Immersive Extended Reality and Affective-Behavioral Outcomes in Nursing Students: A Systematic Review and Meta-Analysis of Randomized Studies

Extended reality (XR) technologies, including virtual, augmented, and mixed reality, are increasingly used in nursing education to enhance experiential learning and emotional engagement. However, their effectiveness across learning domains remains uncertain. This systematic review and meta-analysis synthesized evidence from 32 randomized studies (n = 1,578) to evaluate XR's impact on cognitive, psychomotor, and affective outcomes in nursing students. Five databases were searched (2012-2024). Meta-analyses were conducted using Review Manager 5.4 and R 4.3.3, and study quality was assessed with the Joanna Briggs Institute checklist. Certainty of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation approach, and subgroup sensitivity analyses explored heterogeneity. XR interventions produced significant effects on learner satisfaction (standardized mean difference [SMD] = 0.50, <i>p</i> = 0.02) and psychomotor performance (SMD = 0.46, <i>p</i> = 0.01). Effects on confidence (SMD = 0.45, <i>p</i> = 0.06) and cognitive outcomes (SMD = 0.24, <i>p</i> = 0.26) were smaller and inconsistent. Limited effects were found for attitudes and values. Subgroup analyses suggested that XR showed benefits for psychomotor outcomes relative to mannequin-based simulations and for satisfaction compared with video comparators, while value over lecture-based controls was limited. Removing outliers improved estimates and reduced heterogeneity. Findings suggest that XR may enhance skill acquisition and foster emotional engagement, although evidence for cognitive gains and attitudinal change remains limited. Results highlight XR's potential to influence learner motivation, presence, and self-efficacy. Future studies should explore long-term outcomes, mixed reality, and adaptive XR systems. Broad integration should consider technical skills and affective and behavioral mechanisms essential to professional development.