Introduction

Virtual reality (VR) refers to an immersive digital technology that was first conceptualized in the 20th century [,] and involves using computer devices and hardware to interact with a specific artificial sensory environment. VR technology can create a standardized, safe, flexible, and virtual environment and provide real-time, strategic, and goal-directed feedback []. Because of these advantages, VR technology entered the medical field in 1993 []. More and more countries have introduced policies to promote the application of VR technology in the field of health care []. Evidence suggests that VR could be beneficial in enhancing the surgical abilities of physicians and minimizing errors during surgical procedures []. Additionally, some research indicates that VR may elicit neurophysiological changes, beyond basic distraction, that contribute to its efficacy for pain management [,]. The potential of VR indicates that there will be few areas of medicine that do not take advantage of this improved computer interface.

As popular equipment for health care assistance, VR technology plays an important role in the field of clinical nursing, and VR environments are ideally suited to the measurement of many variables of interest in clinical nursing practice. VR was first used by nurses in the field of clinical rehabilitation nursing and gradually became extensively used in the fields of neurological disease, cancer, and wound care [-]. Several studies indicate that VR rehabilitation training is more effective among patients with Parkinson disease, especially in improving gait and balance ability [,]. VR can also be used as a distraction from pain and anxiety among pediatric patients and patients with cancer. Mohammad and Ahmad [] found that immersive VR is an effective distraction intervention for managing pain and anxiety among patients with breast cancer. It is also reported that using immersive VR as an auxiliary intervention is more effective than using morphine alone in relieving pain and anxiety []. Moreover, the use of VR technology may be an effective, auxiliary, nondrug method for managing kinesiophobia [].

Although it has been shown in various publications that VR has the potential to help in clinical nursing practice, there remain controversies on the functions, effects, and intervention protocols of VR application in clinical nursing. In addition, the results of multiple meta-analyses that discussed VR intervention effects in different patients are inconsistent [-]. Further, the methodological limitations of current evidence impede definitive conclusions regarding the superiority of VR interventions over conventional approaches. A meta-analysis that examined the effect of VR training on patients’ participation noted uncertainty regarding evident publication bias [], indicating that conclusions regarding the superiority of VR should be made cautiously. Researchers believe that further rigorous research is required to engender robust evidence substantiating the prospective benefits of VR technology [].

Umbrella reviews can evaluate the strength of the evidence from existing meta-analyses. An umbrella review integrates data and evaluates information on all clinical outcomes, and it can be used to provide a thorough, high-level summary of the evidence landscape for VR application in clinical nursing practice []. Given the background presented herein, we performed an umbrella review in which we synthesized and appraised evidence from selected meta-analyses to generate robust conclusions regarding the state of the literature.

MethodsStudy Design

An umbrella review of meta-analyses was carried out according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines, as described in and . The research questions used to guide this umbrella review were as follows:

What is the current scope and extent of VR technology integration in clinical nursing practice?For which clinical nursing issues has VR been principally used as an intervention, and what evidence exists regarding the efficacy and safety of VR in these contexts?What are the primary barriers impeding the broader adoption of VR in clinical nursing settings, and what are the future research directions that may facilitate expanded VR application in nursing practice?Inclusion and Exclusion Criteria

The eligibility criteria were as follows: studies that used a meta-analytic method, meta-analyses about VR intervention in clinical nursing practice, and meta-analyses published in English. The exclusion criteria were as follows: meta-analyses that collected ≤2 intervention studies and meta-analyses that had no 95% CI and heterogeneity data.

Search Strategy

We conducted the umbrella review by searching Web of Science, Embase (Ovid), Cochrane Library, PubMed, and relevant reference lists. Eligible studies were published between December 1, 2012, and September 1, 2023. The searches were rerun on September 20, 2023, to identify any recent publications. We reran the searches before the submission of this paper, and no extra literature was found. We searched for publications that included the following terms (including variations of these terms) in the title, abstract, and keywords list: virtual reality, VR, virtual environment, immersive, nursing, care, meta-analysis, and review. We also searched the reference lists of the most recent systematic reviews and meta-analyses. The literature retrieval strategy is shown in .

Data Extraction and Collection

One researcher conducted the electronic database searches, eliminated duplicates and titles that were clearly outside the scope of the umbrella review, and then uploaded the remaining citations to NoteExpress version 3.7.09258 (Aegean Software Corp). Two reviewers independently examined the remaining full-text articles to identify those that met the inclusion and exclusion criteria. If there were multiple meta-analyses with the same research objectives and outcome indicators, the one with the highest quality score was selected. Any disagreements were resolved through discussion with a third reviewer.

Data were extracted and managed independently by 2 reviewers using a predefined extraction form. Any concerns were discussed with a third reviewer.

The following data were extracted: (1) characteristic indicators of meta-analyses (first author, year of publication, study design, study period, and number of component primary studies); (2) characteristics of primary studies (trial design, number of participants, and sectionalization); (3) population information (diagnosis and sample size); (4) VR intervention information (VR platform, population, and intervention course); and (5) statistical summaries (outcomes and effect measures with 95% CIs and heterogeneity).

Data Analysis

We did not reanalyze the other data or primary studies included in the meta-analyses because of the clinical and statistical heterogeneity between the study objectives and outcome indicators of the meta-analyses, and many of the articles did not provide the original data of the original clinical studies. As a result, a descriptive analysis was conducted to encapsulate the impact of VR on clinical nursing practice over the past decade. The process of executing this descriptive analysis involved presenting research results, such as participant details, outcomes, sample sizes, and study designs. These data were meticulously extracted into a predefined Excel (Microsoft Corp) form by YH and XY. Following this, the two authors conducted a thorough review and verification of the collected data to ensure their accuracy and reliability. In instances of disagreement, a consensus was achieved through discussion. In particular, the theme—discerning the relationships between VR interventions and patient outcomes—was summarized.

Quality Evaluation of Included Literature

AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 [] and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist [] were used to independently evaluate the methodological quality of the selected meta-analyses. Two researchers separately evaluated the evidence strength of meta-analyses. If there was disagreement, another researcher was asked to make a judgment.

We reviewed the full texts and supplementary materials of included meta-analyses. Two researchers extracted the estimated pooled effect and heterogeneity of each outcome reported in the meta-analyses. The estimated pooled effect, along with its 95% CI, for each included meta-analysis was extracted. We used the I2 metric to assess heterogeneity (<25%: might show no heterogeneity; 25%-50%: might show moderate heterogeneity; 50%-75%: might show substantial heterogeneity; 75%-100%: considerable heterogeneity), and heterogeneity and P values (significant at P<.05) were used to assess publication bias.

Ethical Considerations

The protocol for this umbrella review was originally registered with PROSPERO in December 2022 (registration number: CRD42022381382). No ethical approval was needed, as we used data from published studies.

ResultsStudy Selection

The electronic literature search identified 768 records from 4 databases and the reference lists of included reviews. We screened the titles and abstracts of 634 records after removing 134 duplicate records. A total of 260 reviews remained after the titles and abstracts were screened for inclusion against predefined criteria. After reading the full texts, 74 articles were finally selected. Further details can be found in .

‎Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram for the search and selection of the eligible studies included in the umbrella review. Studies were identified via databases and registers. VR: virtual reality. Basic Features of Included Studies

The included meta-analyses were meta-analyses of randomized controlled trials (RCTs), cross-over studies, pre-post studies, interrupted time series studies, quasi-controlled trials, case reports, controlled trials, or controlled clinical trials, and details of all included meta-analyses are listed in and .

Table 1. Characteristics of all included meta-analyses.Study (author, year)PeriodStudy design analyzedPopulation analyzedSample size, n (VR group and control group)Chen et al [], 20141993-2013RCT/CRNeurology128 (100 and 28)Välimäki et al [], 20141994-2012RCTPediatrics156 (80 and 76)Cheok et al [], 20152010-2014RCTNeurology166 (84 and 84)Chen et al [], 20152008-2015RCTNeurology76 (38 and 38)Christensen et al [], 20161997-2013RCTOlder adults343 (183 and 160)Howes et al [], 20172003-2015RCTOlder adults719 (364 and 355)Bukola and Paula [], 20172002-2013RCTCancer144 (71 and 73)Laver et al [], 20172004-2017RCTNeurology2470 (N/A)Scheffler et al [], 20181981-2013RCTSugery/wound178 (135 and 43)Wang et al [], 20192003-2018RCTOsteoarthritis126 (63 and 63)Eijlers et al [], 20191999-2018RCT/ITSSPediatricsN/ALei et al [], 20192011-2018RCTNeurology555 (N/A)Kim et al [], 20192003-2017RCT/CTNeurology271 (150 and 121)Perrochon et al [], 20192013-2017RCTNeurology613 (306 and 305)Zeng et al [], 20192013-2018RCT/CCT/PPSCancer225 (137 and 136)Corregidor-Sanchez et al [], 20202011-2019RCTOlder adults491 (336 and 155)Custodio et al [], 20202012-2018RCTPediatricsN/ADe Miguel-Rubio et al [], 20202010-2018RCT/COS/CRPediatrics188 (131 and 57)De Miguel-Rubio et al [], 20202012-2018RCTPediatrics150 (81 and 69)De Miguel-Rubio et al [], 20202011-2018CTPediatrics103 (57 and 46)Ding et al [], 20202013-2019RCTSurgery/wound723 (363 and 360)Dominguez-Tellez et al [], 20202007-2018RCTNeurology874 (440 and 434)Georgescu et al [], 20202000-2018RCTSurgery/wound1452 (659 and 793)Lauwens et al [], 20202000-2019RCT/CRSurgery/wound142 (N/A)Lopez-Valverde et al [], 20202001-2009RCTPediatrics891 (485 and 406)Low et al [], 20212004-2019RCTPediatrics297 (154 and 143)Czech et al [], 20212002-2018RCTPediatrics617 (394 and 223)Fandim et al [], 20212003-2019RCTNeurology1233 (629 and 604)Chen et al [], 20212007-2020RCTNeurology1428 (656 and 772)Jung et al [], 20212010-2021RCTNeurology41 (21 and 21)Li et al [], 20212012-2020RCTNeurology836 (426 and 410)Sajeev et al [], 20212005-2020RCTPediatrics1085 (537 and 548)Yen and Chiu [], 20212012-2020RCTOlder adults1022 (503 and 519)Zhang et al [], 20212011-2019RCTNeurology3540 (1783 and 1757)Zhang et al [], 20212011-2020RCTNeurology894 (414 and 480)Zhong et al [], 20212014-2021RCTNeurology744 (374 and 370)Blasco-Peris et al [], 20222006-2021RCTOlder adults152 (81 and 71)Bu et al [], 20222013-2021RCT/QCT/PPSCancer478 (330 and 148)Chan et al [], 20222012-2021RCTNeurology48 (16 and 32)Chen et al [], 20222007-2021RCTNeurology789 (380 and 409)Chen et al [], 20222016-2021RCTNeurology1149 (571 and 578)Chen et al [], 20232017-2019RCTSurgery/wound529 (263 and 266)Czech et al [], 20222005-2021RCT/COSSurgery/wound587 (481 and 106)Huber et al [], 20222008-2020RCTNeurology214 (108 and 106)Kim et al [], 20222012-2021RCTNeurology793 (357 and 436)Mo et al [], 20222012-2021RCT/PPSCancerN/AObrero-Gaitán et al [], 20222015-2022RCT/PPSCancer1547 (783 and 764)Saliba et al [], 20222006-2020RCTPediatrics930 (468 and 462)Simonetti et al [], 20222017-2019RCTSurgery/wound602 (297 and 305)Suleiman-Martos et al [], 20222012-2021RCTSurgery/wound603 (300 and 303)Tas et al [], 20221999-2020RCT/ITSSPediatrics1695 (N/A)Thi et al [], 20221998-2017RCTCancer201 (92 and 109)Wang et al [], 20232015-2021RCTKinesiophobia488 (208 and 280)Wang et al [], 20222019-2021RCTSurgery/wound1146 (571 and 575)He et al [], 20222007-2021RCTSurgery/wound1258 (588 and 670)Zhang et al [], 20222016-2020RCT/QCTCancer443 (236 and 207)Zhang et al [], 20222016-2019RCTNeurology609 (303 and 306)Wong et al [], 20232002-2022RCTAnxiety720 (N/A)Liu et al [], 20232017-2019RCTNeurology752 (N/A)Hao et al [], 20232017-2022RCT/CCTCancer799 (N/A)Kodvavi et al [], 20232018-2022RCTSurgery/wound375 (188 and 187)Parra et al [], 20232011-2022RCTNeurology898 (N/A)Chen et al [], 20232008-2022RCTOlder adults482 (N/A)Kavradim et al [], 20232013-2022RCTOlder adults739 (369 and 370)Shen et al [], 20232012-2021RCTNeurology423 (N/A)Bok et al [], 20232009-2017RCTNeurology761 (383 and 378)Tian et al [], 20232004-2021RCT/QCTCancer797 (N/A)Yan et al [], 20232012-2022RCTPediatrics818 (404 and 414)Gao et al [], 20232017-2022RCTSurgery/wound892 (N/A)Wu et al [], 20232018-2022RCTCancer425 (202 and 223)Ren et al [], 20232011-2021RCTOlder adults2404 (1181 and 1223)Lee et al [], 2023Not reportedRCTOlder adults1095 (N/A)Burrai et al [], 20232003-2022RCT/COSCancer459 (222 and 237)Percy et al [], 20232015-2021RCTOlder adults265 (162 and 103)

aVR: virtual reality.

bRCT: randomized controlled trial.

cCR: case report.

dN/A: not applicable.

eITSS: interrupted time series study.

fCT: controlled trial.

gCCT: controlled clinical trial.

hPPS: pre-post study.

iCOS: cross-over study.

jQCT: quasi-controlled trial.

Table 2. Outcomes of included meta-analyses.Studies (author, year) and outcomesEstimated effect (95% CI)Heterogeneity (I2), %Publication bias, P valueChen et al [], 2014Motion1.00 (0.45 to 1.56)56N/AVälimäki et al [], 2014Cognition4.67 (–1.76 to 11.1)8N/ASatisfaction5.1 (1.03 to 9.17)0N/ACheok et al [], 2015Balance0.39 (–0.25 to 1.04)85.02Chen et al [], 2015BI−0.5 (−2.4 to 0.13)27N/ABalance−0.5 (−0.7 to 0.37)0N/AChristensen et al [], 2016HbA1c–0.10 (–0.33 to 0.14)0.71Howes et al [], 2017Balance0.56 (0.25 to 0.87)66.10Mobility–0.12 (–0.48 to 0.03)6.54Cognition–0.65 (–1.03 to –0.28)58.07Fear0.28 (–0.50 to 1.05)0.55Bukola and Paula [], 2017Pain–0.64 (–1.10 to –0.17)61.3N/ALaver et al [], 2017Gait0.09 (–0.04 to 0.22)10N/ABalance0.39 (–0.09 to 0.86)10N/AMobility–4.76 (–8.91 to –0.61)50N/AMotion0.01 (–0.60 to 0.61)0N/AScheffler et al [], 2018Pain0.69 (0.40 to 0.98)72NoAnxiety0.36 (0.20 to 0.52)0NoWang et al [], 2019Pain–0.25 (–0.48 to –0.02)32N/ABalance29.36 (–6.99 to 65.71)88N/AEijlers et al [], 2019Pain1.30 (0.68 to 1.91)93NoAnxiety1.32 (0.21 to 2.44)96NoLei et al [], 2019Gait0.15 (–0.50 to 0.19)32HighBalance0.22 (0.01 to 0.42)0HighMobility–1.95 (–2.81 to –1.06)60HighKim et al [], 2019Cognition0.42 (0.24 to 0.60)5.001Physical fitness0.41 (0.16 to 0.65)0<.001Emotion0.14 (0.07 to 0.36)36.20Execution0.07 (0.34 to 0.49)66.34Feasibility0.12 (0.10 to 0.34)54.30Perrochon et al [], 2019Motion0.53 (–0.35 to 1.42)0.58Satisfaction0.08 (0.03 to 0.13)0.001Safety0.17 (–0.02 to 0.36)1.15Zeng et al [], 2019Anxiety–3.03 (–6.20 to 0.15)95.001Depression–1.11 (–3.17 to 0.96)0.51Fatigue–2.50 (–4.28 to –0.73)16.27Pain–1.63 (–4.15 to 0.89)94.001Cognition0.40 (4.64 to 5.44)36N/ACorregidor-Sanchez et al [], 2020Motion–0.56 (–0.90 to –0.21)55HighCustodio et al [], 2020Pain–0.46 (–0.91 to –0.01)82NoAnxiety–3.37 (–4.57 to –2.81)71NoDe Miguel-Rubio et al [], 2020Balance3.42 (2.54 to 4.29)70N/ADe Miguel-Rubio et al [], 2020BI–0.37 (–1.38 to 0.64)68N/ADe Miguel-Rubio et al [], 2020ROM–0.93 (–1.95 to 0.09)0N/ABalance–0.27 (–0.82 to 0.27)56N/ADing et al [], 2020Pain–0.64 (–1.05 to –0.22)69N/ADominguez-Tellez et al [] , 2020Motion1.53 (0.51 to 2.54)92NoQOL2.37 (–0.25 to 4.98)0NoMBI0.77 (0.05 to 1.49)95NoGeorgescu et al [], 2020Pain0.95 (0.32 to 1.57)86NoCognition0.94 (0.33 to 1.56)51NoLauwens et al [], 2020Pain0.94 (0.92 to 1.27)52N/ALopez-Valverde et al [], 2020Pain–0.67 (–1.58 to 0.24)0.18Anxiety0.20 (–0.48 to 0.87)0.54Low et al [], 2021Satisfaction0.45 (–0.07 to 0.97)70N/ADissatisfaction0.72 (0.25 to 1.20)44N/ACzech et al [], 2021Pain−2.85 (−3.57 to −2.14)0N/AFear−0.19 (−0.58 to 0.202)94N/AAnxietyN/A93N/ASatisfactionN/A83N/AFandim et al [], 2021Motion–0.08 (–0.45 to 0.29)6NoBalance1.43 (0.61 to 2.24)53NoChen et al [], 2021BI0.23 (0.13 to 0.34)0.28Jung et al [], 2021Cognition0.45 (0.20 to 0.71)42.58Li et al [], 2021Balance0.66 (N/A)64.23QOL–0.28 (N/A)0<.001MBI0.62 (N/A)0<.001Depression–0.75 (N/A)80.75Sajeev et al [], 2021Pain–0.43 (–0.67 to –0.20)81N/AAnxiety–0.61 (–0.88 to –0.34)89N/AYen and Chiu [], 2021Cognition0.53 (0.32 to 0.73)2.57Memory0.51 (0.06 to 0.96)58.50Attention0.49 (–0.10 to 1.08)88.44Execution0.05 (–0.37 to 0.46)81.79Depression–1.00 (–1.51 to –0.45)55.90Zhang et al [], 2021Motion3.01 (1.91 to 4.11)70N/ABalance and gait3.51 (2.10 to 4.92)80N/ACognition0.81 (−0.41 to 2.03)66N/AMBI7.02 (4.96 to 9.08)18N/AZhang et al [], 2021Cognition0.32 (–0.43 to 1.06)89.29Attention0.78 (0.23 to 1.33)6.04Depression0.20 (–0.25 to 0.64)16.55QOL3.01 (1.51 to 4.31)12.17Zhong et al [], 2021Cognition0.42 (0.04 to 0.79)3NoAttention0.09 (−0.26 to 0.44)0NoBlasco-Peris et al [], 2022QOL0.22 (−0.37 to 0.81)3N/ADepression0.17 (−0.36 to 0.70)0N/ABu et al [], 2022Anxiety–6.47 (–7.21 to –5.73)83NoDepression–4.27 (–4.64 to –3.91)0NoPain–1.32 (–2.56 to –0.09)87NoFatigue8.80 (8.24 to 9.36)0NoChan et al [], 2022Balance0.12 (–0.66 to 0.89)0N/AMotion0.13 (–0.65 to 0.91)0N/AChen et al [], 2022Anxiety–0.35 (–0.70 to 0.01)0N/ADepression–0.48 (–0.84 to –0.12)0N/AChen et al [], 2022Cognition3.00 (2.28 to 3.71)7NoBI6.14 (4.56 to 7.72)0NoMBI6.06 (1.27 to 10.85)86NoChen et al [], 2023Anxiety−0.91 (−1.43 to −0.39)86LowCzech et al [], 2022Pain–0.47 (–0.78 to –0.15)41N/AROM0.44 (−0.23 to 1.11)50N/AHuber et al [], 2022Cognition0.43 (0.22 to 0.64)24N/AKim et al [], 2022Depression−0.54 (−0.79 to –0.29)73NoMo et al [], 2022Pain–0.59 (–1.15 to –0.04)78NoFatigue–0.53 (–0.88 to –0.18)15NoDepression–0.60 (–1.04 to –0.15)29NoSatisfaction–0.68 (–1.25 to –0.11)55NoObrero-Gaitán et al [], 2022Pain–1.03 (–1.52 to –0.54)7.09Anxiety–1.79 (–2.7 to –0.91)32.55Depression–2.7 (–4.39 to –0.99)46.92QOL0.76 (0.42 to 1.11)0.90Saliba et al [], 2022Pain2.54 (0.14 to 4.93)99N/AAnxiety0.89 (0.16 to 1.63)95N/ASimonetti et al [], 2022Anxiety–0.34 (–0.62 to –0.11)39NoSuleiman-Martos et al [], 2022Anxiety–10.62 (–13.85 to –7.39)84NoTas et al [], 2022Pain–0.67 (–0.89 to 0.45)68.30Anxiety–0.74 (–1.00 to 0.48)59.56Thi et al [], 2022Pain–0.93 (–2.63 to 0.76)86N/AWang et al [], 2023Fear−0.53 (−0.90 to −0.17)64N/AWang et al [], 2022Fear−1.52 (−2.18 to –0.86)51N/AAnxiety−2.79 (−4.07 to –1.54)0N/APain−2.17 (−3.37 to –0.97)92N/AHe et al [], 2022Pain–1.13 (–2.01 to –0.26)97NoZhang et al [], 2022Anxiety–2.07 (–3.81 to –0.34)95N/AFatigue–0.92 (–4.47 to 2.62)99N/AZhang et al [], 2022BI0.31 (0.10 to 0.51)31