Background: Mass casualty incidents (MCIs) are infrequent, which limits the opportunities for ambulance clinicians (ACs) to develop the experience and routine required to apply best practices and strengthen their preparedness for such situations. Their learning, both as students and their lifelong learning for professional competence, to manage an MCI, depends on training. For this training to be effective, it should take place in realistic settings and be repeatable to support learning. Virtual reality (VR) simulations offer promising support for developing these competencies. However, it is crucial to assess the strengths and limitations of VR before adopting it broadly in educational and clinical practice. Therefore, this thesis aimed to evaluate VR as a pedagogical method when learning about MCIs.

Methods and results: Study I was a systematic integrative literature review that included 17 studies and revealed that training with VR allows for repetition in a way that is not possible with live simulation, and the realism is similar but less stressful. It demonstrated that VR provides a cost-effective and safe learning environment and concluded that the usability of VR depends on the level of immersion, the technology being error-free, and ease of use. Study II was a mixed-methods study with an embedded design, where the data were integrated into the discussion section. It involved 95 participants who underwent VR training for MCI. The study confirmed that VR training allows for repeatable and realistic simulation training of MCIs. The participants expressed motivation to repeat the training and experience expanded VR scenarios. This study indicated that the acceptability and applicability of using VR for training MCIs were generally high across all examined dimensions for most users, with some exceptions, such as experiences of technical disruptions and physical symptoms. Study III was a Randomized Controlled Trial (RCT), in which 72 nursing students were enrolled for training in triage for mass casualty incidents in two parallel arms: VR-based training as the intervention and table-top training as the control. It showed that VR-based triage training led to better long-term knowledge retention than standard triage training, with a significant difference (P=0.012). Although nursing students in the control group performed triage more accurately and quickly, the longer triage times in the VR group may have reflected real-life MCI conditions. The findings suggest that VR training can be an effective pedagogical method for MCI training despite an initial performance gap. Study IV was a qualitative interview study using the chart-stimulated recall technique to enable the 11 included senior ACs to articulate their clinical reasoning after VR training for an MCI. This study enhances understanding of ACs' clinical reasoning in MCIs and provides insights into the use of VR as a pedagogical method for simulation training and reflection on action. All phases of the clinical reasoning cycle were found to be reflected upon by the participants during the interviews, although with varying levels of analytic reflectivity. Utilizing VR simulation facilitated training and reflection on action safely and systematically, increasing self-awareness among the ACs regarding their preparedness for MCIs.

Overall conclusion: Both usability and learning aspects must be addressed to optimize VR as a pedagogical method for MCI training. Regarding usability, the focus should be on including realistic, varied scenarios and intuitive technology that accommodates different user needs, including those with glasses or sensitivity to motion sickness. Alternative methods should be available when VR is not suitable. Regarding learning, psychological reactions during training were thought to enhance preparedness for real-life stress, while the VR environment allowed for safe mistake-making and correction. When compared to other pedagogical methods, VR was seen as a flexible, accessible, and engaging approach for realistic and repeatable MCI training, with high user satisfaction overall. The potential of VR to support feedback and reflection - both computer-generated and instructor-led - was also emphasized. Further, VR training showed promising results for knowledge retention, compared to tabletop exercises, though further research is needed to generalize these findings. Ultimately, if the identified aspects found in this thesis are carefully implemented, VR holds strong potential to bridge an educational gap and improve MCI preparedness among students and ACs.