Table 2.

The context-mechanism-outcome configurations identified in our initial program theory.

Context	Mechanisms	Outcomesa
1. Realistic (high-fidelity) simulations	Perceptions of realistic haptics and imagery Triggers interactive learning Lack of perceived realism in haptics or tactile sensation	Enhanced skills and proficiency Learner satisfaction with realism More effective learning Preference for non-VRb learning, for example, laboratory dissection or physical reality
2. Artificial intelligence–enabled VRc	Provides feedback and highlights deficiencies	—d
3. VR or ARe that immerses learners	Engages or exposes learners in deep immersion Provides a safe environment free from patient harm Cybersickness	Higher engagement and participation in training Improved learning, knowledge, and comfort with knowledge Improved skill performance
4. Comfortable devicesc	Cybersickness	Poor learning experience
5. VR or AR that delivers standardized teaching	Provides feedback to leaners Enables repeated practice	Improves skill or performance Leads to better patient outcomes in the future
6. Visualization through VR or AR	Interactive experience Easier and more detailed visualization of patient anatomy Perceived realism of the imagery	Learner satisfaction with tool and realism Increased understanding or learning of content Improved performance or skill
7. Accounts for physical and mental workloadc	Psychological improvements (reduced stress and improved self-confidence)	Decreased mental demand, effort, and physical workload scores
8. Team training delivered by AR or VRc	Interaction between learners and environment, as well as real-time collaboration and communication	Improves teamwork Results in learner satisfaction
9. Knowledge or skill transfer	Enhances skills Practice in safe environment (with no risk to patients) Deliberate practice	Knowledge transfer to clinical practice Skills transfer to cadaver, box trainer, and surgery and procedure Better patient care in the future
10. Used with a teacherc	—	Improved instruction
11. Embedded in curriculumc	—	—
12. Limited training opportunities	Provides feedback on performance, skill or technique Repeated practice Access to experiential learning opportunities Safe and stress-free learning environment	Skill improvement, technical proficiency, and reduced incidence of complications or errors Learner satisfaction Improvements for learners with less experience
13. Novices	Feedback and objective measurement of skills or knowledge Independent or self-directed training Safe, static, and risk-free environment without endangering patients Repeated practice Exposure to experience	Technical proficiency and skill acquisition Improved performance (including operative performance) Learner satisfaction: VR was preferred Novices (less experienced people) improved most

^aContext + Mechanisms = Outcomes.

^bVR: virtual reality.

^cThe context-mechanism-outcome configurations for which we had low confidence that there would be evidence available to test them.

^dNot available.

^eAR: augmented reality.