INTRODUCTION: First responders' training and learning regarding how to handle a mass-casualty incident (MCI) is traditionally based on reading and/or training through computer-based scenarios, or sometimes through live simulations with actors. First responders should practice in realistic environments to narrow the theory-practice gap, and the possibility of repeating the training is important for learning. High-fidelity virtual reality (VR) is a promising tool to use for realistic and repeatable simulation training, but it needs to be further evaluated. The aim of this literature review was to provide a comprehensive description of the use of high-fidelity VR for MCI training by first responders.

METHODS: A systematic integrative literature review was used according to Whittemore and Knafl's descriptions. Databases investigated were PubMed, CINAHL Complete, Academic Search Ultimate, Web of Science, and ERIC to find papers addressing the targeted outcome. The electronic search strategy identified 797 potential studies. Seventeen studies were deemed eligible for final inclusion.

RESULTS: Training with VR enables repetition in a way not possible with live simulation, and the realism is similar, yet not as stressful. Virtual reality offers a cost-effective and safe learning environment. The usability of VR depends on the level of immersion, the technology being error-free, and the ease of use.

CONCLUSIONS: This integrative review shows that high-fidelity VR training should not rule out live simulation, but rather serve as a complement. First responders became more confident and prepared for real-life MCIs after training with high-fidelity VR, but efforts should be made to solve the technical issues found in this review to further improve the usability.

Background: Because health professionals can end up being first responders to a mass casualty incident, they must train to improve preparedness and increase the preconditions of victim outcomes. Training and learning on how to handle a mass casualty incident is traditionally based on reading, lectures, training through computer-based scenarios, or sometimes through live simulations. Professionals should practice in realistic environments to narrow the theory-practice gap, and the possibility of repeating the training is important for learning. Virtual reality is a promising tool for realistic and repeatable simulation training, but it needs further evaluation. This study aimed to describe the acceptability and applicability of using VR for training in mass casualty incidents.

Methods: A mixed-methods evaluation design was used, where the qualitative and quantitative findings were embedded into the discussion with a realist inquiry approach. A virtual reality simulation with mass casualty incident scenarios, named GoSaveThem ( www.crash.nu ), was used, and the participants were directed to perform triage. After the simulation, the participants filled in a questionnaire with open-ended questions and ratings on technical aspects, learning experiences, and improvement of preparedness. Eleven of the participants underwent interviews. The qualitative data was analyzed either summarily or with a conventional content analysis. Data were extracted from computer recordings of how long it took for each participant to triage the first 10 victims and to what extent the triage for the first 10 victims was correct. Descriptive statistical analyses were done, and a comparison was made to see if there were any differences between age, sex, educational background, and previous experiences that affected the outcome of triaging.

Results: Training with virtual reality enables repeatable and realistic simulation training of mass casualty incidents. The participants expressed motivation to repeat the training and experience expanded virtual reality scenarios. This study shows that the acceptability and applicability of using VR for training MCIs were high overall in all examined dimensions for most users, with some exceptions.

BACKGROUND: How ambulance clinicians (ACs) handle a mass casualty incident (MCI) is essential for the suffered, but the training and learning for the ACs are sparse and they don't have the possibility to learn without realistic simulation training. In addition, it is unclear what type of dilemmas ACs process in their clinical reasoning during an MCI. With virtual reality (VR) simulation, the ACs clinical reasoning can be explored in a systematic way. Therefore, the objective was to explore ambulance clinicians' clinical reasoning when simulating a mass casualty incident using virtual reality.

METHODS: This study was conducted as an explorative interview study design using chart- stimulated recall technique for data collection. A qualitative content analysis was done, using the clinical reasoning cycle as a deductive matrix. A high-fidelity VR simulation with MCI scenarios was used and participants eligible for inclusion were 11 senior ACs.

RESULTS/CONCLUSION: All phases of the clinical reasoning cycle were found to be reflected upon by the participants during the interviews, however with a varying richness of analytic reflectivity. Non-analytic reasoning predominated when work tasks followed specific clinical guidelines, but analytical reasoning appeared when the guidelines were unclear or non-existent. Using VR simulation led to training and reflection on action in a safe and systematic way and increased self-awareness amongst the ACs regarding their preparedness for MCIs. This study increases knowledge both regarding ACs clinical reasoning in MCIs, and insights regarding the use of VR for simulation training.