Virtual reality simulation for early recognition of clinical deterioration in undergraduate nursing education: An implementation-oriented conceptual framework

Background Early recognition of clinical deterioration is a core patient safety capability requiring knowledge, clinical judgement and contextual decision-making. Virtual reality (VR) simulation offers scalable, repeatable opportunities for deterioration learning; however, outcomes vary and are often insufficiently aligned with learning theory, simulation standards and implementation conditions. Method An integrative review was conducted using Whittemore and Knafl's methodology and reported in accordance with PRISMA guidelines. Six databases (CINAHL, PubMed, MEDLINE, Scopus, Web of Science and Embase) and references were searched from January 2015 to December 2025. Study quality was appraised using the Mixed Methods Appraisal Tool. Results Twenty studies met the inclusion criteria. Four analytic functions were identified: (a) cognitive processing and clinical cue integration; (b) motivation, engagement and confidence calibration; (c) simulation standards and reflective practices operationalizing learning; and (d) implementation conditions influencing usability, feasibility, fidelity and adoption. Implementation conditions were reported inconsistently, limiting the interpretation of learning outcomes. Conclusion The framework links learning mechanisms, implementation determinants and outcomes to guide theory-informed simulation design, curriculum integration and evaluation of VR simulations for clinical deterioration. It also supports future empirical testing of VR-based educational interventions.