies focused exclusively on the adult population or other health professions. 10. Sources of Information The search will be conducted on the following databases and platforms: PubMed/MEDLINE Scopus CINAHL PsycInfo It will also be a cross-check of references from key articles included (snowballing) will also be performed. 11. Search Strategy The strategy is developed using MeSH terms and free-text descriptors. MeSH terms: Students, Nursing; Education, Nursing; Simulation Training; Artificial Intelligence; Virtual Reality; Pediatrics; Clinical Competence; Decision Making. Example String (for PubMed): ("nursing student*" OR "student nurse*" OR "pre-licensure nursing student*" OR "nurse education" OR "education nursing" OR "nurse training" OR "nurse trainees" OR "nursing trainee") AND (pediatric* OR pediatric* OR child OR children OR neonatal* OR neonate*) AND (simulation* OR "virtual reality" OR "high fidelity simulation training" OR VR OR fidelity OR "reality virtuality continuum" OR immersion OR "virtual environment" OR "virtual simulation" OR "extended reality") AND ("clinical competence" OR "Clinical Competency" OR "Clinical Skill*" OR Skill OR "Professional Competence" OR "Pediatric Skill*" OR "nursing competence" OR "nurse competency" OR "clinical performance" OR "nursing skill pediatric" OR "diagnostic reasoning" OR "clinical judgment" OR "critical thinking" OR self-confidence OR "self confident") 12-13. Study Selection and Data Extraction Study selection will be performed by two independent reviewers. The process will be documented using the PRISMA Flow Diagram. Data will be extracted into a pre-tested standardized spreadsheet, which will include: study details, PICOS characteristics, simulator/AI type, outcome measures, and main results. 14-15. Risk of Bias and Methodological Quality The methodological quality of the included studies will be assessed by two independent reviewers: Randomized Controlled Trials (RCTs): The Cochrane Risk of Bias tool (RoB 2.0) will be used. Non-Randomized Studies (NRS): The ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool will be used. 16-17. Outcomes Primary Outcome: Development and improvement of pediatric clinical skills (measured by performance scores or OSCE). Secondary Outcomes: Improvement in decision-making skills; improvement in problem-solving and critical thinking skills; students' levels of self-efficacy and confidence; satisfaction and acceptability of AI technology. Additional Outcomes: Long-term retention of acquired skills; cost-effectiveness of AI system implementation. 18. Data Synthesis A formal data synthesis is planned (Yes). Quantitative Synthesis (Meta-Analysis): This will be performed if the data are sufficiently homogeneous by type of intervention and outcome. Heterogeneity will be tested using the I2 index and the Q test. The random-effects model will be used. Narrative Synthesis: If Meta-Analysis is not feasible due to excessive heterogeneity, a systematic narrative synthesis will be performed, grouping the results according to primary and secondary outcomes. ADDITIONAL INFORMATION AND ETHICS (PRISMA-P Item 4, 5c) Ethical Aspects and Algorithmic Bias Ethical Approval: Not required for this type of study Algorithmic Bias: The review will dedicate a section to the extraction and documentation of potential algorithmic biases reported in the literature (such as the limited representativeness of rare clinical cases in the AI training dataset) and to the planned mitigation strategies, in order to inform the future implementation of the application in the thesis project.