Virtual reality simulation to teach communication for undergraduate nursing students: a scoping review

Abstract

Background

Effective communication critically influences nursing care quality. Developing communication skills requires sustained practice, but conventional training faces implementation barriers. Virtual reality (VR) technology, by generating realistic and controllable clinical environments, possesses inherent advantages for clinical communication training. This scoping review maps evidence on VR simulation for developing communication skills in undergraduate nursing education.

Methods

A systematic search was conducted in 8 databases from inception to January 2025: CINAHL, Scopus, Embase, Web of Science, Cochrane CENTRAL, Ovid MEDLINE ALL, PsycINFO and ERIC. PubMed was additionally searched to ensure coverage completeness. This review focused on studies on VR simulation as a pedagogical intervention for training communication skills in undergraduate nursing education. Educational settings included academic institutions and clinical environments. Data were extracted and organized using a modified extraction tool from the Joanna Briggs Institute (JBI) reviewers’ manual. Qualitative analysis followed a six-phase thematic framework. We documented the specific study characteristics, VR simulation protocols, key outcomes, and primary conclusions.

Results

Seven studies were included. These studies utilized VR simulation for clinical communication training in pre-clinical undergraduate nursing students. Multiple metrics including communication knowledge, attitude, self-efficacy, and confidence were quantified to determine the effectiveness of VR-based educational interventions. The findings suggested that VR simulation is potentially effective in enhancing communication skills training for both nurse-patient interactions and interprofessional collaboration. However, scenario fidelity and time-sensitive interaction design require further refinement and enhancement.

Conclusions

VR simulation represents a promising strategy for enhancing communication skills in undergraduate nursing students. To realize its full potential, future work could establish implementation standards and generate further evidence of its long-term efficacy across diverse socioeconomic settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08450-7.

Introduction

Communication is a dynamic process which reflects the transmission and feedback of thoughts and feelings between individuals. It is an indispensable component of clinical nursing practice. Effective communication directly enhances care quality and ensuring patient safety through error reduction [1]. In nursing practice, nurses’ communication competence is essential for establishing therapeutic relationships with patients, which in turn improves treatment adherence and care satisfaction [2]. Additionally, nurses possessing strong communication skills demonstrate enhanced self-efficacy and increased confidence in clinical practice, particularly among newly qualified nurses and undergraduate nursing students [3, 4]. Therefore, to promote nursing advancement, it is essential for nursing educators to prioritize the improvement of communication skills among nursing students.

Developing effective communication skills requires sustained practice and cannot be achieved instantaneously. Nurse educators utilize various training methodologies to cultivate communication competencies in undergraduate nursing students [5]. However, the allocation of time and resources poses a significant challenge in implementing these training programs [6]. Conventional communication training methods, such as standardized patient encounters and panel discussions, often face constraints regarding location and cost [7]. Furthermore, standardized patients frequently experience anxiety, fatigue, and physical discomfort during training sessions [8]. A systematic review has showed that although all interventions produce significant improvements in communication-skills training, the most effective method remains unclear [5].

Virtual reality (VR) utilizes computer technology to construct an interactive three-dimensional (3D) environment, enhancing users’ sense of spatial presence. Over the past few years, VR has been recognized as an effective teaching method in nursing education [9]. Through advanced computer technology, virtual patients offer interactive simulations of authentic clinical scenarios, which are instrumental in facilitating the training, education, and assessment of healthcare providers [10]. The auditory and visual impacts of VR, combined with its immersive experience, are particularly effective in training communication skills. Czech et al. [11] illustrated that VR seems to be an effective therapeutic support for pain management during burn wound care procedures. In the acquisition of airway management capacity, VR presents a promising platform for consistent, reproducible, and asynchronous training and skill retention [12]. Furthermore, VR simulation was verified to effectively enhance blood transfusion education, improving knowledge, satisfaction and self-confidence among nursing students [13]. This suggests that VR simulation is a promising teaching approach, characterized by its high flexibility, consistency, and repeatability compared to traditional analog or digital training methods [14]. In addition, the use of virtual patient or virtual medical practitioner conversations could enhance the authenticity of clinical scenarios through simulated face-to-face interactions [15].

Accumulating evidence demonstrates the efficacy of virtual simulation in professional nursing education and training. For instance, undergraduate nursing students reported that VR helped build their confidence, enhance their nursing skills, and facilitate the acquisition of knowledge [16]. The application of VR simulation also serves as a valuable tool for enriching undergraduate midwifery students’ learning experiences and promoting engagement; it offers comparatively economical costs relative to alternative methods [17]. Liaw et al. [18] verified the effectiveness of VR simulation in cultivating interprofessional communication among undergraduate medical and nursing students. The aim of this scoping review is to map the available evidence regarding VR simulation for enhancing communication skills training in undergraduate nursing education in clinical environments.

Methods

We conducted a scoping review to summarize and interprete findings from both quantitative and qualitative studies. Our approach adhered to the Joanna Briggs Institute guidelines [19] and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [20]. The scoping review protocol was not registered or published.

Formulating the research question

The following two questions were formulated after a preliminary discussion:

1. How are educators integrating virtual reality into communication instruction?

2. What challenges have arisen during the teaching process?

Search strategy

The search strategy was based on Population, Concept and Context (PCC) elements [21]. A systematic search was executed in eight databases from inception to January 2025: CINAHL, Scopus, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE ALL, PsycINFO and ERIC. We also performed a manual search of PubMed until January 2025 to ensure coverage completeness. This end date was selected to capture the latest publications available during the final stages of manuscript preparation. The search strategy used Boolean operators (e.g., ‘OR’, ‘AND’), customized to match each database’s syntax requirements. We have provided the full search strategy for PubMed as an example (Table 1). Furthermore, a comprehensive search concept framework was provided in the supplementary material (Table S1) for brevity and transparency.

Table 1.

PubMed search strategy

Number	Search items
#1	((((“students, nursing” [MeSH]) OR (“undergraduate nurses” [Title/Abstract])) OR (“nursing undergraduates” [Title/Abstract])) OR (“pupil nurses” [Title/Abstract])) OR (“pre-registration nurses” [Title/Abstract])
#2	(((((“communication” [MeSH]) OR (“personal communication” [Title/Abstract])) OR “(communication program” [Title/Abstract])) OR (communication skills [Title/Abstract])) OR (communication training [Title/Abstract])) OR (interaction [Title/Abstract])
#3	(((((((“education” [MeSH]) OR (“educational activities” [Title/Abstract])) OR (“literacy programs” [Title/Abstract])) OR (“training programs” [Title/Abstract])) OR (“pedagogical methods” [Title/Abstract])) OR (“teaching methods” [Title/Abstract])) OR (learning [Title/Abstract])) OR (teaching [Title/Abstract])
#4	((((“virtual reality” [MeSH]) OR (“educational virtual reality” [Title/Abstract])) OR (“instructional virtual realities” [Title/Abstract])) OR (“virtual simulation” [Title/Abstract])) OR (“immersive virtual reality” [Title/Abstract])
#5	((((“university” [MeSH])) OR (“teaching hospital” [Title/Abstract])) OR (“academic medical center” [Title/Abstract])) OR (“nursing school” [Title/Abstract])
#6	#1 AND #2 AND #3 AND #4 AND #5

Inclusion and exclusion criteria

We included studies that incorporated communication skills training interventions in nursing education. Additionally, studies were required to utilize virtual reality simulation as an educational intervention, with explicit documentation of its implementation methodology. We focused on educational interventions in either academic or clinical settings, primarily targeting undergraduate nursing students. Studies involving predominantly undergraduate nursing students alongside other healthcare students (e.g., medical students) were included, but the analysis focused on studies that included nursing students. We excluded studies that did not involve undergraduate nursing students or evaluate communication skills outcomes. Non-English publications were also excluded to ensure methodological consistency.

Screening process

The screening process was performed independently by two researchers across three stages: (1) title/abstract screening of identified records; (2) full-text assessment of potentially eligible studies using predefined inclusion criteria; and (3) supplementary searches through manual reference scanning of included articles.

Data extraction

We implemented a modified version of the data extraction tool from the Joanna Briggs Institute (JBI) reviewers’ manual for scoping reviews [19]. Two researchers independently performed data extraction using the modified tool, with the second researcher blinded to the first researcher’s extraction results. All extractions were cross-verified against source documents, with discrepancies resolved through consensus or by consultation with a third researcher. The extracted data included the following study characteristics: publication year, study design, participants, intervention, key outcomes, main conclusion, and methodological limitations in the research.

Collating, summarizing and reporting the results

In this scoping review, we employed independent dual screening of titles, abstracts, and full texts using predefined eligibility criteria, with a third reviewer resolving discrepancies. Relevant characteristics of all records were summarized after the extracted data were verified for accuracy. Owing to the heterogeneity in clinical settings, VR applications, and assessment instruments, a quantitative synthesis was not justified. Consequently, we collated and summarized the findings using the six-phase thematic synthesis framework [22]. Following initial data familiarization through an iterative, inductive mapping approach, we systematically identified, analyzed, and reported coded data. All included articles were analyzed collectively before clustering results into thematic categories. Any discrepancies were resolved through team discussion and collaboration. Given the exploratory nature of the scoping review, a formal quality assessment was not conducted.

Results

Literature search and selection process

A total of 1317 articles were identified by searching the databases. Following duplicate removal, we screened 871 records by title and abstract, subsequently selecting 213 articles for full-text assessment. Ultimately, 7 studies met predefined eligibility criteria. These articles have been structured in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [20] (Fig. 1).

Fig. 1.

Flow chart outlining literature search and selection process

Characteristics of the included studies

Among the 7 studies, four were from Singapore [3, 15, 18, 23], two from Taiwan [4, 24], and one from Brazil [25]. All studies focused on undergraduate nursing students before entering clinical practice. Most studies examined VR-based simulations that visually represented nurse-patient interactions in clinical case scenarios [3, 4, 15, 23–25], while Liaw et al. [3, 18] focused on nurse-physician communication. The participants also included clinical facilitators [23], professors [25], and medical students [18] (Table 2). Nursing professors or clinical facilitators served as evaluators of students’ communication skills or VR utility.

Table 2.

Characteristics of the included publications

Category and author, year of publication	Design Participants	Intervention or technological application	Main outcomes	Key conclusions	Methodological limitations
Shorey et al., 2019 [15]	Development Study. 150 year 2 and year 3 nursing undergraduates.	Developed a virtual counseling application using artificial intelligence, with virtual patients (VP) and four semesters for training.	The effectiveness of VP imitating standardized patients and providing role-playing was proved.	VP simulations application improved nursing students’ communication and interview skills. Further refinements and constant enhancements are needed to train the VPs to enhance clinical conversation realism.	Non-randomized allocation
Liaw et al., 2023 [3]	Mixed methods design. 32 final year nursing students participated the study.	Nursing students interacted with an AI doctor via AI-enabled virtual reality simulation system. The entire process required approximately two hours.	A novel AI-enabled VR simulation significantly enhanced nursing students’ communication knowledge and self-efficacy.	The AI-enabled virtual reality simulation demonstrated high efficacy in advancing communication skill acquisition.	Lack of a control group and long-term follow-up limits causal inference and evaluation of sustained effects.
Shorey et al., 2020 [23]	A descriptive qualitative study design. 24 nursing undergraduates and 6 clinical facilitators.	Developed a virtual counseling application using artificial intelligence, with virtual patients (VP) and four semesters for training.	VP improved nursing students’ communication skills. Several key areas were needed to improve, such as enhancing realism and language training.	Students and clinical facilitators expressed satisfaction with the application. Several deficiencies requiring continuous improvement were identified.	Sample drawn from a prior study cohort, which may limit representativeness.
Hara et al., 2021 [25]	A methodological, quantitative study. 13 nursing professors and 30 nursing students.	Comunica-Enf, a 3D immersive virtual reality serious game.	Participants considered that Comunica-Enf was suitable for facilitating students’ communication competence learning.	Comunica-Enf provided a safe and pleasant environment with validated appearance and usability. It was suitable for nursing students’ communication education.	Contextual constraints of the study design
Liaw et al., 2020 [18]	A randomized controlled trial study. 60 medical students and 60 nursing students.	Participants were randomly assigned to two groups and underwent 3 h of team training on nurse-physician communication. One group undertook the virtual reality simulation into the 3D virtual environment. The live simulation group entered simulated ward setting for their training.	There were no significant differences in the communication performance between virtual and simulation groups. Both groups showed significant increases in interprofessional attitudes, and no significant differences were reported between the groups over the 3 time points.	This study approved the use of virtual reality to replace traditional simulations for communication team training.	Blinding not possible (due to intervention type)
Chou et al., 2024 [4]	A pragmatic randomized controlled trial with four within-participants assessments (at the baseline, 1 st week and 3rd week of the clinical practice and 1 week after the end of the clinical practice assessments). 84 s-year nursing students, 42 in the experimental group and 42 in the control group.	The intervention group learned communication skills using the HTC Vive Focus 3 HMD, the control group learned the skills by watching a nurse–patient communication teaching video.	Communication ability scores, communication confidence and learning satisfaction were significantly higher in the experimental group than in the control group. Clinical practice stress scores were significantly lower in the experimental group than in the control group.	The effectiveness of virtual reality communication simulation was validated. And it should be arranged as soon as possible in fundamentals of nursing practice courses to develop communication abilities.	Blinding not possible (due to intervention type)
Hwang et al., 2022 [24]	A quasi-experimental study. 40 senior nursing students (VP-based social learning approach group = 20, control group = 20).	The experimental group adopted the VP-based learning approach, the control group adopted the conventional learning approach.	Students’ learning performance, self-efficacy, and communication skills were significantly greater in the experimental group than in the control group.	The VP-based social learning approach would be an effective strategy to improve students’ communication skills.	Non-randomized allocation

Methodological considerations of the included studies

Consistent with the aims of a scoping review, a formal risk-of-bias assessment was not performed. Key methodological features of the included studies are summarized in Table 2. The evidence comprised diverse study designs with limitations indicative of an evolving field. Common considerations involved the use of non-randomized allocation, inability to blind participants due to the VR intervention nature, and limited long-term follow-up, which constrains conclusions regarding sustained communication skill improvement. Additionally, contextual factors such as single-center designs and convenience sampling suggest that results should be interpreted within their specific settings.

VR-based nursing communication training approach

All seven studies employed VR technology to enhance nursing students’ communication skills, although there were subtle differences in their methodologies and approaches. Shorey et al. [15, 23] and Hwang et al. [24] used a specific computer program designed to simulate standard patients, namely virtual patient (VP). Students could interact with VPs to train their communication skills. The VP systems objectively recorded the communication and interactive learning process while also assessing their cognitive and decision-making ability. Additionally, Shorey et al. [15, 23] developed four VP case scenarios incorporating communication with family members and other professionals. Two studies [3, 18] focused on interprofessional communication by using the Unity 3D game engine. In the 3D virtual environment, a virtual hospital ward, a virtual patient, a nursing avatar role and an artificial intelligence (AI) doctor agent were created [3]. Medical and nursing students were randomly paired and assigned to two simulation groups [18]. Each dyad (one medical student and one nursing student) participated in two clinical scenarios featuring the same virtual patient with varying clinical presentations [18]. Participants rotated between role-playing clinicians and observers, while simultaneously practicing interprofessional communication through repeatedly reporting the patient’s condition to the AI doctor after assessing and managing the VPs [3]. Hara et al. [25] developed a 3D virtual immersive scenario to provide better realism. The developers used a laboratory to create an environment where players could physically interact with patients. Similarly, Chou et al. [4] designed a communication simulation system using the Unity 3D game engine. In this system, students were required to complete four learning tasks (self-introduction, nurse–patient relationship establishment, interaction and medical history collection) within a VR scenario.

VR-based intervention assessment strategy

A simulation-based assessment was administered across all participating institutions to validate the effectiveness of VR technology in nursing communication education. Primary outcomes included communication knowledge, attitude, self-perceived efficacy, and confidence. Four studies [3, 4, 18, 24] utilized validated instruments for communication skills evaluation and self-efficacy measurement. In contrast, one study [15] utilized self-administered questionnaires to assess communication attitude and confidence. One study employed thematic analysis to assess the impact of VR-based training on students’ communication skills and confidence [23]. Additionally, the validation of the three-dimensional immersive VR system was evaluated as an assessment method [25]. Four studies [3, 15, 23, 25] assessed the learning outcomes immediately after participants completed virtual simulation training. Multiple researchers enhanced measurement validity by comparing pre- and post-simulation assessment scores, which objectively quantified participants’ performance improvements [4, 18, 24]. Two studies [4, 18] assessed the subsequent effects of VR-based simulation at one week and two months post-intervention.

VR-based intervention outcome indicators and effects

The primary outcomes were communication knowledge, attitudes, and self- efficacy. Qualitative findings of participant interviews regarding their VR experiences revealed that virtual patient integration actively enhanced communication skill development [23]. Several quantitative studies [3, 4, 24] illustrated that a significant improvement in nursing students’ communication knowledge and self-efficacy was observed following VR simulation training with virtual patients and clinicians in a virtual clinical environment. In addition, a randomized controlled trial [4] demonstrated that VR simulation improved students’ communication attitudes and confidence. This was attributed to the authentically replicated clinical setting, where students practiced free from performance pressure during interactions with virtual patients. One study [18] demonstrated that VR-based nurse-physician communication training improved attitudes toward interprofessional communication and was non-inferior to live simulation. This finding affirms the feasibility of VR as a scalable alternative training modality that enables deliberate practice. It should be noted that the findings represented composite outcomes from a mixed cohort of nursing and medical students, and thus cannot be attributed exclusively to nursing students.

Challenges of VR-based nursing communication education

Evidence from the seven studies indicates signals of benefit for communication training, especially for improvements in learners’ self-efficacy, attitudes and knowledge. However, there are deficiencies requiring continuous refinements and constant enhancements. The prominent challenge is ensuring that conversations in the VR environment are relevant to real-life situations. This stems from virtual agents’ constrained capacity for affective communication and risks of dialogic discontinuity [3, 15, 23, 25]. Secondly, virtual simulation characters (e.g., virtual patients, doctors, or nurses) lack situational sensitivity and clinical urgency. These characters tend to respond reactively based on specific inputs, retrieving only predefined responses, which limits the realism and depth of interactions. Another significant issue is the language barrier [15, 23]. Limited language proficiency may impede students’ development of interpersonal communication skills, particularly during interactions with non-native speakers, potentially compromising learning efficacy. Three studies [4, 18, 24] omitted documentation of implementation challenges in VR-based nursing communication training.

Discussion

Seven studies were identified that focused on communication education using VR simulation for undergraduate nursing students. The collective findings suggest that VR simulation holds promise for developing nursing students’ communication competence, with benefits particularly noted in self-reported outcomes such as knowledge acquisition, self-efficacy, and confidence. Most studies (6/7) were conducted in high-income regions. This observed trend may reflect certain technical and financial investments required for developing and implementing VR-based simulation systems in foundational medical training [26]. Although the heterogeneity among the studies indicated that adopting a systematic synthesis method may not be recommended. However, analysis of these findings provided valuable insights for nursing educators, facilitating their ability to effectively utilize the benefits and unique features of VR simulation in nursing communication training.

VR is primarily characterized by elements such as interaction, immersion, immediacy, participation, and presence [27], which enable the creation of high-fidelity, clinically relevant communication environments [3, 15, 24]. These environments provide a safe platform for communication practice, accommodating flexible scheduling, and allowing for customizable learning experiences. Historically constrained by structural barriers such as limited clinical access or safety requirements, nursing students have frequently lacked opportunities for hands-on training in healthcare settings. VR simulation is a multifaceted platform for communication skills training, enabling the safe, private practice of high-risk scenarios without clinical consequences [28], which is particularly advantageous for shy or introverted students [23, 25, 29]. This foundational safety enables deliberate, repeated practice using standardized, on-demand scenarios, facilitating the systematic development of communication competence [4]. Beyond safety and repetition, VR also offers controlled exposure to high-acuity clinical environments such as intensive care and emergency departments, fostering skills in information synthesis and complex scenario clinical management [30].Therefore, VR has been suggested to be a viable substitute for live simulations in clinical communication skills training [18].

Based on these technical capabilities, VR offers systematic opportunities for immersive skills practice while supporting evidence-based educational approaches such as simulation-based mastery learning and deliberate practice frameworks [31]. Multiple studies [31–33] indicated associations between VR-integrated experiential/project-based learning and improvements in nursing students’ communication skill and academic performance. Additionally, VR simulation is associated with multifaceted educational outcomes, including enhanced critical thinking, knowledge integration, and the progressive development of psychomotor, cognitive, and interpersonal skills. It also shows promise in boosting key learner attributes such as self-efficacy, confidence, and satisfaction. This technology provides accessible and cost-effective clinical practice opportunities [34]. Nurse educators can utilize the distinctive benefits of VR to develop targeted communication training programs for undergraduate nursing students, thereby enhancing efficiency and optimizing resource allocation.

However, the evidence regarding VR’s efficacy paints a nuanced picture. A meta-analysis [35] found that while VR demonstrated efficacy in promoting knowledge acquisition, it showed no significant advantage over conventional methods for skill development, learner satisfaction, or confidence. This may be attributed to limitations in study design and a lack of long-term outcome validation. A critical challenge in implementing VR simulation is the demonstrable gap between technological capabilities and human performance, which can limit system efficacy, particularly in replicating complex therapeutic communication within clinical contexts [15, 23]. Some participants reported that VR scenarios lacked a sense of clinical urgency, highlighting that time can be critically important and usually represents patients’ lives in real care situations [3]. Close collaboration between nurse educators and technology developers is key to addressing this issue. Educators can provide developers with an immersive understanding of clinical urgency and contribute by co-designing VR scenarios rooted in authentic clinical cases. These may include challenging communications during conflicts, resuscitation, or the management of pain and psychological distress. Furthermore, nurse educators can use scenario-based videos to illustrate critical clinical concepts and decision points for developers. Through this collaborative and iterative refinement, they can effectively bridge the gap between real-world clinical practice and VR technology, creating realistic and targeted simulation scenarios.

VR technology leverages advances in computer graphics, digital image processing, multimedia technology, and sensor technology to create diverse virtual environments [36]. Another significant challenge identified is the lack of language resources. Shorey et al. [23] suggested that expanding language-learning resources or dialect-specific training for students would enable them to better understand the fundamental patient needs. Developers and educators could incorporate essential language components into clinical simulation platforms or integrate AI-driven natural language processing capable of generating dynamic, multilingual clinical scenarios. This expands the linguistic database, equipping learners to practice context-specific clinical communication and thereby significantly improving training outcomes [37].

Limitations

This scoping review has several limitations. First, although our search was systematic, its complexity introduces the possibility that some relevant publications were not captured. Second, the generalizability of our findings is potentially limited by geographic bias, with 6/7 studies from high-income settings. Third, the inability to disaggregate outcomes by discipline in the one study with a mixed-profession cohort limits conclusions specific to nursing students. Finally, the swift pace of innovation in virtual reality hardware and software may limit the long-term relevance of our results, as technical capabilities are likely to advance beyond those assessed in this study.

Conclusions

Evidence from this review supports VR simulation as an effective method for cultivating clinical communication competencies in undergraduate nursing students, serving as a valuable alternative or supplement to traditional training methods. To facilitate broader adoption, future work should focus on establishing the standardized implementation frameworks. We recommend multi-center longitudinal studies to assess long-term effectiveness across diverse socioeconomic contexts and to inform evidence-based guidelines for curricular integration.

Authors’ contributions

C.X. and J.D. conceived and designed the study. J.C., C.X., L.W. and J.D. acquired and interpreted the data. J.D., L.W. and Y.T. analyzed the data and drafted the manuscript. X.G. and C.X. substantially contributed to the revision of the manuscript. All authors reviewed and approved the final manuscript.

Funding

No funding was received.

Data availability

The data used and/or analyzed in the present scoping review will be available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This scoping review focused on previously published articles and did not include any human participants, approval by an institutional review board was not required.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.