Mixed-reality simulation education for caring of older adults with cognitive impairment among undergraduate nursing students: a sequential explanatory mixed methods study

Delirium and dementia represent significant cognitive impairment (CI) challenges in older adults globally, yet undergraduate nursing students receive limited education on these conditions, particularly delirium superimposed on dementia (DSD). Mixed reality (MR) simulation using HoloPatient technology offers innovative educational opportunities, but its effectiveness has not been rigorously evaluated using mixed methods approaches. This study examined the effect of MR simulation-based education on nursing students’ knowledge of CI and attitude towards older adults with CI, and explored students’ perceptions of the learning experience. We employed a sequential explanatory mixed methods design with 60 fourth-year nursing students at a university in South Korean between May and June 2024. Following a 50-minute lecture, participants engaged in 100-minute MR simulation-based education using HoloPatient technology featuring DSD scenarios, structured with prebriefing, HoloPatient observation and group clinical reasoning, and whole-class debriefing. We administered one-group pre-post-test design assessing CI knowledge (using case vignettes, 0–25 scale) and attitudes toward older adults with CI (using Dementia Attitude Scale, 20–140 scale). Based on quantitative results, we purposively selected 10 students representing varied response patterns for two focus group interviews to explain quantitative findings and explore MR simulation experiences. We integrated findings through joint display analysis. Significant improvements occurred in CI knowledge (t=-14.50, p<.001, Cohen’s d = 1.87) and attitudes toward older adults with CI (t=-6.74, p<.001, Cohen’s d = 0.87). Qualitative analysis revealed enhanced learning outcomes and positive perceptions of MR simulation experiences, including improved realism, safe learning environments, and effective debriefing processes. Integration demonstrated that effectiveness derives from synergistic combination of immersive technology, safe learning environment, and evidence-based debriefing rather than technology alone. MR simulation-based education significantly enhances nursing students’ CI knowledge and attitudes toward older adults with CI. This technology-enhanced approach provides realistic, immersive learning experiences that prepare students for complex clinical scenarios involving older adults with CI.