Emergency and critical care nursing skills are essential for effective clinical practice. Internationally, emergency nursing and critical care nursing are distinct specialties. Emergency nursing focuses on the immediate assessment and stabilization of patients with acute, undiagnosed conditions. In contrast, critical care nursing involves the sustained, life-sustaining management of patients with established, life-threatening conditions (Hartman and Vose, 2017). Both specialties require the same core high-acuity competencies to manage unstable patients. Meanwhile, they are fundamentally connected in the “chain of survival” for critically ill patients. Therefore, in many developing countries, emergency nursing and critical care nursing are often taught as a continuous spectrum of care—from emergency response to intensive management in undergraduate nursing teaching.

Emergency and critical care nursing domain is characterized by a wide variety of diseases, frequent emergencies and numerous resuscitation events (Jachmann et al., 2025), making the work highly risky and stressful. National policies further emphasize the importance of building a seamless continuum of care from the initial crisis through to intensive monitoring and treatment, as highlighted in the "Guidelines for the Construction and Development of Critical Care Medicine in China (2025 Edition)" (Chen et al., 2025).

Clinical settings are experiencing growing demand for nurses' emergency and critical care capabilities. This trend is driven by an aging population, stricter teaching ethics, frequent emergencies and post-pandemic challenges (Jianling et al., 2020). The unpredictable clinical trajectories of critically ill patients demand a unique skill set from caregivers, presenting greater challenges to undergraduate nursing students (Viderman et al., 2022). However, this growing demand contrasts sharply with empirical evidence showing that nurses' proficiency in managing such critical events remains low to moderate (Amberson et al., 2020).

It is essential for students to master basic first aid techniques before entering the workplace, such as cardiopulmonary resuscitation (CPR) and the use of automated external defibrillators (AEDs) (Omelchuk et al., 2022). Evidence shows that CPR quality depends significantly on the performer's knowledge and skill level. However, skill retention is challenging without frequent practice (García-Suárez et al., 2019). Therefore, students need adequate training and regular reinforcement to ensure they can handle emergencies effectively.

However, significant challenges persist in teaching these skills. Limited curriculum hours often prevent clinical practice courses from achieving their educational objectives. As a result, educators must independently develop high-risk or disaster emergency scenario learning resources (Zhao et al., 2022). Additionally, conducting skill drills in actual clinical environments may disrupt medical operations and compromise patient safety.

In response to these challenges, high-fidelity simulation (HFS) has emerged as a promising solution. HFS represents the third-generation evolution in nursing simulation education, building on task trainers (1970s) and standardized patients (1990s) and now incorporating virtual reality (VR) and mixed reality (MR) technologies (Watts et al., 2021, Zhao et al., 2022). This methodology facilitates the application of theoretical concepts to practical scenarios, allows for error-tolerant practice and promotes guided reflection (Kuszajewski, 2021, Watts et al., 2021, Yu et al., 2025). Studies demonstrate that HFS significantly enhances undergraduate nursing students' professional competencies, including knowledge acquisition, clinical judgment, problem-solving skills and team collaboration efficiency(Jawabreh et al., 2025).

In recent years, a large number of original studies have emerged in the field of emergency and critical care (Kim et al., 2020, Tawalbeh, 2020, Salameh et al., 2021, Takhdat et al., 2022, Tong et al., 2024). The main purpose of these studies was to explore whether HSF can promote the knowledge level, skill level and critical thinking of undergraduate nursing students. Although the International Nursing Association for Clinical Simulation and Learning (INACSL) has established best practice standards (McDermott et al., 2021, McMahon et al., 2021), significant heterogeneity persists in simulation teaching practices (Labrague et al., 2019). Given that the results of these studies have not been effectively integrated, it remains unclear whether high-fidelity simulation training has a positive impact on the knowledge, skills and critical thinking of undergraduate nursing students in the fields of critical care and emergency care.

A systematic review attempts to collate all empirical evidence that fits pre-specified eligibility criteria to answer a specific research question; a meta-analysis uses statistical techniques to quantitatively pool the results of the included studies when heterogeneity is acceptable (Higgins et al., 2011). However, most existing systematic reviews on HFS have broad subject ranges, combining undergraduates, postgraduates and registered nurses without stratification (Labrague et al., 2019, Kean, 2022). Few reviews focus specifically on emergency and critical care nursing or address its unique skill requirements.

The purpose of this systematic review and meta-analysis is to systematically analyze the existing research evidence (randomized controlled experiments and quasi-experimental studies) on HFS training in emergency and critical care nursing scenarios regarding the knowledge, skills and critical thinking of undergraduate nursing students. The specific research questions are as follows: Whether high-fidelity simulation training teaching for emergency and critical care nursing cases can promote the knowledge, skills and critical thinking of undergraduate nursing students?

This review addresses these gaps through three key distinctions: (1) exclusive focus on undergraduate nursing students, unlike reviews combining diverse learner levels; (2) specific scope in emergency and critical care nursing- a high-acuity clinical scenarios where patients experience physiological instability and life-threatening conditions requiring immediate advanced life support and intensive monitoring; and (3) unique emphasis on the retention of knowledge, skills and critical thinking, moving beyond the immediate post-intervention effects typically reported in prior syntheses, aiming to guide future educational interventions, curriculum development and simulation design.