This study, we mapped a knowledge network of VS in nursing research from 1999 to 2021. Meanwhile, we 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[15]. The overall trend of publication in this filed was upward, and 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, previous study found before the year of 2005, the applications of virtual patient in medical education were small[20]. Since 2020, the number of papers got a sharp increase. We speculate several reasons account for this. First, because of social isolation during the COVID-19 pandemic, educators were forced to change the way of program delivery [21]. Numerous online programs has emerged during the COVID-19, such as virtual lab environments[22], three-dimensional virtual world (3DVW)[23], personal protective equipment (PPE) virtual simulation games[24]. Such VS programs effectively enhanced nursing student interest and provided nurse educators with novel and engaging means of content delivery[21]. Second, COVID-19 pandemic accelerated the demand for more nursing staff and higher quality nursing care. Indeed, not all nurses or medical staff have the chance to face such an outbreak. It is difficult to educate and train these back-ups with any physical touch. However, the greatest strength of VS could provide an almost real environment that simulated any emergency in COVID-19. It is perfect to solve this problem.
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. Other areas displayed the similar leading position of the USA, such as radiation-induced lung injury [25], and human-computer interaction[26], etc. Interestingly, in terms of the number of productive authors and institutions, Canada ranked ahead of the USA. Extensively studies showed that collaborations tends to be stronger between institutions or countries with shorter geographical distances[7]. We speculated the cooperation links between authors and institutions within Canada were stronger than that in the USA. As expected, Figure S1 and Figure 4B further corroborated our hypothesis. There are scattered links between numerous American authors and institutions, but relative close relationships between Canadian authors and institutions. 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 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 particular attention on them, because some 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 quickly[10]. We found the keywords with largest node size were following areas: virtual simulation, nurse education, and skills. Moreover, from the color assigned to keywords by VOSviewer, the trend shifted to nurse education, students, clinical simulation, and communication skills. They all indicated that virtual simulation for nursing teaching is a hot topic in current research. Basically, one of the principles of registered nurses is "do no harm" to patients [27]. However, the traditional apprenticeship learning model does not ensure nurses' acquisition of adequate theory and practical skills before handling the clinical workplace [28]. Therefore, 3D virtual environment such as second Life laboratory to practice the students' experience of learning decision-making skills and communication skills got considerable attention in recent years[29-32]. More importantly, the advanced VS program, virtual patients, was developed to provide numerous realistic standard clinical situations to train the students' skills, like clinical reasoning[33-35], communication skills[36-38], situation awareness, and teamwork capability[39] which paved the way of the medical education into a new era. But we should noticed that while 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[40], effective and objective assessment methods related to learning outcomes are still lacking[41-43]. Despite Carina,Georg[44]developed 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.
4.1 Limitations
First, the papers on VS in nursing were searched based on the WoSCC. Although WoSCC 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 accepted[45]. 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.