Virtual Reality Technology in Nursing Professional Skills Training: Bibliometric Analysis

Background: Nursing professional skills training has undergone significant transformation due to the exponential growth of computer and medical technology. The innovative use of virtual reality (VR) in nursing education has emerged as a cutting-edge technical support technique that has gained attention as a highly effective method for improving nurse training quality. Objective: This study aims to review the current status of VR technology in nursing professional skills training, research hotspots, and emerging trends in the last 15 years. Methods: The Web of Science Core Collection database was used to search for literature on VR technology in nursing professional skills training covering the period from 2006 to 2022. Biblioshiny (K-Synth Srl) was used to import and convert the records to Bibliometrix (K-Synth Srl) for analysis, and R (R Core Team) was used for descriptive bibliometric analysis. VOSviewer (Leiden University) was used to cluster co-occurring keywords, and Scimago Graphica (version 1.0.16; Scimago Lab) was used to generate a geographical visualization of published countries and regions. Results: A total of 1073 papers were analyzed, indicating a surge in research on the application of VR in nursing professional skills training in recent years, as evidenced by a positive trend in annual publication of relevant literature. The majority of studies were from the United States (n=340) and Canada (n=107), and Margaret Verkuyl was the most prolific author, leading the way with 9 publications. Furthermore, “Computerized Virtual Patients in Health Professions Education: a Systematic Review and Meta-Analysis” was the most frequently cited reference. Keywords such as education , simulation , skills , students , and care were most commonly used by researchers. Conclusions: The bibliometric analysis provides a comprehensive overview of the use of VR in nursing professional skills training, indicating that VR-based training is an effective means of improving the skills and competencies of nursing students and professionals alike. The COVID-19 pandemic has reinforced the importance of developing VR-based distance education, despite challenges such as integrating virtual and real-world training and mitigating safety risks.


Background
Nursing work holds a crucial position in health care. Nursing students, serving as a valuable pool of talent for the clinical nursing team, are essential figures in the advancement of nursing practice. They play a pivotal role in promoting the growth and development of the nursing profession and are a crucial component of the health care workforce [1]. Nursing educators face a significant challenge in cultivating the necessary expertise and skills among nursing students to provide effective patient care [2]. Considering the low efficiency of traditional nursing professional skills training methods, it can be challenging to motivate nursing students to engage with enthusiasm [3]. To ensure that nursing students possess sufficient expertise and are qualified to work in hospitals, many nursing educators use a variety of teaching strategies, including using VR, to enhance the quality of nursing professional skills training.
A virtual reality (VR) system can be defined as a highly interactive 3D digital media environment that generates a simulated reality and creates an immersive experience through the user's senses of vision, hearing, and touch. Essentially, it provides users with the feeling of being present in a separate virtual environment. The characteristics of VR systems can be summarized into 3 pivotal elements: immersion, interactivity, and sensory perception [4]. VR technology has been extensively applied in nursing theory teaching, nursing skills training, and clinical nursing teaching, both domestically and internationally. Yang and Huang [5] found that traditional nursing skills teaching fails to replicate the actual clinical environment. Students often lack the opportunity to gain genuine sensory experience of nursing operations and may learn various nursing procedures in a conventional and generic manner. This may hinder their ability to effectively transition into clinical work in the early stages of their career. Chu et al [6] showed that a VR-based immersive experiential learning model could be implemented for teaching and that situational learning was achieved through virtual laboratory and simulation training. Gao and Yao [7] provided a new idea for a method to teach endoscopic retrograde cholangiopancreatography to nurses by combining a VR endoscopic simulation system with microteaching. Jung and Park [8] built a head-mounted VR platform to enable students to observe the process of intravenous catheter implantation by modeling the angiography room. These examples provide a compelling argument for the potential of VR technology in enhancing the professional skills of nurses and nursing students.

Research Problem and Aim
The concept of "bibliometrics" was proposed by Pritchard in 1969, and it is defined as "the application of mathematical and statistical methods to books and other knowledge dissemination media" [9]. Bibliometrics offers a highly efficient tool for analyzing the progress of scientific research. It enables quantification of information on a specific research topic derived from online scientific citation databases, such as details on authors working in a field, publication numbers, and the distribution of research institutions [10]. Bibliometrics is a powerful tool that can assist in identifying significant literature in a research field and provide valuable data, such as keywords, institutions, country linkages, and distribution characteristics, in the form of a knowledge map. By quantifying the current state and future trends of the research topic, bibliometrics serves as an essential aid in comprehending the development of a particular field [11]. Generally, the greater the number of references included in a bibliometric method, the better we can comprehend the landscape of a research field [12]. A scoping review conducted by Yang and Huang [5] outlines the applications of VR technology in nursing professional skills training. There has been limited research on the scientific output of this field using bibliometric and visualization analyses. As a result, it is critical to comprehend the research status and hot spots of this field to aid in the advancement of nursing professional skills for nurses and nursing students. This study strives to offer a comprehensive analysis of the research field using the Web of Science (WOS) Core Collection as a basis and to serve as a valuable reference for future research.

Data Sources and Search Strategy
For this study, articles and reviews that were published in English between 2001 and 2021 were included, using the WOS Core Collection database as the primary data source: (1) the retrieval expression was constructed using a formula that used a Boolean logic operator: TS=(virtual reality OR VR OR virtual medicine OR augment reality OR mixed reality OR virtual simulation) AND TS =(nursing* OR nursing practice OR nursing training OR academic training OR serious game), and the scope of literature was restricted to only articles and reviews; (2) the English language was selected; (3) there were 1073 documents retrieved in the search of WOS (as updated on 11 November 2022); and (4) all records were exported to plain text files, including the full record and cited references.

Bibliometric Analysis
A description of the bibliometric analysis method can be found in Aria and Cuccurullo [13]. Five rigorous steps, namely study design, data collection, data analysis, data visualization, and interpretation, were included in the analysis [14]. The complete methodology is schematically illustrated in Figure 1. The initial stage was the study design phase; nursing professional skills training was selected as the study topic. The research data resource chosen was the WOS Core Collection database, from which literature retrieval returned 1242 documents during the data collection phase. The review followed the structured approach outlined by Kable et al [15] for researching and evaluating literature. In this study, 2 reviewers (CH and LW) conducted an independent screening of the search results, with cross-checking used to resolve any disagreements. Training in document retrieval and screening was received by all researchers based on the textbook Medical Literature Information Retrieval [13]. A document-type filter was applied to the WOS, and articles and data papers were included, resulting in a sample of 1073 papers published between 2006 and 2022. All records were imported to Biblioshiny (K-Synth Srl) and converted to Bibliometrix (K-Synth Srl) for subsequent analysis. In the third stage, R (R Core Team) was used for descriptive bibliometric analysis and to develop a matrix of all documents. Biblioshiny, the Tidyverse package ggplot2 (Hadley Wickham), and VOSviewer (Leiden University) were used in the fourth stage to create a keyword cluster map. Scimago Graphica (version 1.0.16; Scimago Lab) was used to generate geographic visualization maps of the countries or regions. To identify influential sources, the Bradford law was used to unveil the journal distribution. The Methods section presents an interpretation of the data analysis and visualization outcomes.  [13] and Secinaro et al [14].

Ethical Considerations
An ethical approval application was not filed for this paper. The Chinese Hospital Association has stated that an ethics review is unnecessary for secondary analyses of published data.

Descriptive Bibliometric Analysis
Each period's publication count is a reflection of the research field's development trends. Figure Table 1 provides essential details on the 1073 research papers published in the WOS Core Collection database from 2006 to 2022. The annual average number of published research papers was 61.29, with each paper having an average citation count of 11.52. These papers had 4369 authors, with 59 of them being single-author papers. The average number of authors for each research paper was 2 (2.33). The collaboration index, which is the total number of authors of multi-authored papers divided by the total number of multi-authored papers, was 2.38. These papers also produced a total of 2388 author keywords.

The WOS Research Areas
One or more subject categories (SCs) are linked to each publication indexed in the WOS. In this study, the number of research areas covered by VR-based nursing professional skills training education literature increased from 2 in 2006 to 22 in 2022 ( Figure 3). Figure 4 displays the annual changes in productivity in the top 10 areas of VR-based nursing professional skills training education, which illustrates changes in the focus areas of VR-based nursing professional skills training education. The most popular research area was nursing, followed by education and educational research and health care sciences and services. With the increasing maturity of VR technology and stable production of VR equipment, the explosive growth in publications in the field of nursing professional skills training can be attributed to the use of various teaching strategies, including VR, by many nursing educators to enhance the quality of education.    Figure 5), countries with more than 5 publications were analyzed using Scimago Graphica. The lines on the map indicate the degree of cooperation between different countries, with the thickness of the lines reflecting the extent of cooperation. It is evident from the map that the United States, Canada, Australia, China, and other countries have actively collaborated with other countries. Additionally, several scholars from Europe have shown interest in VR-based nursing professional skills training education and have conducted joint research projects to a certain extent. Table 3 highlights that while the United States has the highest number of publications, Canada's top 10 institutions rank higher in total citations, suggesting that both countries have robust support and funding for VR-based nursing professional skills training research.   Table 4 (Table 4). According to the Bradford law, the source journals of VR-based nursing professional skills training papers were widely scattered, and the top 10 most influential journals were selected based on the number of local citations. Journals that were identified as core source journals in the field of VR-based nursing professional skills training according to the Bradford law are marked in Figure 6.

Most Influential Authors
The H index is a widely accepted measure of scientific performance based on the number of citations received by a scientist's published papers [16]. Table 5

Most Influential Papers
This section provides a list of the most influential papers (based on the number of citations) published between 2006 and 2022. Cocitations within a group of authors suggest that certain documents may include concept symbols. It is noteworthy that Tables 6 and 7 show a difference between the local citation score (LCS), which reflects the number of citations within the field, and the global citation score (GCS), which represents the total number of citations in WOS. The paper with greatest influence according to LCS was "Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial" (n=49). The paper with greatest influence according to GCS was "Computerized Virtual Patients in Health Professions Education: a Systematic Review and Meta-Analysis" (n=273). The papers in question may encompass theories that form the foundation of the field, early works that lay groundwork, and methodological principles [17].

Distribution of Keywords
By conducting data cleaning to eliminate coding errors that could arise from different articles using varying keywords to introduce the same concept, we identified 2388 author keywords in 1073 published papers on VR-based nursing professional skills training between 2006 and 2022. The keyword analysis enables summary of the study's topics in the field and exploration of hotspots. For instance, nursing and nurses were recorded as Nurses to prevent discrepancies. Education had the highest frequency of 178 among the keywords, with other high-frequency keywords being Simulation (n=148), Skills (n=95), Students (n=84), Care (n=77), Impact (n=64), Knowledge (n=64), Nurses (n=62), Virtual-reality (n=58), and Technology (n=47), as shown in Table 8. Additionally, Multimedia Appendix 1 shows a keyword cluster map created using VOSview, while Figure 8 depicts the thematic evolution of the keywords.

General Information
Based on the annual number of publications, the publication years can be divided into 3 phases: 2006 to 2013, 2014 to 2019, and 2019 to 2022. The first phase, spanning from 2006 to 2013, saw an increase in the number of articles, albeit at a relatively slow growth rate. The second phase, from 2014 to 2019, was marked by significant advancements in VR device and software technology. This was exemplified by the launches of Project Glass by Google in 2012 and the first generation of the Oculus Rift VR headset by Oculus. These improvements resulted in an increase in the availability and quality of VR components [17]. In the period between 2014 and 2021, there was a noticeable increase in interest among scholars in computer science, as evidenced by periods 2 and 3. In the most recent phase, from 2019 to 2021, the number of publications exceeded 75 for the first time, with 76 articles published. This trend indicates an expanding interest among scholars in exploring the potential of VR technology in the field of nursing professional skills training.
Contributions to VR-based nursing professional skills training came from various countries worldwide, including the United States, Canada, China, Australia, the United Kingdom, Brazil, Korea, Spain, Singapore, and Turkey, with some taking a more prominent role. Notably, China is one of the few Asian countries to contribute to this field, indicating a lack of research emphasis on this topic among Asian scholars. In contrast, Canadian institutions and scholars have demonstrated continued interest in research in this area. A bibliometric analysis of VR and nursing professional skills training revealed Canada to have the highest contribution among all countries [23].
The frequency of cocitation can serve as a reflection of a journal's quality and influence. Among the ten journals with the highest cocitation frequency, half were found to be ranked in the top quartile. This suggests significant impact and recognition in the international community, indicating that the application of VR in nursing professional skills training has gained worldwide attention.
Following the analysis of cocited papers, it was found that "Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial" (n=49) was the most influential paper in terms of LCS. This study may contain foundational theories, pioneering early work, and methodological principles in the field. Similarly, "Computerized Virtual Patients in Health Professions Education: a Systematic Review and Meta-Analysis" (n=273) was deemed the most influential paper in terms of GCS. These works demonstrate how innovative research can impact an academic discipline for years to come and continue to inform contemporary research in the field.

Research Hot Spots and Frontiers
By using a combination of high-frequency keyword statistics, visualization analysis, and including relevant literature, this study indicates that an overwhelming majority of both domestic and international researchers have concentrated their efforts on exploring the application of VR technology in nursing education with a particular emphasis on nursing professional skills training.
Owing to variations in technological advancement, each country and region has conducted research to its own specifications with regards to the use of VR in nursing education. As an illustration, the VR nursing skills training system can provide a significant contribution to ensuring the proficiency of nursing students by enabling them to learn essential operational skills without the need for physical attendance, thereby providing them with the opportunity to review training materials anywhere at any time [23]. International research in this field commonly uses desktop VR system software to enhance students' clinical thinking skills. This type of software emphasizes immersive patient scenarios presented on the computer screen in which students are "placed" in a simulated clinical setting to observe and address the patient's discomfort and pain. The aim is to develop students' proficiency in making informed clinical decisions based on complex patient conditions [36]. The VR system can be improved in a short time according to teaching and learning needs, quickly meeting the skills training and teaching needs of various courses and improving the training effect. In order to give full play to the maximum benefit of the virtual system, it is suggested that schools and hospitals with suitable conditions choose VR technology to carry out skills training for students and promote their early adaptation to clinical practice.
In the field of nursing education, there are notable technical issues that exist with the application of VR technology at present. Caylor et al [37] pointed out that VR systems are faced with the problem of unclear navigation mechanisms within the operation interface. Poor experiences among nursing students during simulation learning are attributed to the confusing nature of the navigation interface within VR software platforms. Wilson et al [38] suggested that in future research on VR technology more attention be given to creating a simulation system with high fidelity, increasing the complexity of the cases presented within VR and reproducing challenging clinical case scenarios to enhance subjects' diagnostic reasoning abilities. Moreover, the development level and quality of VR software must be improved. This improvement is necessary due to the lack of understanding among VR technicians of the medical care field, which leads to failures to accurately reflect the key points and difficulties that teachers aim to emphasize. Additionally, it is vital to combine the advantages of VR teaching with existing nursing practices to ensure that VR technology is used effectively in nursing education [39]. To maximize the potential of VR technology in nursing education, researchers must consider providing a more comprehensive VR technology intervention, emphasizing multidisciplinary cooperation, and enhancing the familiarity of software technology developers with the nursing field. Additionally, teachers' proficiency in the operation of the virtual teaching process must be improved. To better explore the efficacy of VR technology in nursing education, it is crucial to enhance the VR teaching environment to improve nursing students' ability to apply the skills learned in virtual settings to clinical practice.

Applications and Development Trends in Research
Over the last 15 years, VR technology has been extensively implemented in nursing professional skills training. As mobile computing and sophisticated software programs continue to develop, highly immersive VR systems have become increasingly affordable and accessible [40]. Popular VR systems currently used in nursing professional skills training include Kinect from the United States, Nintendo Wii from Japan, HTC Vive from Taiwan, China, and Samsung Gear VR from South Korea. By integrating these VR systems into nursing education, we aim to facilitate the development of students' initiative and promote self-directed learning abilities, ultimately enhancing their clinical practice acumen.
As COVID-19 continues to impact the world, students' access to skills training may be limited. However, VR technology offers a viable solution to this problem. VR-based nursing skills training immerses students in a simulated environment, offering an opportunity to develop critical skills despite the pandemic. According to research, the use of a VR immersive experiential learning model for teaching fosters situational teaching through virtual laboratory and simulation training [6]. Furthermore, Gao and Yao [7] combined use of a VR endoscopic simulation system with the microteaching method to provide a new idea for teaching nurses endoscopic retrograde cholangiopancreatography. Jung and Park [8] developed a head-mounted VR platform for observing the process of intravenous catheter implantation in a highly realistic sensory scenario. This platform enabled students to view the entire arterial and venous system of the body, strengthening their theoretical and practical operation skills. Zhang et al [41] developed a highly realistic scenario simulation system for improving teachers' teaching ability and cultivating students' initiative, enthusiasm, and autonomous learning ability.
To establish VR technology as a reliable tool for improving nursing professional skills training, researchers must integrate knowledge from various fields, including nursing, computer science, neuroscience, psychology, social cognition, multisensory perception, and multimedia development. This requires an interdisciplinary approach that takes into account the needs of all stakeholders, including students, teachers, nurses, and software developers [42]. Thus, research on VR-based nursing professional skills training must involve a broad range of individuals to create effective teaching strategies that meet the unique needs of every student. High-quality research is necessary to explore the full potential of VR technology across various disciplines.

Strengths and Limitations
This is the first bibliometric analysis of VR-based professional skills training in nursing, providing a comprehensive understanding of the current state of VR in nursing education. Through analyzing keywords, countries or regions, institutions, authors, journals, and references, we have gained valuable insight into the research landscape. In the future, longitudinal in-depth studies on current hot topics or large, multicenter, high-quality randomized controlled studies guided by research trends can further enhance this field. At present, research in this field is predominantly limited due to technology and cost. To promote growth, policy and financial support should be provided to encourage researchers to learn from foreign advanced experience and enhance VR technology. Nursing staff must participate in program design from a nursing education perspective to create more suitable VR equipment and procedures. By vigorously developing the application of VR in the field of nursing education, we can better prepare our students for clinical practice.
However, it is important to note that this study used only one database (WOS), which may have excluded high-quality papers in the field. Additionally, the current word segmentation algorithm used in bibliometrics lacks necessary intelligence, leading to inaccurate extraction of some keywords. Thus, future bibliometric studies must strive to enhance the semantic understanding of citation data to facilitate accurate word segmentation and intelligent extraction of bibliometric knowledge. To ensure a more comprehensive and precise theoretical basis, future research should expand the database and source high-quality papers both domestically and internationally. This will better promote the advancement of nursing education and practice to new levels.

Conclusions
To review the application of VR technology in nursing professional skills training, this study used the WOS database, R, Scimago Graphica, and VOSview to provide a scientific and intuitive analysis. Bibliometric analysis indicates that research on VR-based professional skills training in nursing has experienced rapid development over the past 15 years. This is evident from the rising number of publications in core journals and increased collaboration between authors and countries or regions. Although this paper demonstrates an exponential growth trend in VR-based nursing professional skills training and positive feedback in the field's advancement, further investigation is required to understand the feedback mechanism.