Integrating augmented reality virtual patients into healthcare training: A scoping review of learning design and technical requirements

Farshid Chahartangi; Nahid Zarifsanaiey; Manoosh Mehrabi; Bahareh Zeynalzadeh Ghoochani

doi:10.1371/journal.pone.0324740

Peer Review History

Original SubmissionMarch 5, 2025
Decision Letter - Ziyu Qi, Editor PONE-D-25-10169Integrating Augmented Reality Virtual Patients into Healthcare Training : A Scoping Review of Learning Design and Technical RequirementsPLOS ONE Dear Dr. Zarifsanaiey, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== ACADEMIC EDITOR: Please address the concerns by all the reviewers before I consider accepting your manuscript. ============================== Please submit your revised manuscript by May 22 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols . We look forward to receiving your revised manuscript. Kind regards, Ziyu Qi Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. In the online submission form, you indicated that the data supporting this study's findings are available from the corresponding author on request. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. 3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 4. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments : Please address the concerns by all the reviewers before I consider accepting your manuscript. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Augmented reality and virtual patients offer interactive and immersive learning experiences, with AR enhancing the understanding of complex concepts and VPs providing hands-on practice in clinical scenarios. In this well-written review, the authors have done a nice job to summarize the relavent literatur. This review may be helpful for the readers to get a quick picture of this popular topic. Reviewer #2: Manuscript Number: PONE-D-25-10169 Article Type: Research Article Title: Integrating Augmented Reality Virtual Patients into Healthcare Training : A Scoping Review of Learning Design and Technical Requirements Dear Sir/madam Thank you for your efforts, and for considering our journal for publication of your work. Title Title is concise and reflect the study content properly. Abstract - Abbreviations appearing for the first time and not explained before (like; AR, VP,..). authors need to make sure these are established as the beginning before continue using it. For example augmented reality (AR) at the start. - As a review article your database you carried the search on should be included in full rather than etc. - A summary of inclusion/ exclusion criteria is needed, how you filtered 924 into 27? (no details needed) Methods - Clearly state if studies using only one technology (VP) or (AR) were included in the review, and if so does your objectives restrict the study to inclusion of those using both technologies only? - The time frame of the included studies need to be clarified? Was it from specific date (ex; 2000) or open to any available literature? Results - Results are well structured and represent the objectives. - Authors need to explain the justification behind including IT students? Exclusion criteria mentioned studies not conducted at healthcare level. - The paragraph headed “Medical Specialties and Educational Focus”, and the sub “Overview of Medical Specialties and Educational Contexts” are repetitive with high redundancy. Authors are advised to draft this section. - Authors also need to explain how these classifications were made? Why stroke diagnosis were put with “therapeutic skills” category? Was there any method/ software of qualitative analysis used to draw these data? Discussion - The discussion section started by re-stating the aim and the main finding which is good. - However, detailed data were presented. Authors need to focus on bringing more comparison with the existing literature rather than detailing the same data presented at the results section. - Limitations were clearly stated, authors may as well explain what has been done to address these limitations and its potential effect on the presented results. Conclusion - Conclusion represent the stated objectives and data. Future implications and recommendations were presented. Reviewer #3: The authors reference PRISMA-ScR and JBI guidelines and adopt a PCC framework, which is appropriate. The manuscript refers to a “systematic scoring process” for evaluating included studies (p.6); however, no validated appraisal tool is cited. In “Data collection process”, clarify whether the authors formally appraised the quality of the included studies, and if so, to: Name the tool used (e.g., JBI checklist), Explain the process, and Justify its use in the context of a scoping review. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy . Reviewer #1: Yes: Xiaolei Chen Reviewer #2: No Reviewer #3: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Reviewers Report.docx https://doi.org/10.1371/journal.pone.0324740.r001
Revision 1
21 Apr 2025 Author Response Dear Esteemed Reviewers of PLOS ONE, I am pleased to resubmit the revised manuscript titled “Integrating Virtual Patients and Augmented Reality in Healthcare Professional Education: A Scoping Review of Learning Design and Technical Requirements.” I sincerely appreciate the constructive feedback from the editor and reviewers, which has significantly enhanced the quality of this article. We have made several positive changes based on your suggestions, and the revised manuscript includes highlighted modifications for your review. I would like to express my profound gratitude for the time and attention you dedicated to this review. Your insightful critiques have been invaluable in improving the structure, content, and scientific rigor of our research. Additionally, I extend my heartfelt thanks to Dr. Ziyu Qi, the Academic Editor of PLOS ONE, for his diligent follow-up and for the opportunity to publish in this esteemed journal. In the following sections, we will address each of the reviewers' comments in detail and outline the corresponding revisions made in the manuscript. Sincerely yours, Dr. Nahid Zarifsaniey Reviewer #1: We extend our sincere gratitude for your kind consideration and positive feedback regarding the present study. Receiving such encouraging and affirmative responses, particularly your assessment of the research as beneficial, effective, and possessing scientific merit, is a source of considerable satisfaction and reinforces our motivation. Your encouragement and validation significantly strengthen our resolve to pursue high-quality research and contribute to the advancement of knowledge in this field. We deeply appreciate the meticulous attention and time you dedicated to the thorough review of our manuscript, and we are highly gratified that our work has met with your approval and endorsement. Reviewer #2: We would like to express our sincerest gratitude and deepest appreciation for your valuable insights and profound understanding of this manuscript. Your meticulous observations and expert guidance have not only clearly illuminated the strengths and weaknesses of our study but have also paved a clear path for its improvement and the enhancement of its scientific quality. We firmly believe that you’re constructive and precise suggestions have significantly contributed to the enrichment of the content and the strengthening of the methodological rigor of our research, transforming it into a more robust and scientifically sound work. The positive impact of your invaluable feedback will be clearly evident in the revised version of the manuscript. Abstract - Abbreviations appearing for the first time and not explained before (like; AR, VP). Authors need to make sure these are established as the beginning before continue using it. For example augmented reality (AR) at the start. Response: Your valuable comment was taken into consideration and added to the text of the article. Text added to the article abstract: "Augmented reality (AR) enables users to view the real world with enhanced digital information, making it a transformative tool in education. Virtual patients (VPs) technology is also defined as “a specific type of computer-based application that simulates real-world clinical scenario. AR and VPs offer interactive and immersive learning experiences, with AR enhancing the understanding of complex concepts and VPs providing hands-on practice in clinical scenario." - As a review article your database you carried the search on should be included in full rather than etc. Response: Your valuable comment was accepted and this section was fully stated. Text added to the article abstract: "MEDLINE (PubMed), Science Direct (Elsevier), Web of Science (Clarivate), Cochrane library, ERIC, Scopus." - A summary of inclusion/ exclusion criteria is needed, how you filtered 924 into 27? (no details needed). Response: Your suggestion has been incorporated, and the necessary corrections are now present in the manuscript. To ensure a rigorous selection process aligned with the study's purpose and specified criteria, two researchers independently performed the abstraction and full-text review of the identified studies. A third researcher then conducted an independent verification of the extracted information, which resulted in the final set of articles. Text added to the article abstract: "A comprehensive search yielded 924 potential studies. Articles were selected via a two-stage screening process, involving title/abstract and full-text reviews based on predefined inclusion criteria. Disagreements were resolved through consultation, resulting in 27 studies being included." Methods - Clearly state if studies using only one technology (VP) or (AR) were included in the review, and if so does your objectives restrict the study to inclusion of those using both technologies only? Response: We selected articles that integrated both virtual patient and augmented reality technologies. The selection of studies involved identifying articles with relevant keywords in their title or abstract. However, for example, in some articles where the term "virtual patient" was absent from their title, but upon review of the abstract and full text, the use of virtual patient simulation (such as: brain tumors and heart problems, etc.) was evident and aligned with the objective of the present study. - The time frame of the included studies need to be clarified? Was it from specific date (ex; 2000) or open to any available literature? Response: No date limitations were applied in this study, resulting in an open literature review. The absence of a date filter was a deliberate choice to allow for the inclusion of all pertinent studies. Inclusion Criteria: Study Focus: Only studies integrating both augmented reality (AR) and virtual patient (VP) technologies in healthcare professions education were included. Studies utilizing only one technology (AR or VP alone) were excluded unless they explicitly combined both. Study Designs: Observational (e.g., cohort studies), quasi-experimental (e.g., randomized controlled trials, pre-post studies), and descriptive (e.g., case studies, qualitative studies). Language: English-language publications. Timeframe: No date restrictions were applied; all available literature meeting the criteria was considered. Exclusion Criteria: • Grey literature, non-full-text articles, studies not directly addressing AR/VP integration, and publications from dubious databases. • Studies focused solely on virtual reality (VR) without AR or VP components. The PCC framework Population: Healthcare profession students (medical, nursing, allied health) engaged in AR-based VP educational interventions. Concept: Integration of AR and VP as educational tools, including: Design, implementation, and evaluation of AR-based VP simulations. Impact on learning outcomes (e.g., knowledge acquisition, clinical reasoning). Context: Healthcare education settings (undergraduate, postgraduate, continuing professional development). • Population (participants): Healthcare profession students (e.g., medical, nursing, and…). Results - Authors need to explain the justification behind including IT students? Exclusion criteria mentioned studies not conducted at healthcare level. Response: We sincerely appreciate the reviewer’s valuable feedback. We corrected the terminology from "IT students" to "medical informatics students" throughout the manuscript to accurately reflect their role in healthcare technology development. - The paragraph headed “Medical Specialties and Educational Focus”, and the sub “Overview of Medical Specialties and Educational Contexts” are repetitive with high redundancy. Authors are advised to draft this section. Response: Thank you for your constructive feedback regarding redundancy in the sections titled “Medical Specialties and Educational Applications” and “Overview of Medical Specialties and Educational Contexts.” We have revised these sections to reduce repetition and enhance clarity, ensuring that the content is more concise and focused. Medical Specialties and Educational Applications The included studies (n=27) showcased the application of augmented reality-based virtual patient (AR-VP) technology across various medical specialties. Two reviewers independently extracted and classified the data according to the primary educational focus of each study, resolving discrepancies through discussion and consulting a third reviewer when necessary. The classifications were derived inductively from study objectives and outcomes, without utilizing qualitative analysis software. The major themes and applications identified included: • Advanced Clinical Procedures: Examples include mpMRI-guided prostate biopsies, emergency cardiac arrest management, and treatment planning for colorectal cancer metastases. • Anatomical and Physiological Education: Focus areas encompass female breast anatomy, lower limb structures, skeletal system, and congenital heart abnormalities, alongside the use of CT scans for pulmonary lesion assessment and heart physiology. • Diagnostic and Therapeutic Training: This includes diagnostic skills such as stroke diagnosis and critical patient assessment, as well as therapeutic skills like brain tumor management, prescription writing, and patient communication. Stroke diagnosis was classified under "therapeutic skills" when studies emphasized treatment decision-making. • Practical Clinical Skills: Hands-on training involved vital sign monitoring, chest screw placement, and heart rate interpretation. • These studies underscore the importance of comprehensive training across medical specialties and the critical role of immersive technologies in developing essential clinical skills. Overview of Medical Contexts The reviewed studies covered a wide range of medical specialties and educational contexts, including: • Advanced Procedures: mpMRI-guided prostate biopsies, emergency cardiac arrest responses, and colorectal cancer management. • Anatomical Education: Female breast, lower limb, and skeletal anatomy. • Diagnostic Training: Heart anatomy, physiology, pulmonary lesions, and radiological techniques (e.g., CT scans). • Therapeutic Skills: Stroke diagnosis, brain tumor management, and patient communication. • Practical Skills: Heart rate monitoring, chest screw placement, prescription writing, and vital signs management. - Authors also need to explain how these classifications were made? Why stroke diagnosis were put with “therapeutic skills” category? Response: Thank you for your valuable feedback and insightful questions regarding our classification process. The classifications in our study were made through a comprehensive review of the literature. Two reviewers independently extracted and categorized data based on the primary educational focus of each study. Any discrepancies between the reviewers were resolved through discussion, and a third reviewer was consulted when necessary to ensure accuracy and consensus. Stroke diagnosis was categorized under "therapeutic skills" because many studies emphasized its role in treatment decision-making. This classification reflects the importance of integrating diagnostic skills with therapeutic interventions, particularly in acute scenarios where prompt treatment is essential. Was there any method/ software of qualitative analysis used to draw these data? Response: To ensure a comprehensive evaluation of the studies included in this scoping review on AR-based virtual patients in healthcare training, two independent reviewers conducted a thorough quality assessment. Each reviewer systematically appraised the studies against predefined criteria, focusing on several key areas: methodological quality, relevance to learning design and technical requirements, and alignment with the objectives of the review. To address any initial disagreements in assessments, the reviewers engaged in iterative discussions, ultimately reaching a consensus. This collaborative approach guaranteed an unbiased and standardized selection process: To ensure a comprehensive evaluation of the studies included in this scoping review on AR-based virtual patients in healthcare training, two independent reviewers conducted a thorough quality assessment using the JBI checklist. Each reviewer systematically appraised the studies against predefined criteria, focusing on several key areas: methodological quality, relevance to learning design and technical requirements, and alignment with the objectives of the review. To address any initial disagreements in assessments, the reviewers engaged in iterative discussions, ultimately reaching a consensus. This collaborative approach guaranteed an unbiased and standardized selection process. A structured scoring system was utilized to evaluate critical aspects of each study, including: Research Design Validity: Assessing the robustness of the study's design. Technical Implementation Rigor: Evaluating the thoroughness of the technical execution. Educational Outcomes Measurement: Analyzing how effectively educational outcomes were measured. Reported Limitations: Reviewing the transparency and acknowledgment of limitations within each study. The reviewers meticulously documented their scoring rationales to enhance transparency, creating an auditable trail for methodological decisions. This rigorous approach prioritized studies that effectively addressed the integration of AR virtual patients in healthcare education while upholding high scientific standards. Collating and Summarizing Data Following the quality assessment phase, the data were systematically categorized and analyzed. A summary table was created to outline the characteristics and findings of the included articles, and a comprehensive list of studies was compiled. An overview of the studies was conducted by systematically analyzing their geographic distribution, publication years, outcomes, and content to identify the benefits, effects, and challenges associated with the study's objectives. Discussion - However, detailed data were presented. Authors need to focus on bringing more comparison with the existing literature rather than detailing the same data presented at the results section. Response: We extend our sincere gratitude for your meticulous suggestion. Considering that this is a scoping review study, our initial approach involved specifying the findings and subsequently comparing them with other studies based on these identified results. The body of literature employing the integration of these technologies was limited, often providing scant detail. Nevertheless, the research team endeavored to discuss those articles demonstrating the highest relevance to the study's objective. Notwithstanding these limitations, we sought to examine the comparisons with due attention to the specific details presented within the articles. Text added to the article abstract: "A central theme identified across the reviewed literature is the prevalence of student-centered learning approaches, often facilitated by instructor guidance. Our analysis reveals a consistent application of pedagogical strategies like problem-based learning, prototype-based learning, situational learning, and game-based learning to enhance learner engagement and knowledge acquisition (12, 43, and 44). These strategies are commonly embedded within simulations of varying fidelity—high, medium, and low—leveraging a rich array of multimedia content, including audio, images, videos, 3D models, and avatars, to create realistic and interactive learning scenarios (12, 21, 27, 28). In terms of interaction, VP/AR systems support a diverse set of methods such as commanding, conversing, manipulating, exploring, and responding, all of which contribute to active participation and the development of essential skills (45-47). The provision of feedback, categorized as diagnostic, formative, and summative, is consistently highlighted, with formative feedback being particularly emphasized for its role in guiding learning and improving outcomes (12, 17, and 21). Our study both corroborates and extends existing research on VP/AR technologies in healthcare education. For example, the emphasis on location-based AR Attachments Attachment Submitted filename: Response to Reviewers (1).docx https://doi.org/10.1371/journal.pone.0324740.r002
Decision Letter - Ziyu Qi, Editor Integrating Augmented Reality Virtual Patients into Healthcare Training : A Scoping Review of Learning Design and Technical Requirements PONE-D-25-10169R1 Dear Dr. Zarifsanaiey, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Ziyu Qi Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0324740.r003
Formally Accepted
Acceptance Letter - Ziyu Qi, Editor PONE-D-25-10169R1 PLOS ONE Dear Dr. Zarifsanaiey, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Mr. Ziyu Qi Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0324740.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .