Table 9 Disadvantages of VR simulations in medical education as reported by included reviews. Linked to RQ7.

 High costs (time-intensive development and design requiring multidisciplinary team, acquisition of high-end hardware, personnel and technical support for maintenance, updates, training and administration).

30

[19, 29, 30, 34, 35, 37, 40, 41, 47, 48, 55, 59, 61, 63, 65, 66, 72, 84, 85, 92, 96, 97, 99,100,101, 104,105,106,107, 110]

TECHNICAL LIMITATIONS

 Limitations of how accurate real-life scenarios can be represented in VR (controllers instead of actual instruments, lack of realistic feedback like bleedings, variations in anatomy, tissue replication and deformation, depth perception in case of 2D simulations, complexity of human behaviour, reactions, traits and the diversity of population)

24

[29, 30, 35, 37,38,39, 41, 44, 48, 50, 58, 65, 73, 75, 84, 96, 98,99,100, 102, 104, 109, 112, 117]

 Haptic feedback missing or unreliable (e.g., lack of force input, ergonomic limitations)

18

[29, 34, 35, 37, 38, 41, 48, 50, 65, 66, 68, 71, 75, 76, 84, 99, 100, 102]

DIDACTIC ASPECTS AND SCIENTIFIC EVIDENCE

 Inconsistent or missing evidence for the broad range of validity dimensions of acquired knowledge and skills, cost-effectiveness or cost-benefit-ratio due to the heterogeneity of objective study outcome measures and VR hardware. Missing theoretical learning framework as backbone of studies

24

[3, 11, 32, 36, 43, 44, 47, 60, 61, 63, 70, 75, 77, 84, 101, 103, 104, 107, 111, 113, 117]

 Scenarios are often simplified, repetitive, highly specific with isolated tasks and not complemented with additional learning material, variation is limited

9

[34, 44, 47, 60, 64, 84, 100, 104, 107]

 Lacking evidence for long-term retention of acquired knowledge and skills

5

[42, 44,45,46, 55]

 Lack of multiplayer-scenarios including face-to-face communications and interconnection with team

5

[19, 34, 39, 47, 105]

 Except for surgical simulators, most VR simulations focus on teaching cognitive skills, rarely on procedural or affective applications, lack of decision-making scenarios, consent processes, effective communication, leadership, i.e., non-technical skills

4

[39, 44, 48, 84]

 Bias introduction in case of unfamiliarity with immersive VR and potential technical errors

4

[44, 64, 73, 75]

 Unequal representation of medical specialties in VR applications

2

[3, 113]

 Individual needs of lecturers not necessarily integrated in application design

1

[44]

USER EXPERIENCE

 Cybersickness in case of immersive VR using HMDs (e.g., motion sickness, nausea/vomiting, dizziness, cold sweats, asthenopia, fatigue, headache, neck discomfort, blurred vision, post-VR changes in static balance)

10

[34, 49, 50, 61, 66, 73, 85, 92, 105, 107]

 VR simulations may induce overconfidence

1

[109]

 Serious content of scenarios can cause stressful experiences, anxieties about performance or interpersonal dynamics

1

[61]

 Potential of misuse, excessive use or game addiction

1

[61]