Immersive technology and hand hygiene: scoping review

Abstract

Background

The use of immersive technology in healthcare education is on the rise, yet its impact on learner engagement, knowledge retention, and specifically in areas like hand hygiene training, remains underexplored. The aim of this scoping review was to summarize the existing studies of immersive technology in hand hygiene training of healthcare providers and health professions students.

Methods

A scoping review following the Levac et al. framework was conducted. The literature search was performed in databases PubMed, CINAHL Ultimate, ScienceDirect (Elsevier), Web of Science in addition to Google Scholar and ProQuest Dissertation & Theses. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Reviews (PRIMSA-ScR) guideline was used to report the results. We analysed data using tabular and descriptive summary.

Results

In the final analysis 11 studies from seven countries were included. Most of the studies (n = 10, 90,91%) used virtual reality in hand hygiene training of healthcare providers and health professions students. Most studies have found that immersive technology is useful in teaching hand hygiene (n = 6, 54,55%). There are some theories and concepts that support the teaching of hand hygiene with immersive technology, but most of the research is not supported by them. Theories or concepts were included in two studies (18,18%).

Conclusion

Immersive technology, especially virtual reality, enhances hand hygiene learning and engagement compared to traditional methods. However, most studies lack theoretical support. To advance this field, exploring immersive technology for further research and incorporating relevant theories is encouraged. Additionally, conducting a thorough cost-effectiveness analysis and establishing a robust evaluation framework, encompassing both short-term and long-term outcomes, will be beneficial for a comprehensive understanding of the impact of immersive technology in hand hygiene education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-06320-2.

Background

Virtual environments are rapidly integrating into the realm of educational technology and have achieved good results [1, 2]. In immersive technology, the surrounding environment creates a feeling of immersion by simulating a sense of being present or immersed in a physical environment through the means of a digital or simulated environment [3]. Suh and Prophet [4] define immersive technology as a combination of virtual reality (VR) and augmented reality (AR). VR is a fully digital experience where users wear head-mounted display (HMD) to explore and interact in a virtual world, separate from the real one [5]. AR overlays digital elements onto the real world using HMD like smartphones or glasses, adding information or objects to the physical environment [6]. Mixed Reality (MR) combines VR and AR, allowing digital and physical elements to interact in real time, enabling virtual objects to blend seamlessly with the real world [7]. Recently, AR, VR, and MR have been collectively categorized as extended reality (XR) [8, 9]. In a VR environment, the participating observer is fully immersed, while a strictly real environment is governed by physical laws. Rather than viewing these concepts as opposites, it is more appropriate to consider them as opposite ends of the reality-virtuality (RV) continuum [10, 11].

Immersive technology is widely used across health to enhance and facilitate learning [12]. Extensive evidence supports the use of that XR in medical and nursing education [13, 14]. In-depth immersive technology is prevalent in medical education [15, 16] and in different medical fields, for example, anesthesiology [17], emergency medicine [18, 19], dental medicine [20] and urology [21]. Immersive technology is also widely used in nursing education [13, 22, 23]. Following this, immersive learning is an educational method where artificial experiences that are perceived as non-mediated are used as learning tools. Examples of artificial experiences include XR games, apps, and simulators [24]. VR in nursing has proven effective in teaching procedures such as intravenous catheter insertion [25, 26], Foley catheter insertion [27], wound care [28] and tracheostomy care [29]. VR has proven to be a particularly useful tool in education, as it helps to motivate and retain knowledge [30]. The use of immersive technology, especially VR learning, has shown promising results in infection control and educating about the transmission of infections during the 2019 Coronavirus pandemic [31, 32]. VR learning is an educational method that leverages immersive VR technology to create interactive, simulated environments, enabling learners to engage with and explore concepts in a lifelike 3D space [33].

Hand hygiene serves as the cornerstone of infection control, with compliance being a pivotal quality indicator [34] for patient safety [35]. Healthcare-associated infections are often transmitted between patients through the contaminated hands of healthcare workers, making hand hygiene a critical prevention and control strategy [36–38]. Performing it correctly may prevent many costs and fatalities [39]. Advances in technology have expanded the possibilities for monitoring hand hygiene training [40]. AR [41, 42] and VR [43–45] are frequently employed for hand hygiene training.

While microorganisms are invisible to the human eye, VR training can be effective for hand hygiene training because it enables exploration and interaction in a virtual setting [46]. VR is an interesting and contemporary approach to teaching hand hygiene among healthcare workers and can be viewed as a useful supplement to conventional hand hygiene lectures [44]. AR also holds promise, as it enables self-directed learning, potentially improving the quality of hand hygiene instruction and reducing instruction time for healthcare organizations [47].

The integration of immersive technology, encompassing VR, AR, and MR has rapidly transformed the landscape of educational technology. While the potential benefits of immersive technology are increasingly recognized, there remains a notable research gap in understanding optimal implementation strategies and learner experiences. Effective implementation of pedagogical concepts and theories is crucial for enhancing the learning process. However, the theoretical underpinnings of using immersive technology in education have received limited attention thus far [48]. Learning theories offer a framework for designing VR in education, guiding educators on how learners engage, process information, and construct knowledge. VR design could benefit from cognitive load, experiential, and constructivist theories, which guide efficient information processing, hands-on learning, and active knowledge construction [49]. Jacobs et al. [12] identified several pedagogical concepts and theories used for learning and understanding experiences in relation to immersive technology, while Kuhail et al. [50] in most cases did not perceive precise pedagogical strategies but different aspects of teaching approaches. This discrepancy underscores the need for a more comprehensive examination of pedagogical frameworks. Researchers have also yet to determine the most effective strategies for integrating immersive technology into hand hygiene training. This includes identifying the best type of technology, timing, duration, frequency, assessment, and perceived usefulness of immersive training sessions. By addressing this research gap, we can contribute valuable insights to the evolving landscape of immersive technology in healthcare education and training, ultimately fostering improved patient safety and infection control practices in healthcare settings.

Methods

A scoping review was conducted following the steps of Levac et al. [51]: identifying the research question, identifying relevant studies, study selection, charting the data, collating, summarizing, and reporting the results. Although Arksey and O’Malley’s (2005) framework is widely used, Levac et al. (2010) introduced enhancements to improve rigor and consistency [52]. Given these improvements, we adopted the Levac et al. approach, which has also been applied in recent studies on immersive technology [53–55]. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [56] was followed for reporting. Scoping review protocol has been on the OSF Registries under registration DOI 10.17605/OSF.IO/EW8R2.

Identifying the research question

The aim of this scoping review was to summarize the existing studies of immersive technology in hand hygiene training of healthcare providers and health professions students. Three specific research questions were asked:

• How and what type of immersive technology has been applied in hand hygiene training of healthcare providers and health professions students?

• What are healthcare providers and health professions students’ perceptions of the immersive learning usefulness for hand hygiene training?

• What pedagogical concepts and theories underpin immersive learning in hand hygiene training of healthcare providers and health professions students?

Identifying relevant studies

Literature was searched in international databases PubMed, CINAHL Ultimate, ScienceDirect (Elsevier), Web of Science in addition to Google Scholar and ProQuest Dissertation & Theses to identify grey literature and citation searching. First, on the 16th of February 2023, an initial search was done by the first author in PubMed and CINAHL to identify keywords and analyse the text words found in the title, abstract, and index terms to build a comprehensive search strategy. Subsequently, a search across all databases was conducted on 2nd March 2023 using the following search strategy: (Immersive technology OR Virtual reality OR Augmented reality OR Mixed reality OR 360 VR OR 360 degree videos OR 360 video) AND (Education OR training OR teaching OR learning) AND “Hand hygiene”. Furthermore, references of all included articles were reviewed to locate additional sources. We conducted a citation searching in November 2023. We have included quantitative, qualitative, or mixed methods studies, including review articles (type of research), including healthcare providers and health professions students (type of participants) and immersive technology for hand hygiene training (concept). We did not limit ourselves in terms of language and time. Exclusion criteria included failure to meet the above criteria, we also excluded opinions, conference papers, and abstracts.

Study selection

The screening was performed using the Rayyan online tool for managing systematic reviews [57]. First, titles and abstracts were screened for eligibility by two independent reviewers, the first and last authors of this article. Second, selected studies were also reviewed in full text for eligibility by the first and last authors. In case of disagreement, a third researcher was involved. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, excluded full texts are listed in the table of excluded studies (Appendix 1).

Charting the data

A data extraction tool was designed and subjected to testing in a preliminary stage, which encompassed the independent assessment of five articles by two authors. Subsequently, the results were compared for validation. The final data extraction tool included the author(s), publication year, country of origin, type of study, sample, type of immersive technology, number of learners, frequency or duration, assessment, perceived usefulness, and pedagogical concepts and theory.

Collating, summarizing, and reporting the results

The results were analysed using tabular and descriptive summary and are presented in subsections. The data on countries, study population, study design, comparator, perceived usefulness and inclusion of the theory or concept are presented in percentages in Table 1.

Table 1.

Overview of included studies (n = 11)

Countries
Germany	1 (9,09%)
Switzerland	2 (18,18%)
Japan	2 (18,18%)
Australia	1 (9,09%)
South Korea	2 (18,18%)
United Kingdom	2 (16,6%)
Greece	1 (9,09%)
Study population
Medical students	4 (36,36%)
Healthcare professionals	4 (36,36%)
Nursing students	2 (18,18%)
College students	1 (9,09%)
Study design
Mixed methods study	2 (18,18%)
Qualitative realist study	1 (9,09%)
Prospective randomized controlled pilot study	1 (9,09%)
Randomized controlled pilot study	1 (9,09%)
Pilot study	1 (9,09%)
Exploratory single group design study	1 (9,09%)
Prospective cross-controlled trial	1 (9,09%)
Two-group experimental design study	1 (9,09%)
Methodological study	1 (9,09%)
Playtest method	1 (9,09%)
Comparator
Without comparison	5 (45,45%)
With lecture or traditional learning	5 (45,45%)
With non-immersive VR training	1 (9,09%)
Perception of usefulness
Established usefulness	8 (72,73%)
Concepts and theories
Application of concepts and theories	2 (18,18%)

Results

A total of 483 references were identified in the databases and 1497 references on other websites (ProQuest Dissertations & Theses and Google Scholar). After removing duplicates, the 229 references from the databases were screened by title and abstract, leaving 31 references that were sought for retrieval and screened for eligibility. Of them, 23 were excluded because of concept inadequacy and 11 were included in the final review. Of 1497 references identified from websites, 406 were not retrieved. Our inability to retrieve reports from 406 studies indicates that these studies were either inaccessible, untraceable, or unavailable in a form suitable for inclusion in the review. We have clarified this point in our methods section. We also found three references through a citation search. We screened 1,091 reports for eligibility, excluding 862 for not addressing immersive technology for hand hygiene training (concept) and 229 because of inadequate type of research. The PRISMA flow diagram is shown in Fig. 1.

Fig. 1.

PRISMA flow diagram

Research included mixed methods studies [42, 58], a qualitative realist study [41], a randomized controlled pilot study [59], a prospective randomized controlled pilot study [31], an exploratory single group design study [46], a prospective cross-controlled trial [44], a two-group experimental design study [45], a methodological study [60], a pilot study [61] and a playtest method [62]. Five included studies (45,45%) divided the participants into two groups (intervention and control, or those who used immersive technology and those who were taught using standard traditional methods) [31, 44, 45, 58, 59]. All 11 studies included in the review were published between 2010 and 2023. The publications originate from Germany, Switzerland, Japan, Australia, South Korea, Greece, and the United Kingdom (Table 1).

Teaching hand hygiene with immersive technology was targeted at medical students [31, 45, 46, 59], healthcare professionals [41, 44, 58, 61], nursing students [42, 60] and college students [62]. The sample size ranged from 17 [42] to 150 participants [62]; in total 489 participants. The duration of VR training was 15 min [45, 58] and 30 min [59] respectively, while the learning period ranged from two weeks [62] to one year [44].

Questionnaires were the most used to assess the success of VR or AR hand hygiene training [31, 42, 44–46, 58, 59, 61, 62] such as System Usability Scale (SUS) [58, 59], After-Scenario Questionnaire (ASQ) [31, 59], User Satisfaction Evaluation Questionnaire (USEQ) [31, 59], and Simulator Sickness Questionnaire (SSQ) [31, 59]. Omori et al. [45] also used Objective Structured Clinical Examination (OSCE) method for assessment. Birrenbach et al. [31] assessed hand hygiene at enrolment, immediately after the intervention and one month after the intervention, while Eichel et al. [44] evaluated the situation immediately after the completion of the VR training and gave feedback in percentages. Désiron et al. [46] also used questionnaires just before and after VR training. The above results are presented in Table 2.

Table 2.

Data extraction table

Article information
Reference and country	Type of study	Sample	No of learners	Frequency or duration	Assessment	Perceived usefulness
Birrenbach et al. (2021), Switzerland [31]	Prospective randomized controlled pilot study	n = 29 medical students (15 in intervention group and 14 in control group)	n = 29	3 months; participants completed two runs of the simulation	They assessed the performance of hand disinfection; ASQ for both training modules and USEQ; SSQ for visually induced cybersickness. 6-item questionnaire developed by Slater-Usoh-Steed: for presence and immersion.	Participants in both groups were significantly better after the hand hygiene training; A significant difference between the intervention and control groups was not found regarding hand hygiene performance or missed areas during hand disinfection. VR is a useful tool for acquiring simple and complex clinical skills.
Choi & Noh (2020), South Korea [62]	Pre-test, post-test using survey Cross-sectional quantitative quasi-experimental study	n = 150 college students at large private university in Gangwon Province, South Korea They were generally well educated and more aware of the importance of hand washing than the general population	n = 150	Over a 2-week period in May 2017	Pre-survey questionnaire on demographics and questionnaire about VR video experiences (presence, flow, fear, attitude toward handwashing, and hand washing intention), survey questions regarding their playing or watching experience.	VR technology is positioned as an effective tool for fostering people’s intention to engage in preventive health behavior.
Désiron et al. (2022), Switzerland [46]	Exploratory study, single group design	n = 43 medical students (University Hospital of Zürich)	n = 43	Introductory video was 7 min long, after that participant filled questionnaire and completed 3-level VR training	Before using VR hand hygiene trainer participants filled questionnaire for technology acceptance; At the end of the training, participants completed questionnaires on their commitment to the training, acceptance of the technology and demographics.	It was found that VR training improved virtual hand hygiene procedures (p < 0.001); The effectiveness of hand hygiene increased significantly when potential pathogens were visible and in a part of the research when time pressure was present and at the same time microorganisms were invisible.
Eichel et al. (2022), Germany [44]	A prospective, cross-controlled trial	n = 81 trainings (48 VR and 33 by lecture), two wards in a tertiary care hospital; healthcare professions	n = 81	One year interval, training duration of about 20 min	A standardized questionnaire with Likert-Scale; Hand rub consumption was measured continuously.	Hand hygiene improved non-significantly after VR training (p = 0.12); VR training was well accepted by healthcare workers.
Gasteiger et al. (2023), United Kingdom [41]	Qualitative realist study	n = 25 English-speaking care homeworkers (carers and managers) in Northern England, aged over 18 years. AR part of the study was excluded because of our inclusion criteria [58].	n = 25	29–59 min interviews	NVivo using deductive and inductive (open-coding) method.	Participants felt that VR can lead to more effective teaching of hand hygiene, better infection control and higher staff satisfaction.
Gasteiger et al. (2024), United Kingdom [58]	Realist mixed methods study	n = 21 care staff (21 in VR training group, 8 in non-immersive VR training group). AR part of the study was excluded because of our inclusion criteria [58].	n = 48	About 15 min long VR training	SUS, NVivo using deductive and inductive approach.	VR training was highly accepted, 95% of employees supported its continued use, while only 63% of respondents would support the continued use of non-immersive VR. The results of SUS show the good usability of VR training.
Hagiya et al. (2023), Japan [61]	A pilot study	n = 25 participants (20 nurses and 5 nursing aids)	n = 25	NM	Post-VR questionnaire.	All participants responded that the VR experience had been helpful in raising awareness of the 5 Moments for Hand Hygiene. Compliance with hand hygiene was found to be significantly high among nurses and the results show the educational usefulness of VR videos.
Mather et al. (2017), Australia [42]	Mixed methods study	Nursing students; n = 17 respondents	n = 17	NM	Completed surveys	Surveys completed by users indicate a positive response to the system.
Omori et al. (2023), Japan [45]	Two-group experimental design	n = 42 medical students (University in Japan) (21 in VR group and 21 in lecture group)	n = 42	One time 15 min learning VR video	OSCE; post-test questionnaires.	VR group scores were significantly higher than lecture group scores on the post-test (p = 0.024).
Yu & Mann (2021), South Korea [60]	Methodological study	Nursing students and novice nurses	NM	3 scenarios, each 10 to 15 min	NM	NM
Zikas et al. (2022), Greece [59]	Randomized controlled pilot study	n = 29 medical school students (15 in intervention group (VR simulation) and 14 in control group (traditional learning methods))	n = 29	20–30 min long VR training	SUS, ASQ, USEQ, adapted SSQ, National Aeronautics and Space Administration Task Load Index, Self-assessment manikin.	ASQ revealed that the results were much better in the VR group and user satisfaction was also higher in the VR group. The SSQ showed that the simulation was well tolerated.

NM = Not mentioned

Perceptions of the usefulness of immersive learning for hand hygiene training

Immersive technology has been found useful, with study participants demonstrating improved hand hygiene performance using it [31, 45, 46, 59, 61], higher motivation to learn [43] and a positive attitude towards this way of learning [42, 44] without cybersickness [31]. Cybersickness has been identified as a negative aspect of utilizing XR in healthcare education [63]. Research has shown that the use of immersive technologies was at least as effective as traditional teaching methods and more engaging for participants. The results show that VR teaching was at least as effective as traditional hand hygiene lectures [31, 45], while Eichel et al. [44] found no greater impact, but they still think VR makes it more interesting. In a qualitative study conducted by Gasteiger et al. [41] participants felt that VR can lead to more effective teaching of hand hygiene, while Mather et al. [42] show that users indicate a positive response to the system for teaching hand hygiene. Other included research also shows the benefits of using immersive technology to teach hand hygiene. For example, Gasteiger et al. [41] found that participants considered the use of VR led to higher satisfaction and better infection control, while Désiron et al. [46] concluded that VR training was effective even if participants were previously unfamiliar with the technology and did not accept it in advance. VR group scores were significantly higher than lecture group scores in a study by Omori et al. [45] and in the same study students also think that VR training was more fun, and they would like to continue learning this way (Table 2).

Pedagogical concepts, theories, and types of immersive systems for hand hygiene training

Two studies included a theoretical framework or pedagogical concepts, namely Lave and Wenger’s Situated Learning Theory [60] and conceptual framework of the elaboration likelihood model [62]. Lave and Wenger’s Situated Learning Theory was used to develop the VR program in a study by Yu and Mann [60]. It involves active participation in authentic activities that are directly related to the learning objectives. In this regard, learners can acquire knowledge that is normally only available in the ‘real world’ through participation in situations that require the solution of real problems [60]. In the study by Choi and Noh [62] the conceptual framework of the elaboration likelihood model was used. They use it to understand how people process the content of health promotion videos to change their attitudes toward hand washing. On examining and testing the VR Clean Hands (Tork, UK) and COVID-19 VR Strikes Back (ORamaVR, Switzerland) software, we noticed the incorporation of gamification elements such as points, leaderboards, and feedback. Intriguingly, none of the studies analyzed mentioned the use of gamification in teaching hand hygiene. Research indicates that integrating gamification into VR enhances learning, cognitive, and psychomotor performance [64, 65]. According to the RV continuum, VR emerged was the predominant XR technology in the analyzed studies, with 90,91% (10/11) employing it [31, 41, 44–46, 58–62]. Based on Azuma’s widely recognized definition of AR in “A Survey of Augmented Reality” outlines three critical requirements for an AR system: 1) it must blend real and virtual elements, 2) offer real-time interactivity, and 3) align real and virtual components in a three-dimensional space only one study in our review used AR [66]. Among VR studies, only two studies used headsets that transformed a smartphone into a Head-Mounted Display (HMD) [58, 62], while the rest used HMDs with built-in computers [31, 41, 42, 44, 46, 59–61]. In one study, the specific technology used was not reported [45]. The most frequently used headsets were from Meta, accounting for 45.45% (5/11) [31, 41, 44, 59, 61], and HTC, comprising 18.18% (2/11) of the usage [46, 60]. Over half of the XR software used in the studies were not publicly accessible, accounting for 54,54% (6/11) [42, 45, 46, 60–62]. The most frequently utilized XR applications were ‘VR Clean Hands’ by Tork (UK), featured in three studies [41, 44, 58], and ‘COVID-19 VR Strikes Back’ by ORamaVR (Switzerland), used in two studies [31, 59] (Table 3).

Table 3.

Data extraction table

Reference and country	Pedagogical concepts and theory	Hardware and software
		Type of XR (company, name of XR headset, country)	Publicly available software (company, name of software, country)
1. Birrenbach et al. (2021), Switzerland [31]	NM	VR (Meta Platforms, Oculus Rift S, USA)	Yes (COVID-19 VR Strikes Back, ORamaVR, Switzerland)
2. Choi & Noh (2020), South Korea [62]	Conceptual framework of the elaboration likelihood model and the theory of planned behavior	VR (BoboVR, VR Boss, China and smartphone LG Corporation, South Korea) (other information NM)	No (NM).
3. Désiron et al. (2022), Switzerland [46]	NM	VR (HTC Corporation, HTC Vive pro, Taiwan)	No, only free trail (Virtue, Virtue, Switzerland)
4. Eichel et al. (2022), Germany [44]	NM	VR (Meta Platforms, Oculus Go, USA)	Yes (VR Clean Hands, Tork, United Kingdom)
5. Gasteiger et al. (2022), United Kingdom [41]	NM	VR (Meta Platforms, Oculus Go, USA)	Yes (VR Clean Hands, Tork, United Kingdom)
6. Gasteiger et al. (2023), United Kingdom [58]	NM	VR (Destek, Destek V5, USA and smartphone (other information NM)	Yes (VR Clean Hands, Tork, United Kingdom)
7. Hagiya et al. (2023), Japan [61]	NM	VR (Meta Platforms, Oculus Quest, USA)	No (NM)
8. Mather et al. (2017), Australia [42]	NM	AR (Vuzix Corporation, Vuzix Wrap 1200DX, USA)	No (Helping Hands, other information NM)
9. Omori et al. (2023), Japan [45]	NM	VR (NM)	No (Jolly Good Inc., Tokyo, Japan)
10. Yu & Mann (2021), South Korea [60]	Lave and Wenger’s Situated Learning Theory	VR (HTC Corporation, HTC Vive Pro, Taiwan)	No (Samwoo mmersion Co., Ltd., South Korea)
11. Zikas et al. (2022), Greece [59]	NM	VR (Meta Platforms, Oculus Rift S, Taiwan)	Yes (COVID-19 VR Strikes Back, ORamaVR, Switzerland)

NM = Not mentioned

Discussion

The aim of this scoping review was to summarize the existing studies of immersive technology in hand hygiene training of healthcare providers and health professions students. The summary encompassed the use, usefulness and theoretical foundations underpinning the use of immersive technology in hand hygiene training of healthcare providers and health professions students.

Most of the research involved VR. VR and AR are fast-developing technologies that offer a more engaging learning experience when learning skills [67] and they are also often used because they improve the education and skills of healthcare workers in a flexible and efficient way [68]. Frost et al. [69] identify a significant gap in the literature on using MR for patient assessment and nursing education. Our findings reveal that, although VR is more commonly applied than AR for teaching hand hygiene, augmented virtuality or diminished reality within MR remains entirely unaddressed in this area.

Researchers in this field have predominantly employed various forms of VR technology, including VR simulation, 360-degree VR videos, VR trainers, and VR simulation programs. In a study where authors used VR simulation scenarios to train staff on different skills (such as hand hygiene), they found that participants learned faster and had relatively better learning outcomes [32]. In the research where the VR simulation was used, authors did not detect a significant difference between the control and intervention groups, but nevertheless found the usefulness of the simulation [31]. With the VR trainer, an increased internal motivation to perform hand hygiene was shown [43], while with the use of the 360 degree video in study conducted by Omori et al. [45], the intervention group performed significantly better. In addition to those mentioned, we also found a propose of virtual classroom approach for hand hygiene learning [70].

Among the studies included in the scoping review, the duration of training with immersive technology lasted up to 30 min [59], while the entire period of education lasted up to one year [44]. Dai et al. [71] emphasize the advantage of a longer training duration of the participants and their repetition.

The predominant method of assessment and evaluation in research has been questionnaires in the form of grading usability of XR systems [58, 59], measuring user satisfaction with XR, evaluation of cybersickness [31, 59] etc. Research has shown that traditional grading systems often play on students’ fear of punishment, reducing intrinsic motivation and achievement and increasing the desire to outperform classmates [72]. In future, educators could use an immersive technology as an alternative grading system [73] where students are provided with detailed and frequent feedback, giving them more agency in how they are assessed. These methods are designed to reduce student stress and promote engagement by emphasizing the learning process [74].

Hand hygiene, often addressed with only one training session per year in hospital settings, underscores the need for repeated training and feedback to ensure effective retention [47]. In this context, the incorporation of evaluation frameworks is of importance. These frameworks would systematically measure the utility and effectiveness of immersive training initiatives, thereby enabling evidence-based refinements and enhancements in the training process. Incorporating evaluation frameworks would be crucial to systematically measure the usefulness and efficacy of immersive training initiatives, enabling evidence-based refinements and improvements in the training process. One of the best-known models for evaluating training programmes was developed by Donald Kirkpatrick, which provided a framework for examining outcomes and impacts from organisational and individual perspectives [75]. Further research should focus on the implementation of such evaluation frameworks to advance our understanding and application of immersive training in the field, particularly concerning the long-term retention of knowledge and skills.

Most of the research lacked theoretical underpinnings pedagogical theories or concepts. However, we did identify two studies where established theories and concepts were applied: use of Lave and Wenger’s Situated Learning Theory as demonstrated by Yu and Mann [60] and the incorporation of the conceptual framework of the elaboration likelihood model, and the theory of planned behaviour in the work of Choi and Noh [62]. In other literature, we found that for the practice of psychomotor skills (which also includes hand hygiene), the authors also propose related concepts, namely deliberate practice, mastery learning and test-based learning [47]. One study examined the application of learning theories in VR-based education, noting that constructivism was the most commonly employed approach, followed by experiential learning, gamification of learning (educational approach), and John Dewey’s “learning by doing” [49]. Additionally, theoretical frameworks for using immersive technology in education have emerged, particularly drawing on the Cognitive Theory of Multimedia Learning [76]. Clack et al. [43] described the concept of an experiential virtual environment for the training of hand hygiene skills. In this way, associative learning is enhanced and the intrinsic motivation to perform hand hygiene is increased. It is important to emphasize that for immersive learning experiences to be truly effective, integrating established learning theories is imperative. Incorporating learning theories as a foundational basis for developing learning materials and approaches is fundamental to achieving successful and impactful educational outcomes of immersive technology [49].

In our review, we observed a lack of data on the cost-effectiveness of immersive technology in hand hygiene training. Existing literature suggests that immersive technologies, especially VR, offer cost and time efficiency advantages over traditional methods [77]. It is also noted that immersive tech provides cost-effective, standardized, and repeatable training [78]. However, we recommend future research to include a thorough cost-effectiveness analysis, essential for informed decision-making in hand hygiene training.

Limitations

It is possible that the authors did not identify published material available from other data sources and thus is missing from review. Although our review was not restricted by language, we did not identify relevant studies in languages other than English, which is why only English-language studies were included.

Conclusion

In summary, our scoping review showed the prevalent use of VR and AR in hand hygiene training research, with MR largely unexplored. Immersive technology consistently demonstrates utility, improving hand hygiene, motivation, and preference for learning. However, a significant portion of the studies lacked pedagogical underpinnings. None of the reviewed studies included cost-effectiveness analyses. Future research should address these gaps, ensuring a comprehensive assessment of immersive technology’s integration in hand hygiene education. This research should encompass both short-term benefits and long-term sustainability of knowledge and skills acquired through immersive training methods. We also recommend research into learning with immersive technology, specifically examining stress levels and potential side effects, such as motion sickness (cybersickness), visual fatigue, dizziness, disorientation, eye strain, headaches, and reduced focus after use. As immersive technology evolves, its consistent use in terminology is essential in scientific and practice contexts. We suggest using the term XR or spatial computing in forthcoming articles to represent accurately the evolving field of immersive technology, which includes VR, AR, MR, and other similar technology like augmented virtuality [79–81] that merge the physical and digital worlds [9, 82].

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

AR

Augmented reality

MR

Mixed reality

NM

Not mentioned

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta–Analyses

PRISMA

ScR–Preferred Reporting Items for Systematic Reviews and Meta–Analyses extension for Scoping Reviews

RV

Reality–Virtuality

VR

Virtual reality

XR

Extended reality

Author contributions

All authors were involved in the design of the study. The protocol for this scoping review was developed by D.M. and D.V. D.M. and D.V. screened the articles and performed the data extraction. U.R. reviewed the article in case of disagreement. N.F. checked the articles for relevance. D.M., U.R., N.F. and D.V. were involved in data editing, analysis, and preparation of the original draft of the manuscript. All authors participated in the review and editing of the manuscript and also read and approved the manuscript.

Funding

The article is funded by the project Innovative didactic technologies for human and environmental health. The project is co-financed by the Republic of Slovenia, Ministry of Higher Education, Science and Innovation, and the European Union – NextGenerationEU. The project is implemented in accordance with the Smart, Sustainable and Inclusive Growth development area, Strengthening of Competencies component, especially digital competencies and those required by new professions and the green transition (C3 K5), for the investment measure Investment F. Implementation of pilot projects, the results of which will serve as a basis for the preparation of grounds for the reform of higher education for a green and resilient transition to Society 5.0: the project Pilot projects for the Reform of Higher Education for a Green and Resilient Transition.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Declarations

Ethical approval

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.