Effects of virtual reality on pain, fear and anxiety during blood draw in children aged 5–12 years old: A randomised controlled study
J Clin Nurs. 2020;29:1151–1161. wileyonlineli
ary.com/journal/jocn  |  1151© 2019 John Wiley & Sons Ltd
Received: 31 July 2019  |  Revised: 12 December 2019  |  Accepted: 20 December 2019
DOI: XXXXXXXXXX/jocn.15173
O R I G I N A L A R T I C L E
Effects of virtual reality on pain, fear and anxiety during blood
draw in children aged 5–12 years old: A randomised controlled
study
Gülçin Özalp Gerçeker PhD, RN, Associate Professor  | Dijle Ayar PhD, RN  |
Emine Zahide Özdemir RN, MSc  | Murat Bektaş PhD, RN, Associate Professo
Clinical Trial Registration: National Institutes of Health (NIH), ClinicalTrials.gov, NCT XXXXXXXXXXRegistered on 31 July 2019, https :
clini caltr ials.gov/ct2/show/NCT XXXXXXXXXX
Pediatric Nursing Department, Dokuz Eylul
University Faculty of Nursing, Izmir, Turkey
Co
espondence
Gülçin Özalp Gerçeker, Pediatric Nursing
Department, Dokuz Eylul University Faculty
of Nursing, Izmir 35340, Turkey.
Email: XXXXXXXXXX
Abstract
Aim and objectives: Virtual reality (VR) can be used during painful procedures in chil-
dren. The aim of this study was to evaluate the effects of two different VR methods
on procedure-related pain, fear and anxiety of children aged 5–12 years old during
lood draw.
Methods: This randomised controlled study used parallel trial design guided by the
CONSORT checklist, see Supporting Information. The sample of children (n = 136)
was allocated to the VR-Rollercoaster (n = 45), VR-Ocean Rift (n = 45) and control
group (n = 46) using blocked randomisation. The primary outcome was pain scores
after the blood draw and fear and anxiety scores before and after the blood draw.
Before the blood draw, fear and anxiety scores were assessed using self-report and
eports from the parents and the researcher using the Child Fear Scale and Children's
Anxiety Meter. After the blood draw, level of pain experienced was assessed using
the Wong–Baker Faces Pain Rating Scale and the fear and anxiety levels experienced
y the children during the blood draw were re-evaluated.
Results: Pain scores were found to be lower in the VR-Rollercoaster group and the
VR-Ocean Rift group. A statistical difference was found between groups according
to self-, parent- and researcher-reported fear and anxiety scores after blood draw.
While being in VR-Rollercoaster and VR-Ocean Rift group reduced children's fear and
anxiety, being in the control group increased fear levels by 20% and anxiety levels by
34.1%.
Conclusions: VR is an effective method in reducing procedure-related pain, fear and
anxiety in children aged 5–12 years old during blood draw.
Relevance to clinical practice: Evidence-based guidelines and protocols should be
created for nonpharmacological methods such as VR for procedural pain and anxiety
in children.
K E Y W O R D S
anxiety, blood draw, child, fear, pain, virtual reality
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1152  |     ÖZALP GERÇEKER Et AL.
1  | INTRODUC TION
Virtual reality (VR) has firmly stood amongst other technological
devices and can easily be adapted to clinical procedures due to its
low cost. It can be easily used particularly in paediatric care units
ecause it appeals to various age groups and can be adapted to
mobile phones. VR can be used during wound care, preoperative
anxiety, chemotherapy, port access, chronic pain treatment, dental
and routine medical practices (Arane, Behboudi, & Goldman, 2017;
Atzori et al., 2018; Gold, Kim, Kant, Joseph, & Rizzo, 2006; Gupta,
Scott, & Dukewich, 2018; Hoffman, Doctor, Patterson, Ca
ougher,
& Furness, 2000; Hoffman et al., 2001, 2006, 2014; Hua, Qiu, Yao,
Zhang, & Chen, 2015; Jeffs, 2007; Jeffs et al., 2014; Jin, Choo,
Gromala, Shaw, & Squire, 2016; Mo
is, Louw, & Grimmer-Somers,
2009; Nilsson, Finnström, Kokinsky, & Enskär, 2009; Ryu et al., 2017;
Windich-Biermeier, Sjoberg, Dale, Eshelman, & Guzzetta, 2007;
Won et al., 2015).
VR allows the context of therapy to be perceived by the child as a
safe environment where the child can behave freely and without any
isk (Carmona To
es, Cangas Diaz, & Langer He
er, XXXXXXXXXXAlthough
studies indicate that VR can be used in paediatric procedures, fur-
ther research on which procedures and in which age range it can be
used is needed (Lange, Williams, & Fulton, XXXXXXXXXXVR may be a useful
method for health professionals during painful procedures (Malloy
& Milling, XXXXXXXXXXIt can be a very promising analgesic technique that
may be used safely and effectively for pain and discomfort during
medical procedures (Wismeijer & Vingerhoets, 2005).
2  | BACKGROUND
A study found that VR significantly reduced procedural pain and
anxiety during blood draw in children aged 10–21 years old. VR can
e safely used in blood draw units and can increase the adaptation of
children to the procedure by reducing their distress (Gold & Mahrer,
2018). The use of VR alone or combined with standard care is effec-
tive in reducing pain and anxiety (Arane et al., XXXXXXXXXXVR environ-
ment could be safely used during paediatric intravenous procedures,
in a study conducted by Dunn et al XXXXXXXXXXchildren with haemophilia
and parents reported a positive influence of VR distraction on pro-
cedural anxiety and pain.
During a painful procedure which may cause anxiety, VR has the
potential to help children draw their attention away from frightening
and painful procedures by keeping them active. Distraction methods
such as watching TV (Bellieni et al., 2006), listening to music/car-
toon soundtracks, playing video games, watching cartoons (Akgül
et al., 2018; Caprilli et al., 2007; Kaheni, Rezai, Bagheri-Nesami, &
Goudarzian, 2016; Sinha, Christopher, Fenn, & Reeves, 2006), ka-
leidoscope (Canbulat, İnal, & Sönmezer, 2014) and using hand-held
electronic medical devices (Dittoâ„¢) (Brown, Kimble, Rodger, Ware,
& Cuttle, 2014) can be easily applied during painful procedures.
Children may wear VR headsets, as well as watch videos and play
games, during the procedure so as to distract themselves, and
therefore experience less pain and anxiety. Gold et al XXXXXXXXXXre-
ported that diverting the attention of children aged between 8 and
12 to something else using VR headsets during the intravenous
placement was effective in reducing the pain. Another study exam-
ining the effect of VR in children aged 4–6 years old during their
dental treatment showed that VR decreased their pain perception
and state anxiety levels (Aminabadi, Erfanparast, Sohrabi, Ghertasi
Oskouei, & Naghili, 2012).
Even though some studies reported that VR is applied to small
age groups, there are limited studies assessing its effect on fear.
Fear is a situation associated generally with age and pain (Hedén,
von Essen, & Ljungman, 2016) and is rarely addressed in painful pro-
cedures for children (Aydin & Sahiner, 2017; Aydin, Sahiner, & Ciftci,
2016). In a pilot study, Chad, Emaan, and Jillian XXXXXXXXXXapplied VR as
a fear reduction and pain distraction during immunisations; VR was
well received and reduced overall fear and pain at children and par-
ents. Emotional feelings of children such as anxiety and fear can be
educed by interesting, relaxing environment changes. Different VR
applications can be used at this point. The response of each child to
VR may also change. Some children like moving, interesting videos,
while some kids like relaxing, musical videos. VR method may impact
fear, anxiety and pain in children at painful procedures as well as lim-
itations of prior studies in this area, and this study addresses these
gaps in the evidence base. The aim of this study was to evaluate the
effects of two different VR methods on procedure-related pain, fear
and anxiety levels of children aged 5–12 years old during blood draw.
The hypotheses of this study were to:
H1: Children in the two different VR groups will have significantly
less procedure-related pain than those in the control group.
H2: Fear and anxiety scores of the children in the two different
VR groups will be reduced than those in the control group.
3  | METHODS
3.1 | Study design and sample
This prospective, randomised controlled study was conducted at a
university hospital special blood draw unit in Izmir, Turkey, between
September 2017 and November 2017. A parallel trial design was
What does this paper contribute to the wider global
clinical community?
• Distraction methods with the highest level of evidence
are used to reduce children's procedure-related pain.
• This is the first study which used different virtual reality
methods on pain, fear and anxiety during blood draw.
• Virtual reality significantly reduced pain, fear and anxi-
ety of children aged 5–12 years old during blood draw.
     |  1153ÖZALP GERÇEKER Et AL.
used describing two different VR groups (VR-Rollercoaster group
and VR-Ocean Rift group) and a control group (no VR device used)
as the third arm. This study was guided by the CONSORT check-
list (Schulz, Altman, Moher, & the CONSORT Group, 2010), see
Supporting Information. Children aged 5- to 12-year-olds who un-
derwent blood draw were eligible to participate (n = 136). This age
group was selected because they were open to co-operation and
more curious about technology.
It was determined that 18 children in pain dimension and 19
children in fear dimension should be sampled in each group ac-
cording to the one-way analysis of variance for the comparison
of mean self-reported pain and fear scores (Canbulat et al., 2014),
ased on a power of 0.95 and an acceptable Type I e
or size of
0.05 in three groups in the Gpower 3.1.0 statistical program. It is
planned that each group will consist of 45 children, considering
that the parametric test assumptions can be fulfilled and lost in
the study.
3.2 | Randomisation
One hundred and thirty-six children enrolled the study. They were
allocated by the blocked randomisation (gender and age). The alloca-
tion concealment was guaranteed by a computer-generated number
table. One hundred and seventy-three children were assessed for
eligibility; 32 children were excluded; refused to participate (n = 18);
had chronic or genetic