Effect of repeated exposure to an identical multi-user virtual reality anaphylaxis scenario on paramedic trainee performance: a randomized controlled trial.

Immersive virtual reality (VR) may provide reproducible environments for training time-critical emergency workflows, but evidence in paramedic education remains limited. In this single-center randomized controlled trial, 125 German paramedic trainees participated in dyadic simulations after allocation to either one standardized multi-user VR anaphylaxis scenario (VR-C, n = 61) or repeated exposure to the identical scenario (VR-I, n = 64). The common assessment scenario was VR2. Scenario performance was assessed jointly for each dyad using a guideline-derived 62-item checklist and separate time metrics for correct working diagnosis and first intramuscular (IM) epinephrine administration. In VR2, the VR-I group achieved higher total scores than the VR-C group (42.6 vs. 31.1 of 62 points; mean difference 11.5, 95% CI, 9.8 to 13.3) and reached the working diagnosis (1.45 vs. 2.90 min) and first IM epinephrine administration (4.58 vs. 7.43 min) earlier. Knowledge test scores did not show corresponding between-group differences. VR-related symptoms were generally mild, and no simulation was discontinued. Repeated exposure to an identical VR anaphylaxis scenario was associated with improved subsequent scenario-specific, guideline-based performance within the VR environment. The findings support VR as a reproducible tool for deliberate rehearsal, but do not establish transfer to novel cases, real-world care, or superiority over conventional simulation. Trial registration: This trial was retrospectively registered on the Open Science Framework (OSF) prior to journal submission. Data collection was completed at the time of registration. The registration includes the analysis plan and outcome definitions used for this manuscript. Analyses not specified in the registration are labeled exploratory. Registered at the OSF, registration DOI: 10.17605/OSF.IO/V8XME, registration date: 6 February 2026.