In this study, we mapped a knowledge network of VS in nursing from 1999 to 2021 and analyzed the contributions of different authors, journals, institutions, and countries. The number of publications in a field reflects the activity and productivity over the years. We found the overall trend of publication was upward, and the publication time could divided into three phases. Before 2008, the number of articles per year slightly increased. It may be restricted by technology such as internet access or computer popularity. Likewise, other study found before the year of 2005, the number of virtual patient publications were small. Since 2020, the number of papers got a sharp increase. We speculate that there are several reasons accounted for this. First, due to social isolation, educators were forced to change the way of program delivery during the COVID-19 pandemic . Numerous online programs has emerged during the COVID-19, such as virtual lab environments, three-dimensional virtual world (3DVW), personal protective equipment (PPE) virtual simulation games. Such virtual simulation programs can facilitate nursing student interest and provide nurse educators with novel and engaging means of content delivery. Second, COVID-19 pandemic accelerated the demand for more nursing staff and higher quality nursing care. Third, during the COVID-19 pandemic, nurses sustained high levels of workload and stress. Developing virtual simulation relaxation, could help to reduce perceived stress on nurses in the frontlines.
In terms of research category, Nursing, Health Care Sciences Services, Education Scientific Disciplines dominated in this field, suggests that education and health care services is the primary focus on VS in nursing.
Without surprising, the USA leads the VS in nursing research, which requires the collaboration of multiple disciplines, such as medical informatics, education, computer science, and software engineering. Similar leading position can be seen in other areas, such as radiation-induced lung injury , and human-computer interaction, etc. Interestingly, in terms of the number of productive authors and institutions, Canada ranked ahead of the USA. Collaborations tends to be stronger between institutions or countries with shorter geographical distances, and we found co-operation links between authors and institutions within Canada were stronger than that in the United States(Figure S1 and Figure 4B). Considering the scattered collaborations in this field, we hope there will be more inter-institutions and international research in the future.
Key journals, institutions, and authors provide the essential information for a given research field. Clinical Simulation in Nursing, Nurse Education Today, and Journal of Nursing Education are the top three productive and co-cited journals. Researchers should continue to pay attention on them, because some important frontier articles may be published in these journals. In addition, researchers could choose these journals for their draft submission. Institutions like Centennial College, University of Toronto, University of Ottawa, and scholars like Verkuyl M, Luctkar-flude M, Tyerman J, Cook Da, and Hoffman, HG should be followed and maybe the potential cooperation partner.
Keyword network and references analysis facilitates researchers to get insight into a certain field. We found the keywords primarily focused on the following areas: virtual simulation, education, nurse education, nursing, and skills. From the color assigned to keywords by VOSviewer, pain, distraction, intervention, and skills were the primary foci during the early stage. Then, the trend shifted to nurse education, students, clinical simulation, and communication skills. One of the fundamental principles of registered nurses is "do no harm" to patients . However, the traditional apprenticeship learning model does not ensure nurses' acquisition of adequate theory and practical skills before handling the clinical workplace . 3D virtual environment such as second Life laboratory to practice the students' experience of learning decision-making skills and communication skills is a good way to train these students before and after becoming qualified nurses [30–33]. Moreover, another advanced VS program is virtual patients. It was developed to provide a realistic standard clinical situation to train the students' skills, like clinical reasoning[34–36], communication skills[37–39], situation awareness, and teamwork capability. While A number of studies have shown the positive feedback of VS in nursing education, previous research has largely overlooked the significance of assessment methods of learning outcomes. Currently, the predominant methods for assessing learning outcomes are combinations of paper-based exams and observations from clinical teachers, effective and objective assessment methods related to learning outcomes are still lacking[42–44]. Despite Carina,Georgdeveloped the modified visual patient Lasater Clinical Judgment Rubric (vpLCJR) to evaluate nursing students' clinical reasoning, limited studies investigated the method of assessing outcome of nursing students' non-technical skills. Thus, we speculate that virtual patients simulated more clinical situations to train nursing students, develop more reliable and objective assessment methods to validate learning outcomes, maybe the recent and future topics.
First, the papers on virtual simulation in nursing were searched based on the WOS. Although WOS is recognized as one of the most authoritative databases, PubMed, Scopus, and Google scholar are also widely accepted by scientists. Second, the number of citations and H-index are influenced by time and remain controversial as a comprehensive indicator of the quality of one paper or the author. Likewise, the larger number of publications was not the only indicator of influence for the journal, as other indicators (e.g., impact factor, SNIP, CiteScore, SJR) are widely used. Third, we included only English papers in this study, several papers with non-English languages were excluded, such as Chinese, Japanese, and Russian. Finally, The published articles in 2021 only include the first seven months, and database updates may result in discrepancies. However, we believe that the low citation frequency of new publications has less impact on our conclusions.