Simulation-based education is pivotal in nursing as it provides safe environments for clinical practice to enhance competencies. While traditional simulation enhances knowledge, critical thinking, confidence, and metacognition, it is encumbered by limitations like high cost and spatial constraints. Contrarily, virtual simulations, such as multi-user virtual environment simulations, offer immersive and interactive experiences that can help overcome many of these limitations.

We aimed to evaluate the effects of multi-user virtual environment simulations on nursing students' metacognition and competency and examine the impact of varying simulation exposures in a multi-site context.

A multi-site multi-group comparative design was used to assess the effectiveness of multi-user virtual environment simulations.

The study was conducted across five universities in South Korea.

A total of 518 undergraduate nursing students from ten groups at five universities participated in the study.

Participants engaged in child and community health nursing simulations within virtual environments, including settings like hospitals, public health centers, and residential homes. The scenarios were constructed using expert-validated templates to prompt student actions. Metacognition and nursing competency were measured using pretest and posttest questionnaires, with statistical analysis employed to assess the degree of variations.

Significant improvements in metacognition and nursing competency were observed, especially among students with lower initial skill levels. Exposure to three or more scenarios led to significant gains in metacognition and competency. Students in high-cluster groups demonstrated changes in metacognition through the integration of simulation and clinical practicum approaches.

Multi-user virtual environment simulations effectively enhance nursing students' metacognition and competency, providing a cost-effective, immersive, and interactive alternative to traditional simulations. High-quality scenarios and real-time peer feedback are critical for maximizing educational outcomes. Future research should optimize the quantity and quality of scenarios and integrating multi-user virtual environment simulations with clinical practicum to further advance nursing education.