Enhancing Mixed Reality Simulation Training Technology With Real-Time Performance Visualization: Mixed Methods Study With Medical First Responders.

Background: Mixed reality (MR) simulation training is emerging in paramedical education as a way to practice responding to stress-intensive scenarios like mass casualty incidents in a safe and controlled environment. Current training platforms, however, lack real-time stress and human performance monitoring tools. Objective: The study aims to enhance MR training for medical first responders through real-time evaluation of performance and stress levels, leveraging biosignal monitoring and advanced analytics to allow instructors to tailor feedback and maintain optimal challenge and safety levels. Methods: The study includes a structured, multiphase approach including initial requirement gathering (structured interviews and cocreation workshops), an online design survey, iterative prototype development, and a field trial (including training observations and interviews). Data were collected from 5 end user consortium members across Europe. Quantitative data from checklists were analyzed using frequencies and percentages to understand feature usage and event occurrences. Qualitative data from semistructured interviews and cocreation workshops were transcribed, coded, and subjected to thematic analysis to identify patterns and insights into the usability and effectiveness of the enhanced features in the MR training. Results: The study identified a number of requirements that medical first responders have for an MR training system, including requirements not included in currently available solutions. A total of 80 performance metrics were initially identified and refined to a set of 54 metrics, which were categorized into key performance indicator groups such as scene safety, triage performance, and communication. Requirements for smart wearables to monitor stress levels are provided and highlight the importance of a user-centered design process to provide users with effective tools that fit their needs. Stress visualization preferences are described in the form of a dashboard as well as in virtual environments surrounding the avatar. Using an iterative design process and user feedback, a training system was developed, integrating real-time performance tracking and stress monitoring. The field trial provided insights into the practical use of these features during a real training exercise, showed interaction preferences between trainer and trainees, and highlighted further improvement opportunities. Conclusions: This research enhances MR training for paramedics by integrating real-time performance metrics and stress indicators based on a human-centered design approach that aligns with end user needs, thereby laying the foundation for developing more effective and immersive training solutions for high-stress professions.