Different Delivery Modalities of Virtual Reality Training in Emergency Medicine: Systematic Review.

Background: Simulation is a cornerstone of emergency medicine education, and virtual reality (VR) has emerged as a promising immersive and scalable training modality. However, it remains unclear which VR instructional design features most effectively support learning outcomes. Objective: We aimed to provide a systematic overview of the literature on immersive VR delivery modalities in prehospital and in-hospital emergency medicine training, focusing on how different instructional design features influence educational effectiveness. Methods: We conducted a systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines, including English-language articles examining the use of VR for the training of health care professionals, specifically randomized controlled trials (RCTs), non-RCTs, and prospective or retrospective observational comparative studies. PubMed/MEDLINE, Scopus, Embase, and CINAHL were searched up to January 28, 2026. We included studies evaluating immersive headset-based VR for emergency medicine training among qualified health care professionals. Studies involving students, laypersons, nonemergency settings, or augmented, mixed, or web-based reality were excluded. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tools. Given the wide heterogeneity in methodology across studies, a meta-analysis was not performed, and findings were synthesized using a structured narrative approach based on VR delivery modalities. Results: Six comparative studies in emergency medicine training were included from 1770 identified records. The included studies compared different immersive VR delivery modalities, including varying exposure schedules, software with or without gamification, machine-guided versus educator-guided training, active versus observational participation with different persuasive feedback strategies, and VR with or without manikin integration. Educational outcomes were heterogeneous, including knowledge retention, procedural performance, and learner-related measures. Overall, the included studies were of moderate to high methodological quality. While observational studies were more susceptible to selection bias, RCTs demonstrated adequate randomization and statistical analysis. Across the included studies, repeated and temporally distributed VR exposure consistently improved knowledge retention and performance, whereas gamification, increased persuasive feedback, educator-guided delivery, and manikin integration showed inconsistent or no additional educational benefit. Conclusions: Unlike previous reviews focusing on the overall educational value of VR, this review compared different immersive VR delivery strategies in emergency medicine training. The few studies identified suggest that structured and repeated engagement with VR simulations may enhance learning effectiveness, whereas additional technological features do not consistently improve outcomes. The available evidence is limited by the small number of studies, heterogeneous interventions and outcome measures, and moderate risk of bias, restricting the strength of the conclusions. These findings suggest that optimizing instructional design may be more important than increasing technological complexity when developing immersive VR educational programs. Further high-quality studies with standardized outcome measures are needed to identify the most effective VR training strategies for emergency medicine education.