Virtual reality as training technology in the health field: a literature review

The present work is an integrative review that aims to answer the following guiding question: how is virtual reality being applied as an educational technology in the health area? The databases used for the search were Pubmed, Virtual Health Library (VHL) in the health area, IEEEXplore and ACM Digital Library in the technology area. For this work, the following inclusion criteria were established: studies on the use of simulators as educational technology; free access articles; be available online in full; be in Portuguese and / or English; published from 2015 to 2020. Articles of literature review, dissertations, theses and editorials were excluded. A total of 1,563 articles were obtained, of which 21 went on to descriptive analysis. Most of the articles came from the Pubmed database, fourteen, six articles were added from the VHL and only one study was included from the ACM. The discussion of the results emerged from two categories: Characterization of the use of virtual reality in the area of health and Considerations on the applicability of virtual reality in the area of health. As a contribution, this review may serve as a guide for the expansion of virtual reality, while pointing out the potential and weaknesses of its use as training technology in the health area


INTRODUCTION
Virtual Reality (VR) is conceptualized as a simulation in which an individual making use of an electronic device can interact in a real and/or physical way, with a set of images and sounds that reflect an environment or a real situation. Users can experience visual and auditory sensations through the equipment so that they feel fully participants in the environment being simulated (PARK et al., 2019).
Virtual Reality (VR) applied to health has emerged as a teaching strategy since the 1990s and has appropriated 3D vision to improve the teaching-learning process from human anatomy to a more elaborated simulation (SAMADBEIK et al., 2018). This applicability of VR resulted from the need to train competent professionals, with adequate knowledge and skills to work in clinical practice (MORO et al., 2017).
The applications of virtual reality in health are vast, such as: in the teaching of medical students (EROLIN; REID; MCDOUGALL, 2019); in the planning and surgical training of physicians (SUTHERLAND et al., 2019); and a wide range of therapeutic interventions that cover the treatment of phobias, anxiety disorders, post-traumatic stress disorder (PTSD), accident-related deficits and rehabilitation (BANIASADI; AYYOUBZADEH; MOHAMMADZADEH, 2020).
Although this technology is improving and becoming more portable and realistic, there is much to known about the development, implementation and applications of this technological resource in all its application areas, be it in teaching, training or other therapeutic interventions (COUPERUS et al., 2020).
Knowing how virtual reality it is being used by students and health professionals will help to increase the scientific basis for a possible expansion of the use of this technology, to contribute to more effective actions in the areas of health in which it is used. Thus, the aim of this study was to conduct an integrative review on how educational technologies that make use of virtual reality are being used in the health area.

METHODS
To perform this integrative review, the Prisma -Preferred Reporting Items for Systematic Reviews and Meta-Analysesmethodology was used. The study aims to answer the following question guide: how is virtual reality being applied as educational technology in the health area? The databases used for the search were Pubmed, Virtual Health Library (VHL) in the health area, IEEEXplore and ACM Digital Library in technology. The following descriptors were used according to DeCS terminology: Health" AND "Virtual Reality" AND "Patient Simulation"; "Health" AND "Virtual Reality" AND "Simulation Training"; "Health" AND "Virtual Reality" AND "Educational Technology".
A search strategy was developed in 5 stages: 1) selection of studies through the descriptors; 2) reading of titles and abstracts; 3) verification of duplicity; 4) full reading of the articles; 5) analysis of the studies that fulfilled the inclusion criteria, as described in Figure 1.
The inclusion criteria for this study were: studies on the use of simulators as educational technology; open access articles; full online availability; be in Portuguese and/or English languages; published between 2015 and 2020. Literature review articles, dissertations, theses, and editorials were excluded. The selection of articles was carried out in December 2020.
Considering the inclusion and exclusion criteria of the study, 1,563 articles were obtained, of which 21 followed for the descriptive analysis, as it is possible to follow in the flowchart of the study (Figure 1).
To make the word cloud, the software RStudio® (version 1.4.1103) was used, with installation of the packages Bibliometrix and Biblioshiny. In the applied parameters, the Title field was analyzed by measuring the occurrence of the 50 most registered words.
Regarding the analysis of the worldwide production, Microsoft® Excel® (version 2101) was used, with graphic production of a choropleth map, where publications were recorded by country.

RESULTS
Considering the objective of this study to conduct a literature review on how virtual reality is being applied as an educational technology in the health area, we observed that its use was restricted to professionals in nursing, medicine, dentistry, pharmacy and occupational therapy. Although the use of virtual reality in the academic scenario was observed, its use was mostly reported for training of health professionals to improve the teaching-learning process and training the skills of a particular technique.  To identify the frequency of keywords listed in the studies contained in the sample, a cloud of words was generated to explain which were the most recurrent concepts. Figure 3 presents the word cloud elaborated from the RStudio software. In this word cloud, the greater the highlight, the greater the number of times the word was used by the authors. By the search criteria, established in the study, it is justifiable that the terms "Reality", "Virtual" and "Simulation" appear prominently.    It was evident the affirmation of the benefits in the use of virtual reality as a potentiating technology both in the teaching-learning process and in the training of technical skills for the development of a certain procedure between studies.

Characterization of the use of virtual reality in health area
Virtual reality has been used in the health field for didactic development that In the field education, virtual reality has shown to be an ally in the cognitive and  ROBERTS, 2020;COURTEILLE et al., 2018;GUETTERMAN et al., 2019;PADILHA et al., 2019;SHAO et al., 2020;TSCHOLL et al., 2018).
Studies that compared the acquisition of knowledge of health students between the use of the traditional method and the use of patients in virtual reality did not find significant difference in the acquisition or retention of knowledge (CONCANNON; ESMAIL; ROBERTS, 2020;COURTEILLE et al., 2018;PADILHA et al., 2019).
Regarding learning, the effect of teaching with virtual reality on theoretical knowledge reveals that the scores related to basic content, as theory, location, adjacent structure, clinical manifestation, diagnosis and analysis, surgical methods and total score in the VR group exceed those in the traditional teaching group and that the VR teaching group was significantly better than the traditional teaching group (LAM et al., 2019;SAPKAROSKI et al., 2018;SHAO et al., 2020). Technology using virtual games also provides better results in student learning and engagement in the classroom and group work (COURTEILLE et al., 2018;GUETTERMAN et al., 2019;LAM et al., 2019;PADILHA et al., 2019;SHAO et al., 2020).
Immersive VR simulation environments facilitate new ways for users to visualize anatomy and quantify performance, they help develop communication skills and interactions among students (CONCANNON; ESMAIL; ROBERTS, 2020;MAICHER et al., 2017;MIRGHANI et al., 2018;SAPKAROSKI et al., 2018). In a VR simulator training with the participation of undergraduate dentistry students to detect differences in motor performance among students with different levels of training experience, showed sensitivity to differences in performance among students, both in new and experienced students (MIRGHANI et al., 2018). The effectiveness of immersive VR in reducing stateanxiety in Occupational Therapy students who were preparing for the Structured Objective Clinical Examination (OSCE) revealed that students who had access to clinical VR simulation, through standardized virtual patients, using natural language, showed less anxiety compared to traditional methods (CONCANNON; ESMAIL; ROBERTS, 2020). When the competency of physicians who performed virtual reality simulator training was evaluated through a tool developed for this purpose, virtual reality simulator training proved to be more effective than traditional learning training. This can be attributed that VR simulators allow trainees maximum practical time in a standardized and relatively stressful environment for longer, while traditional clinical training is naturally dependent on available patients (KONGE et al., 2015;ZAVERI et al., 2016).

Virtual Reality goes beyond that used in undergraduate education
Findings ratified by the validation study of training for medical procedure (hysterectomy), in which participants with less surgical experience became more efficient in terms of time with successive simulations than those with more surgical experience (BING et al., 2019).
Projects with immersive VR experiences for workforce training can be developed for healthcare workers, in which VR immersion training is shown to be an effective teaching method to help healthcare professionals develop empathy intuitively and allow them to get an overview of the patient's condition more quickly (BING et al., 2019;DYER;SWARTZLANDER;GUGLIUCCI, 2018;TSCHOLL et al., 2018;WONG et al., 2018). In this sense, regarding the use of virtual reality for health professionals, instructors recommend it as a potential learning tool for all, both novice and experienced, and point out that many gaps in the education of current health professionals can be addressed using VR-enabled learning and evaluation activities (WONG et al., 2018).

Considerations about the applicability of virtual reality in healthcare
The possibilities of applicability of virtual reality as a technology for training health professionals have been expanded, given the extension of the perspectives of use and technological advancement. However, there is still a long way to go to make it widely accepted by medical education, including the development and innovation of software and hardware and the strengthening of the optimal relationship with clinical practice (SHAO et al., 2020).
This advantage was pointed out either in teaching to academics or in-service training for trained professionals, to improve a particular technique. The studies that indicated the advantages in teaching emphasize the possibility of taking the laboratory into the student's home, in order to enable learning at the rhythm of each student, besides allowing students to learn using different styles instead of listening in traditional pedagogical teaching practices (LAM et al., 2019;SAPKAROSKI et al., 2018;WONG et al., 2018).
When analyzing the performance in surgical procedures, it was observed that the more often the simulation was practiced and the fewer days occurred between sessions, the faster the participants performed the simulation. In addition, there was an interaction between the number of simulations performed and the level of experience, in which participants with less surgical experience became more efficient in terms of time with successive simulations than those with more surgical experience (BING et al., 2019. Some studies have pointed out that the use of virtual reality can be applied at low cost (BING et al., 2019;MAICHER et al., 2017;SAPKAROSKI et al., 2018;SHAO et al., 2020;YAO;CHALLEN;CAVES, 2019). The first presents that the simulation was designed to be performed with low-cost standard computer game equipment, so that it can be more easily scaled in surgical training programs in less resourced environments.
While a low-cost VR surgical simulation training platform can strengthen training in less resourced environments, it can also be used in environments with higher resources (BING et al., 2019). Another example was brought by presenting that standardized virtual patient simulations have the potential to reduce costs, faculty time, and resources needed to help students develop their communication skills, and interactions can be standardized among students (MAICHER et al., 2017).
These results continue to question the true value of virtual reality (ZAVERI et al., 2016). In a controversial opinion, it is believed that VR allows a competencies-based education and evaluate that, consequently, allows a level of deep learning and the development of clinical skills. Virtual clinical simulation can contribute to reduce clinical error and improve health care safety and quality (PADILHA et al., 2019).

CONCLUSION
The study made it possible to identify the characteristics of the use of VR and some considerations about the applicability of virtual reality in the health area. As a contribution, this review can serve as a guide for the expansion of this technology, while pointing out the potentialities and weaknesses of the use of virtual reality as a training technology in the health area.