L'effetto della realtà virtuale sul dolore procedurale e  sull'ansia anticipatoria nei bambini ricoverati al pronto  soccorso: revisione sistematica e meta-analisi.
10.54103/dn/20520
BACKGROUND: In recent years, the use of virtual reality (VR) as a distraction technique for pain control in paediatric settings has become widespread. Despite the presence of several dedicated systematic reviews in the literature, none focus on the effectiveness of the intervention in the emergency room, a setting that is a source of great stress for children and caregivers.
OBJECTIVE: To evaluate the effect of VR on the pain of children undergoing medical procedures in the emergency room.
METHODS: Systematic review with meta-analysis of parallel-group randomised controlled clinical trials. Studies were retrieved by querying biomedical databases, online resources and trial registries.
VR was compared with standard of care. The primary outcome was pain following the procedure. Risk of bias was assessed with RoB 2. The overall effect size was calculated with a random-effects model. The certainty/quality of the results was assessed with the GRADE approach.
RESULTS: Six studies with 433 patients were included. The risk of bias is high for four studies and raises some concerns for two. Compared to standard of care, the use of VR had a small but statistically significant effect on pain (SMD: -0.32, 95% CI: -0.56, -0.09). Heterogeneity between studies was low.
CONCLUSION: Virtual reality for pain in children undergoing medical procedures in the emergency room seems effective, but further studies are needed to confirm the results.
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Dissertation Nursing
pronto soccorso
L'effetto della realtà virtuale sul dolore procedurale e  sull'ansia anticipatoria nei bambini ricoverati al pronto  soccorso: revisione sistematica e meta-analisi.
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Laura Zoppini
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Gorini A, Riva G. Virtual reality in anxiety disorders: the past and the future. Expert Rev Neurother 2008;8(2):215-33. doi: 10.1586/14737175.8.2.215.
The effect of virtual reality on procedural pain and anticipatory anxiety in children admitted to emergency room: systematic review and meta-analysis.
https://riviste.unimi.it/index.php/dissertationnursing/article/download/20520/19970
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          ISSN: 2785-7263                                                                                           DOI: 10.54103/dn/20520




             DISSERTATION NURSING®
             Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

Systematic review & Meta-analysis

     The effect of virtual reality on procedural pain and
   anticipatory anxiety in children admitted to emergency
         room: systematic review and meta-analysis
                      1
Luca Giuseppe Re          , Viviana Fusetti2, Silvia Cilluffo1, Laura Zoppini4
1 Bachelor
         School of Nursing, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
2 IRCCSIstituto Nazionale dei Tumori Foundation, Milan, Italy
3 DAPSS, ASST Grande Ospedale Metropolitano Niguarda




Findings:                                          ABSTRACT
                                                   BACKGROUND: Virtual reality (VR) is a recent distraction technique used
Virtual reality interventions appear to have a     for pain management in pediatric settings. None of the reviews available in
positive significant influence on pain and
                                                   the literature addresses the effectiveness of intervention in the emergency
anxiety in children admitted to emergency
rooms.                                             room, which is known to be an environment at risk of generating great stress
                                                   for both children and caregivers.

                                                   OBJECTIVE: To measure the effect of VR on procedural pain and
                                                   anticipatory anxiety in children admitted to the emergency room.

                                                   METHODS: Systematic review with meta-analysis of parallel-group
                                                   randomized controlled trials (RCTs). Sources of query, consultation, and
                                                   retrieval were as follows: biomedical databases, online resources, and
                                                   registries of RCTs. VR was compared with usual care. The primary outcome
                                                   was procedural pain; the secondary outcome was anticipatory anxiety. The
                                                   RoB 2 tool was used to assess the risk of bias. The point estimate of
                                                   intervention effect was measured by standardized mean difference (SMD)
                                                   while certainty/quality of outcome was presented by the GRADE approach.

                                                   RESULTS: Six RCTs with 443 subjects and variable risk of bias were
                                                   included. VR demonstrated a small but statistically significant benefit on
                                                   both procedural pain (SMD: -0.32, 95% CI: -0.56, -0.09; N=409) and
                                                   anticipatory anxiety (SMD: -0.26, 95% CI: -0.45, -0.06; N=409).

                                                   CONCLUSION: Children admitted to the emergency room who
                                                   underwent the intervention had a small but significant reduction in
                                                   procedural pain and anticipatory anxiety; however, further studies with a
                                                   larger sample sizes and better methodological quality are needed to confirm
                                                   the findings.
                KEYWORDS: Virtual Reality, Procedural Pain, Anticipatory Anxiety, Children, Emergency Room

        Corresponding author:                                         1
                                                                                                           Submission received: 30/06/2023
        Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                End of Peer Review process: 09/11/2023
        ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                             Accepted: 09/11/2023
        Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                 This work is licensed under a Creative Commons
             Dissertation Nursing V.3, N.1 (01/2024)
           ISSN: 2785-7263                                                                                           DOI: 10.54103/dn/20520




              DISSERTATION NURSING®
              Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

  Revisione sistematica & Meta-analisi

   L'effetto della realtà virtuale sul dolore procedurale e
  sull'ansia anticipatoria nei bambini ricoverati al pronto
       soccorso: revisione sistematica e meta-analisi.
                        1
Luca Giuseppe Re             , Viviana Fusetti2, Silvia Cilluffo1, Laura Zoppini4
1 Corso
      di laurea in Infermieristica, ASST Grande Ospedale Metropolitano Niguarda, Milano
2 FondazioneIRCCS Istituto Nazionale dei Tumori, Milano
3 DAPSS ASST Grande Ospedale Metropolitano Niguarda




Riscontri:                                          ABSTRACT

Interventi di realtà virtuale sembrerebbero         BACKGROUND: La realtà virtuale (VR) è una recente tecnica di distrazione
influire con positiva significatività su dolore e   utilizzata per la gestione del dolore in ambito pediatrico. Nessuna delle
ansia nei bambini ricoverati in pronto
soccorso.
                                                    revisioni disponibili in letteratura affronta l'efficacia di un intervento simile in
                                                    pronto soccorso, che notoriamente è un ambiente a rischio di generare grande
                                                    stress sia per i bambini che per gli operatori.
                                                    OBIETTIVO: misurare l'effetto della VR sul dolore procedurale e sull'ansia
                                                    anticipatoria nei bambini ricoverati in pronto soccorso.
                                                    METODI: revisione sistematica con meta-analisi di studi randomizzati
                                                    controllati a gruppi paralleli (RCT). Le fonti di interrogazione, consultazione e
                                                    reperimento sono state le seguenti: banche dati biomediche, risorse online e
                                                    registri di RCT. La VR è stata confrontata con le cure abituali. L'esito
                                                    primario era il dolore procedurale, l'esito secondario l'ansia anticipatoria. Lo
                                                    strumento RoB 2 è stato utilizzato per valutare il rischio di bias. La stima
                                                    puntuale dell'effetto dell'intervento è stata misurata mediante la differenza
                                                    media standardizzata (SMD), mentre la certezza/qualità dell'esito è stata
                                                    presentata mediante l'approccio GRADE.
                                                    RISULTATI: sono stati inclusi sei RCT con 443 soggetti e rischio di bias
                                                    variabile. La VR ha dimostrato un beneficio piccolo ma statisticamente
                                                    significativo sia sul dolore procedurale (SMD: -0,32, 95% CI: -0,56, -0,09;
                                                    N=409) sia sull'ansia anticipatoria (SMD: -0,26, 95% CI: -0,45, -0,06; N=409).
                                                    CONCLUSIONE: i bambini ricoverati al pronto soccorso che hanno subito
                                                    l'intervento hanno avuto una piccola ma significativa riduzione del dolore
                                                    procedurale e dell'ansia anticipatoria; tuttavia, per confermare i risultati sono
                                                    necessari ulteriori studi con campioni più ampi e una migliore qualità
                                                    metodologica.


                            KEYWORDS: Realtà virtuale, Dolore, Ansia anticipatoria, Bambini, Pronto soccorso

          Corresponding author:                                          2
                                                                                                            Submission received: 30/06/2023
          Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                               End of Peer Review process: 09/11/2023
          ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                            Accepted: 09/11/2023
          Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                  This work is licensed under a Creative Commons
             Dissertation Nursing V.3, N.1 (01/2024)
       ISSN: 2785-7263                                                                                  DOI: 10.54103/dn/20520




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



BACKGROUND                                                       or she is overpowered by pleasant stimuli [15]. The
The recommended approach for the management of                   effect appears to be positively associated with an
procedural pain in pediatric settings should include             increased degree of immersion [16], probably due to
both pharmacological and non-pharmacological                     an incremental overregulation of non-painful neural
interventions [1-3], with the latter being the starting          signaling [17], which is counterbalanced by a
point [4] because they are relatively risk-free, low-cost        progressive suppression of nociceptive processing
and easy to administer and safer and more effective in           [18,19].
relieving pain and anxiety [5]. Among the most widely            The focus on VR as a distraction technique for pain
used      non-pharmacological      interventions      are        and anxiety control is going hand in hand with the
distraction techniques [6]. To more pervasively                  increasing popularity of the intervention in pediatric
capture a child's attention and thus achieve maximum             settings and is also evidenced by the presence of
effectiveness, distraction should be multisensory,               several dedicated systematic reviews in the literature
immersive, neurodevelopmentally appropriate, and                 [7,20-26]. However, none of them focus on the
highly engaging [7,8].                                           effectiveness of intervention in the emergency room,
One of the techniques that has become increasingly               a setting that, for children and caregivers, is a source
popular in clinical settings in recent years is virtual          of great stress due to the hustle and bustle of health
reality (VR). It has been defined as a computer                  workers, loud sounds, bright lights, and long waiting
technology that creates a simulated world that                   times, and because young patients may be subjected
subjects perceive as comparable in terms of objects or           to medical procedures that generate pain, anxiety, and
events to the real one [9]. Through VR, attention is             discomfort [6,27].
diverted away from real-world stimuli and into the
virtual world through the multisensory nature of the             Objective
virtual environment [10]. This is presented in real-             To measure the effect of VR on procedural pain and
time through computer-generated 3D graphics; the                 anticipatory anxiety in children admitted to the
individual interacts with virtuality through input               emergency room.
devices such as position trackers, mouse or interactive
glove, and output devices such as goggles, viewers
equipped with motion detectors, sound-producing                  METHODS
headphones for reproducing audio stimuli and haptic
sensors [11]. Depending on the equipment used, the               Inclusion criteria
content and nature of the virtual world, and the level           The inclusion criteria were as follows: (1) participants:
of engagement, VR interventions can be very                      subjects aged 0-18 years undergoing medical
different [11], although active interaction, navigation,         procedures for diagnostic or therapeutic purposes in
and immersion are recognized as key features [12,13].            the emergency room; (2) intervention: VR; (3)
Although the mechanism by which VR influences the                control: Standard of care (SoC); (4) outcomes
perception of pain remains unclear, it is believed that          (assessed with any type of instrument): (a) primary
this occurs through its ability to attract the child's           outcome – procedural pain reported by the child after
attention [14]: by focusing at a sensory, cognitive,             the procedure; (b) secondary outcomes – anticipatory
affective, and behavioral level on the virtual                   anxiety reported by the child after the procedure,
environment with which he or she is interacting, he              child's pain perceived by the caregiver after the
or she reacts more slowly to pain signals because he             procedure, child's anxiety perceived by the caregiver

      Corresponding author:                                  3
                                                                                               Submission received: 30/06/2023
      Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                      End of Peer Review process: 09/11/2023
      ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                   Accepted: 09/11/2023
      Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                     This work is licensed under a Creative Commons
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       ISSN: 2785-7263                                                                                  DOI: 10.54103/dn/20520




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



after the procedure; (5) study design: parallel-group            Study selection and data extraction
randomised controlled clinical trials.                           The authors (LGR and VF) independently consulted
                                                                 the sources of information, selected records by title
Search strategy                                                  and abstract, or analyzed the full document in
The review protocol was registered in PROSPERO                   doubtful cases. Comparison and discussion were the
(ID: CRD42022312823). The document search was                    basis for resolving any disagreements. The authors
performed on 22 July 2022 and updated on 13                      themselves independently and using a standardized
December 2022. The biomedical databases The                      template extracted these data from each eligible study:
Cochrane Library, MEDLINE (via PubMed),                          first author, year of publication and country; study
EMBASE (via Elsevier), CINAHL (via EBSCOhost),                   design; type of procedure performed; sample
PsycINFO (via Ovid), Web of Science (via Clarivate               characteristics (total and per-group numerosity, mean
Analytics), Scopus (via Elsevier), ERIC (via                     or median total and per-group age, percentage of
Proquest), LILACS (via Virtual Medical Library),                 males); exclusion criteria; intervention characteristics
CNKI and SciELO were queried. The following                      and VR scenario; control characteristics; outcome of
keywords with their synonyms were used: “virtual                 interest and evaluation tools; mean or median
reality," “pain," and “emergency room." The keyword              duration of the procedure in minutes.
"anxiety" was also not implemented to make the                   Risk of bias
search more sensitive. The search strategy (e.g.,
MEDLINE) is shown in Appendix 1.                                 Independently, the authors (LGR, VF, SC) assessed
The resources ProQuest Dissertations & Theses                    the risk of bias with the Risk of Bias 2 (RoB 2) tool
Global, TRIP Medical Database, the websites Google               [28]. Any disagreement was resolved through
Scholar, Grey Guide, Grey Literature Report, Grey                comparison and discussion; if a difference of opinion
Literature in the Health Sciences, and the trial                 remained, the diriment opinion of another author
registries ICTRP, ClinicalTrials.gov, EU Clinical                (LZ) was sought.
Trials Register, and ISRCTN registry were also
consulted. A manual search was performed on                      Data analysis and synthesis
journals that published eligible studies and those               Estimation of the overall mean effect of the
relevant to the topic, such as Virtual Reality, The              intervention was calculated by creating meta-analyses
International Journal of Virtual Reality, International          with a random-effects model and producing forest
Journal of Virtual and Augmented Reality,                        plots in the presence of at least two studies per
International Journal of Virtual Technology, and                 outcome. The standardized mean difference (SMD)
Multimedia. References of both eligible studies and              for continuous measures was operationalized using
those of relevant systematic reviews were analyzed.              Cohen's d; as a function of d values of 0.2, 0.5, and
Finally, the corresponding authors of the eligible               0.8 [29], the effect was assumed to be minor,
studies were contacted by e-mail to find out whether             moderate, or large, respectively. For the calculate the
they had recently completed or were currently                    deviation from the point estimate of the effect in each
conducting other studies of interest. No language or             study and from the overall estimate in the aggregated
publication date limits were imposed.                            studies, a 95% confidence interval was considered.
                                                                 With Cochran's Q test [30], the presence of
                                                                 heterogeneity among studies was assessed, while its
                                                                 quantification    was     performed       with      the

      Corresponding author:                                  4
                                                                                               Submission received: 30/06/2023
      Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                      End of Peer Review process: 09/11/2023
      ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                   Accepted: 09/11/2023
      Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                     This work is licensed under a Creative Commons
         Dissertation Nursing V.3, N.1 (01/2024)
       ISSN: 2785-7263                                                                                           DOI: 10.54103/dn/20520




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



implementation of Higgins' I2 index [31]. A low,                          Publication bias
moderate, high, or very high level of heterogeneity                       The funnel plot [33] was inspected, and the Trim and
was assigned to I2 values ≤ 30%, 30-60%, 60-90%, or                       Fill [34] method was implemented to assess the risk
> 90%, respectively [32]. Data processing was                             of bias, provided at least five studies were available.
performed with ProMeta© version 3.0 software.                             An objective type assessment was also performed
                                                                          through Egger's test [35] and Begg and Mazumdar's
Sensitivity analysis                                                      test [36]. The study adheres to PRISMA guidelines
Sensitivity analysis was performed by regenerating the                    [37] in terms of conduct and presentation.
meta-analysis after the exclusion of studies (a) with a
high risk of bias and (b) that claimed to have received                   Summary of findings.
funding or donations and with at least one author                         The overall assessment of the certainty/quality of
with conflicts of interest.                                               evidence was carried out using the GRADE approach
                                                                          [38] by the authors (LGR, VF) independently of each
Additional analysis                                                       other. Comparison and discussion guided the
Subgroup analyses were performed to assess the                            handling of any disagreements; however, if a
effectiveness of the intervention according to the                        difference of opinion persisted, arbitration by another
gender and age of the participants.                                       author (LZ) was requested.




                                             Figure 1: PRISMA flow chart for records screening.


      Corresponding author:                                          5
                                                                                                        Submission received: 30/06/2023
      Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                               End of Peer Review process: 09/11/2023
      ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                            Accepted: 09/11/2023
      Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                              This work is licensed under a Creative Commons
         Dissertation Nursing V.3, N.1 (01/2024)
         ISSN: 2785-7263                                                                                                                                            DOI: 10.54103/dn/20520




             DISSERTATION NURSING®
                Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



RESULTS
                                                                                                              contacting the corresponding authors of eligible
Selection of studies                                                                                         studies by e-mail. Of the 11 eligible studies, three
As a result of consulting information sources, 484                                                           were excluded because they did not have a
records were returned; Figure 1 shows the selection                                                          measurement of pain after the procedure but only the
flow of identified records.                                                                                  pre-post difference [39-41], one because the authors
No other studies of interest were intercepted through                                                        implemented a different intervention than the one of
analysis of bibliographies of eligible studies and                                                           interest [42], and another because it was a quasi-
previous systematic reviews and by consulting the                                                            randomized clinical trial [43]. A total of six studies
most relevant journals in the field, as well as by                                                           met all the expected inclusion criteria [44-49].
                                                                                                                                Intervention                              Outcome and           Average
     Study
                  Design Country Procedure                          Sample                   Exclusion criteria                     (VR                  Control           evaluation          procedure
     (year)
                                                                                                                                 scenario)                                   tools              duration
    Chen (2020)     RCT        Taiwan         Venous                  N=136              Children with developmental delay,        Interactive,        Verbal comfort      Pain: WBFPS         VR group: 0.9
                                             sampling,               mean age:                  epilepsy, or heart disease;      immersive VR                               Fear: CFS            minutes
                                            intravenous     9.3 years VR group (n=68)      undergoing chemotherapy; with         (roller coaster,                                              Control group:
                                            cannulation      Nine years control group        vision or hearing impairment;            space                                                      1 minute
                                                                      (n=68)              nearsighted with more than eight        exploration,
                                                                   males 56.6%             diopters or farsighted with more       nature park,
                                                                                              than five diopters; who have            travel
                                                                                           suffered a head injury in the last     destinations)
                                                                                           month; obese; in need of blood
                                                                                           transfusions; who have received
                                                                                          two or more injections, who have
                                                                                         had the procedure performed once
                                                                                                          before
    Dumoulin        RCT        Canada         Venous                    N=59                     Children with cognitive            Immersive                Minimal         Pain: VAS          Not declared
     (2019)                                  sampling,               mean age:               impairment, who suffer from         interactive VR            distraction:      Fear: VAS
                                            intravenous     13.9 years VR group (n=20)      epilepsy or migraine, who have        (exploring an         portable DVD
                                            cannulation,         12.7 years minimal            vomiting at the time of the        apartment by          player (Looney
                                                             distraction group (n=24)                   procedure               hitting flies flying    Tunes, Animal
                                                              13.8 years control group                                                around)                Planet's
                                                                       (n=15);                                                                              Funniest
                                                                    males 64.4%                                                                             Animals)
                                                                                                                                                         Control: CLS
                                                                                                                                                        prompting the
                                                                                                                                                       child to choose
                                                                                                                                                           between a
                                                                                                                                                       conversation on
                                                                                                                                                            a topic of
                                                                                                                                                        choice, books
                                                                                                                                                         with puzzles,
                                                                                                                                                        ball of 20 quiz
                                                                                                                                                            questions
     Goldman        RCT        Canada         Venous                   N=66              Children in poor clinical condition      Interactive,             Distraction     Pain: FPS-R          VR group: 5
      (2021a)                                sampling,              median age;          or such that they are excluded from     immersive VR            techniques of     Anxiety: VSA           minutes
                                            intravenous     8.9 years VR group (n=35)       being able to describe pain or      (Roller Coaster)          your choice                          Control group:
                                            cannulation       9.6 years control group     anxiety, with facial trauma at the                              (e.g., books,                          7 minutes
                                                                      (n=31)             point where the garrisons are to be                            DVD movies,
                                                                    males 54.5%                         placed                                              TV, iPad,
                                                                                                                                                       bubbles) + CLS

     Goldman        RCT        Canada       Wound care                   N=62             Children with wounds or injuries to       Interactive,      Distraction          Pain: FPS-R         VR group: 15
     (2021b)                                                         median age:           the face in the area to be covered      immersive VR     techniques of          Anxiety: VSA           minutes.
                                                                       9.8 years                   with the principals            (Roller Coaster)   your choice                               Control group:
                                                                  VR Group (n=32)                                                                    (e.g., books,                              27.4 minutes
                                                               10.4 years control group                                                             DVD movies,
                                                                        (n=30)                                                                         TV, iPad,
                                                                     males 62.9%                                                                   bubbles) + CLS
     Litwin        RCT          Canada         Venous                    N=58               Children with visual, hearing, or       Interactive,     Tablet with            Pain: NRS           VR group: 4
     (2021)                                   sampling,               mean age:            cognitive impairment, psychiatric       immersive VR     marine setting         Anxiety: CFS           minutes
                                             intravenous              12.5 years          conditions, infections, or injuries to  (kindVR Aqua)         video +                                Control group:
                                             cannulation          VR Group (n=31)           the skin, face, ears, upper limbs                        soundproof                                 4.1 minutes
                                                              12.48 years control group                                                             headphones +
                                                                        (n=27)                                                                            CLS
                                                                     males 56.9%
    Osmanlliu      RCT          Canada         Venous                    N=62             Unstable child or urgent procedure;       Interactive,      Distraction           Pain: NRS           Not declared
     (2021)                                   sampling,               mean age:            significant cognitive impairment;       immersive VR       techniques           Anxiety: CFS
                                             intravenous              11.1 years           diagnosis of epilepsy or seizures;     (Dreamland) +      provided by
                                             cannulation          VR Group (n=31)                 caregiver unavailable          caregiver comfort   caregiver or
                                                               12.3 years control group                                                            CLS + caregiver
                                                                       (n=31);                                                                         comfort
                                                                     males 38.7%
   CFS=Children’s Fear Scale; CLS=Child Life Specialist; FPS-R=Faces Pain Scale-Revised; NRS=Numerical Rating Scale; RCT=Randomized Controlled Trial; VAS=Visual           Analogue Scale; VR=Virtual Reality;
   VSA=Venham Situational Anxiety; WBFPS=Wong Baker Faces Pain Scale.


                                                                  Table 1: main characteristics of included studies.

       Corresponding author:                                                                        6
                                                                                                                                                      Submission received: 30/06/2023
       Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                                                            End of Peer Review process: 09/11/2023
       ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                                                                         Accepted: 09/11/2023
       Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                                                     This work is licensed under a Creative Commons
            Dissertation Nursing V.3, N.1 (01/2024)
       ISSN: 2785-7263                                                                                             DOI: 10.54103/dn/20520




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



The main characteristics of the included studies                            distraction (portable DVD player; n = 24) and one
The studies were published between 2019 and 2021,                           with SoC (distraction techniques agreed upon with
conducted in Canada [45-49] and Taiwan [44], and all                        the CLS; n = 15). All studies assessed pain and
in the emergency room of a tertiary care hospital                           anxiety (or fear) reported by the child; one study
(Table I). Three studies [45,48,49] received some                           measured the child's pain as perceived by the
form of funding or donation, and at least one of their                      caregiver [44], one measured the child's distress [48],
authors declared conflicts of interest. A total of 443                      and another measured the child's distress as perceived
children (55.8% male) with a mean age range of 8.9-                         by the caregiver [49]. The instruments used to
13.9 years were included. The sample size ranged                            measure pain included the FPS-R (Faces Pain Scale-
from 58 [48] to 136 [44] individuals. With the                              Revised) [50], the NRS (Numerical Ratings Scale), the
exception of one study, in which the medical                                VAS (Visual Analogue Scale), and the WBFPS
procedure consisted of wound care [47], in the others                       (Wong-Baker Faces Pain Scale) [51]. Anxiety (or fear)
the procedures were venous sampling or intravenous                          was assessed with the Children Fear Scale (CFS) [52],
cannulation. Exclusion criteria included children with                      the VAS, and the Venham Situational Anxiety (VSA)
cognitive       impairment,       epilepsy,     limited                     scale [53]. The average duration range of the
communication skills, impaired vision, and hearing, or                      procedure in the intervention group was 0.9-15
injuries/infections to the upper limbs, face, ears, and                     minutes, and in the control group, 1-27.4 minutes.
head; clinically critical or hemodynamically unstable                       The studies also assessed other outcomes, such as the
children were also excluded. When reported, topical                         number of attempts required for successful venous
anesthetic administration involved up to 96.8% of                           sampling or intravenous cannulation, the level of
children [47]. VR scenarios were heterogeneous,                             satisfaction with the intervention of children and
although the most common was Roller Coaster                                 caregivers, the degree of acceptability of physicians
[44,46,47]. In one study, the intervention was                              and other caregivers, and possible side effects.
combined with caregiver comfort [49]. The control
group received Standard of care (SoC), which could                          Risk of bias
range from verbal comfort [44] to the use of a tablet                       Figure 2 and Figure 3 show the risk of bias
with soundproof headphones and support from a                               assessment of the included studies. Overall, the risk
Child Life Specialist (CLS) [48]. One study [45]                            of bias is high for four studies [44,45,48,49] and of
planned two control groups, one with minimal                                some concern for two [46,47].




                                                             Figure 2: RoB2 summary




      Corresponding author:                                            7
                                                                                                          Submission received: 30/06/2023
      Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                 End of Peer Review process: 09/11/2023
      ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                              Accepted: 09/11/2023
      Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
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         Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing




                                                            Figure 3 – RoB 2 traffic light
Data analysis
Two studies [46,49] illustrated the results using                              children undergoing medical procedures in the
medians and interquartile ranges or ranges; a                                  emergency room were evaluated in 409 participants.
conversion technique was implemented to obtain                                 The aggregate SMD is -0.32 (95% CI: -0.56, -0.09) in
mean and standard deviation [54,55].                                           favor of the intervention; the result is statistically
                                                                               significant (Table 2 & Figure 4). The Q-test shows
Pain – virtual reality vs. Standard of care                                    non-significant (p = 0.247) and low grade of
The effect of VR vs. SoC for procedural pain in                                heterogeneity (I2 = 24.88%).

                                         Virtual Reality     Standard of care                        Std. Mean Difference IV,
                          Study                                                         Weight
                                      Mean SD         Total Mean SD Total                                Random, 95% CI
                          Chen
                                       3.35 2.38         68      4.35     2.95     68    27.62%           -0.37 [-0.71, -0.03]
                         (2020)
                       Dumoulin
                                      21.75 20.92        20     25.33 25.25 15           10.17%            -0.16 [-0.83, 0.51]
                         (2019)
                       Goldman
                                         2      3.09     35       4       3.11     31    16.53%           -0.65 [-1.14, -0.15]
                        (2021a)
                       Goldman
                                       1.84 1.94         32      1,47     2.03     30    16.36%            0.19 [-0.31, 0.69]
                        (2021b)
                         Litwin
                                        2.6      2.1     24      3.8       2.1     24    13.04%            -0.57 [-1.15, 0.01]
                         (2021)
                       Osmanlliu
                                       3.36 3.89         31       3       3.11     31    16.27%            -0.33 [-0.83, 0.17]
                         (2021)
                          Total
                                                        210                       199 100.00%             -0.32 [-0.56, -0.09]
                       (95% CI)
                      Heterogeneity statistics: Q = 6.66 (p = 0.247); I2 = 24.88; T2 = 0.02; T = 0.14
                               Table 2: children's Pain in Emergency Room: virtual reality vs. Standard of care




     Corresponding author:                                                8
                                                                                                               Submission received: 30/06/2023
     Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                       End of Peer Review process: 09/11/2023
     ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                                    Accepted: 09/11/2023
     Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                     This work is licensed under a Creative Commons
        Dissertation Nursing V.3, N.1 (01/2024)
         ISSN: 2785-7263                                                                                                    DOI: 10.54103/dn/20520




            DISSERTATION NURSING®
             Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing




                                                 Figure 4: Std. Mean Difference IV, Random, 95% CI

Anxiety/fear – virtual reality vs. Standard of care                                SMD is -0.26 (95% CI: --0.45, -0.06) in favor of the
The effect of VR vs. SoC on the anxiety/fear of                                    intervention; the result is statistically significant (Table
children undergoing medical procedures in the                                      3 & Figure 5). The Q-test shows no heterogeneity (p
emergency room was evaluated in 409 participants.                                  = 0.430), and the Higgins index is zero.
The                                                 aggregate

                                  Virtual Reality                         Standard of care                                           Std. Mean Difference IV,
Study
                          Mean           SD          Total         Mean           SD          Total             Weight                   Random, 95% CI
Chen 2020                  3.35          2.38          68           4.35          2.95         68                33.46%                   -0.35 [-0.69 -0.02]
Dumoulin 2019             21.75         20.92          20          25.33         25.25         15                8.44%                     -0.35 [-1.02, 0.33]
Goldman 2021a               2            3.09          35             4           3.11         31                16.43%                     0.00 [-0.48, 0.48]
Goldman 2021b              1.84          1.94          32           1,47          2.03         30                15.47%                    -0.04 [-0.54, 0.46]
Litwin 2021                2.6           2.1           24            3.8          2.1          24                11.49%                    -0.08 [-0.66, 0.50]
Osmanlliu 2021             3.36          3.89          31             3           3.11         31                14.71%                   -0.65 [-1.16, -0.14]
Total (95% CI)                                        210                                      199              100.00%                   -0.26 [-0.45, -0.06]
Heterogeneity statistics: Q = 4.89 (p = 0.430); I2 = 0.00; T2 = 0.00; T = 0.00



                          Table 3: children's anxiety/fear in the emergency room: virtual reality vs. Standard of care.




                                                  Figure 5: std. Mean difference IV, random, 95% CI
        Corresponding author:                                               9
                                                                                                                   Submission received: 30/06/2023
        Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                        End of Peer Review process: 09/11/2023
        ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                                     Accepted: 09/11/2023
        Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                         This work is licensed under a Creative Commons
            Dissertation Nursing V.3, N.1 (01/2024)
        ISSN: 2785-7263                                                                                        DOI: 10.54103/dn/20520




           DISSERTATION NURSING®
           Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



Child pain as perceived by caregiver – virtual reality vs.              significance (p = 0.058) and to a moderate degree (I2
Standard of care                                                        = 64.84%).
Only one study [44] evaluated the effect of VR versus
SoC on child pain as perceived by the caregiver, so no                  Additional analysis
meta-analysis was performed.                                            Gender
                                                                        No studies have evaluated the effect of the
Child's anxiety/fear as perceived by caregiver – virtual reality        intervention according to the gender of the
vs. Standard of care                                                    participants.
No studies evaluated the effect of VR versus SoC on                     Age
anxiety or fear of the child as perceived by the                        No studies assessed the effect of the intervention as a
caregiver.                                                              function of the age of the participants.

Other outcomes                                                          Publication bias
The studies that measured the average duration of the                   Publication bias is possible but unlikely (Figure 6).
procedure and/or the number of attempts required                        This consideration is the result of what was obtained
for successful venous sampling or intravenous                           from implementing the Trim and Fill method: since
cannulation always recorded lower values in the VR                      no study was trimmed, the two effect sizes, the
group; furthermore, the level of satisfaction with the                  estimated (in black) and the observed (in white)
intervention of children and caregivers and the degree                  coincide. Statistical significance was not reached by
of acceptability of doctors and other caregivers was                    either Egger's test (p = 0.837) or Begg and
more than satisfactory. The side effects observed                       Mazumdar's test (p = 0.573).
were mild and occasional (eye fatigue, nausea,
dizziness, headache).

Sensitivity analysis
To assess the robustness of the overall effect of the
intervention on pain, the meta-analysis was
regenerated after the removal of studies (a) at high
risk of bias [44,45,48,49]; (b) that received funding or
donations and with one or more authors declaring
conflicts of interest [45,48,49]. The aggregate SMD
after the removal of studies with a high risk of bias is
-0.23 (95% CI: -1.05, 0.59; N = 128) in favor of
intervention; the result is not statistically significant.
                                                                                                 Figure 6: Funnel plot.
The Q-test shows a significant (p = 0.020) and high
degree of heterogeneity (I2 = 81.38%). After
                                                                        Summary of findings
removing studies with conflicts of interest and
                                                                        The GRADE evaluation produced a low
funding or donations, the aggregate SMD was -0.29
                                                                        certainty/quality of evidence for the effect of VR on
(95% CI: -0.72, 0.14; N = 264) in favor of the
                                                                        pain and anxiety/fear in children (Table 4).
intervention; the result is not statistically significant.
The Q-test shows heterogeneity at the limit of

       Corresponding author:                                       10
                                                                                                      Submission received: 30/06/2023
       Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                            End of Peer Review process: 09/11/2023
       ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                         Accepted: 09/11/2023
       Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                            This work is licensed under a Creative Commons
          Dissertation Nursing V.3, N.1 (01/2024)
           ISSN: 2785-7263                                                                                                              DOI: 10.54103/dn/20520




              DISSERTATION NURSING®
               Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing




Summary of findings. Virtual reality for procedural pain and anticipatory anxiety in children in Emergency Room.
Virtual reality compared to Standard of care
Patient or population: children (0 to 18) undergoing medical procedures
Setting: Emergency Room
Intervention: virtual reality
Comparison: Standard of care
Outcome              Anticipated absolute effects*                         N° of           Certainty/quality of                                       Comments**
                     (95% CI)                                              sessions        the evidence
                     Risk with       Risk with virtual reality             (studies)       (GRADE)
                     Standard of
                     care
Children             -               The mean procedural pain (SMD)        409             ⊕⊕⊝⊝                                                       This result equates to a
procedural pain                      level with virtual reality was 0.32   (6 RCTs)        Lowa,b                                                     small difference in
                                     standard deviation lower (0.56 to                                                                                favor of virtual reality.
                                     0.09 lower).
Children's           -               The mean level of anticipatory        409             ⊕⊕⊝⊝                                                       This result equates to a
anticipatory                         anxiety (SMD) with virtual reality    (6 RCTs)        Lowa,b                                                     small difference in
anxiety or fear                      was 0.26 standard deviation lower                                                                                favor
                                     (0.45 to 0.06 lower).                                                                                            of virtual reality.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its
95% CI).
**0.2 represents a small difference, 0.5 is a moderate difference, and 0.8 is a large difference.
CI: confidence interval; SMD: standardized mean difference; RCTs: randomized controlled trials
GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different
Low certainty: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect
a Downgraded once for serious study limitations: trials had some concerns/high risk of bias.
b Downgraded once for imprecision due to analysis based on < 200 participants per group.




                                                                      Table 4: summary of findings

DISCUSSION                                                                                     Implications for practice
The objective of this systematic review with meta-                                             Despite the good results obtained from the
analysis was to measure the effect of virtual reality                                          intervention on procedural pain and anticipatory
versus Standard of care on procedural pain and                                                 anxiety (or fear) in children, it is important to
anticipatory anxiety in children admitted to the                                               emphasize that: (a) all included studies were carried
emergency room. The results show that the                                                      out in an emergency room of a hospital providing
intervention results in the improvement of both                                                tertiary care and thus providing highly skilled clinical
outcomes; although the overall effect size is                                                  care services; (b) except for one case [47], for all other
statistically significant, it is small. The level of                                           studies the medical procedures implemented were
certainty/quality of evidence is low, so the actual                                            venous sampling or intravenous cannulation. What
effect could be substantially different from that                                              was obtained cannot, therefore, be generalised to
estimated. Sensitivity analysis showed that although                                           healthcare facilities providing primary or secondary
the small benefit of the intervention is not disproved,                                        care or to procedures other than those in the studies.
the effect size is no longer statistically significant. The                                    It was not possible to perform subgroup analyses by
risk of publication bias appears unlikely.                                                     gender or age, variables that could play a role in the
                                                                                               effect of the intervention, along with other child
                                                                                               characteristics such as temperament, neurocognitive
         Corresponding author:                                                         11
                                                                                                                               Submission received: 30/06/2023
         Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                                   End of Peer Review process: 09/11/2023
         ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                                                Accepted: 09/11/2023
         Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                                     This work is licensed under a Creative Commons
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       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20520




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



development, previous experiences, coping style,                  hetero-directed or self-directed scales. However, the
attitudes, and empathy of health care providers                   former may lack practicality and accuracy as they
[25,56,57].                                                       involve observing the facial expressions of a child
Although VR is considered a homogenous                            wearing the VR visor with much of the face covered
intervention, due to the lack of shared standards, both           [59]. Anxiety was measured with instruments that
the duration of use and the hardware and software                 were not always adequate [60-62]; this may have
used were different, which may have influenced the                hindered its proper assessment [5]. Furthermore, in
level of immersion and, thus, effectiveness. The                  the included studies, anxiety and fear have been
hardware should be customizable according to the                  treated as synonyms; although in clinical practice, the
age and anthropometric characteristics of the child:              difference is not always relevant, they are theoretical
the few dropouts recorded by the included studies                 constructs with profoundly different meanings that
occurred mainly because, in younger children, the                 should be differentiated more rigorously [25].
headset did not fit properly or the visor tended to slip
off the head or because the interpupillary distance               Implications for research
was inadequate, with negative repercussions on the                Many of the included studies were probably
level of immersion and 3D viewing. To date, there is              underpowered to detect statistically significant
a lack of evidence in favor of the superiority of one             differences; it would therefore be necessary for future
VR environment over another [58], although a                      studies to be not only of higher methodological
practical and usable scenario should be attention-                quality and low risk of bias but also multicentre and
grabbing, highly immersive, simple for younger                    with an adequate sample size for the benefit of
children, and fun for older ones, ethically and                   greater statistical power and the feasibility of
culturally sensitive, and appropriate for use in an               subgroup analysis by gender and age. To test
emergency room [45].                                              variations on pain and anxiety, several VR scenarios
The SoC was also very heterogeneous: it could consist             of different durations should be tested, and different
of verbal comfort from caregivers and/or health                   types of hardware platforms should be compared
workers or include alternative distraction techniques             [58].
and/or the support of the Child Life Specialist (CLS),            The feasibility of a concrete implementation of the
a professional with a degree in the area of psychology            intervention in clinical practice in terms of economic
or educational sciences and specialized in the use of             resources should be considered; specifically, the costs
effective strategies for controlling children's pain and          for the purchase of VR devices, replacement in case
anxiety. A variable but generally high proportion of              of damage or upgrade, and periodic disinfection of
participants used a topical analgesic and/or anesthetic           the hardware should be evaluated. Smartphone-based
prior to the procedure, and in none of the included               devices are systems with orientation functionality that
studies were the times of administration and doses                are generally portable and self-contained and require
delivered specified. In this sense, both the presence of          very little space and set-up time to use, are
CLS and the widespread use of topical analgesics or               lightweight, inexpensive, easy to clean, and can have
anesthetics may have acted as effect modifiers,                   disposable components; systems with orientation and
making it problematic to discriminate the net benefit             tracking functionality include trackers and sensors
of the procedure.                                                 and increase the level of interaction but are more
Pain assessment was carried out, consistent with the              expensive and although to some extent still portable,
child's neurocognitive development and age, with                  they are heavier, require more time for set-up and

      Corresponding author:                                  12
                                                                                                Submission received: 30/06/2023
      Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                       End of Peer Review process: 09/11/2023
      ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                    Accepted: 09/11/2023
      Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                      This work is licensed under a Creative Commons
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       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20520




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



cleaning at the end of use and require sufficient space           sample size of the studies (higher risk of false
for children to move around safely [63].                          negatives) and the already low levels of anticipatory
Since CLSs are often tasked with setting up the VR                anxiety or fear recorded in some studies before the
device and supporting the child during its use in the             implementation of VR, both in the intervention and
included studies, their perspectives should be                    control group.
considered and included in future research. In order
to better clarify the effect size of VR, it would be              Limits
desirable for future studies to ensure greater                    The main limitations, which affect the internal and
homogeneity of the SoC and to specify the timing,                 external validity of the results, include (a) the small
doses, and ways of administration of topical                      number and sub-optimal methodological quality of
analgesics/anesthetics. Finally, little attention was             the included studies; (b) the low overall number of
paid to the rare and mild side effects recorded during            participants (N = 433, of which n = 409 were
VR use. The observed symptoms, which include eye                  available for the VR vs SoC comparison), resulting in
fatigue, headache, dizziness, and nausea, are                     low statistical power; (c) the impossibility, due to the
cumulatively related to cybersickness [64]. To explain            nature of the intervention, of conducting the studies
cybersickness, the currently most accepted theory is              blinded; (d) the limited nature of the medical
that of sensory conflict [65,66]. It traces the cause to a        procedures examined; (e) the setting where the trial
lack of synchronization between the ocular and                    was conducted, for all studies an emergency room of
vestibular systems: this occurs when the senses do not            a tertiary care hospital.
receive the expected sensory feedback in the presence
of a real rather than virtual scenario. This determines           CONCLUSIONS
the fact that children with vestibular abnormalities,             In children admitted to the emergency room, the
seizure disorders, migraines, or headaches may be                 effect of VR compared with SoC on the reduction of
more at risk for cyber sickness, and therefore, for               procedural pain and anticipatory anxiety is statistically
these individuals, the use of virtual reality is                  significant but small; the level of certainty/quality of
contraindicated [67].                                             evidence is low.
                                                                  Until further research provides more data to confirm
Comparison with other reviews                                     the findings, they should be viewed with great
The comparison with previous systematic reviews was               caution; at present, they may provide an indication of
limited to those that focused on the effect of VR for             the effect of the intervention for some medical
procedural pain from venous sampling or intravenous               procedures performed in tertiary care hospitals.
cannulation [25,26] or that performed a subgroup
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      Corresponding author:                                  13
                                                                                                Submission received: 30/06/2023
      Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                       End of Peer Review process: 09/11/2023
      ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                    Accepted: 09/11/2023
      Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                      This work is licensed under a Creative Commons
         Dissertation Nursing V.3, N.1 (01/2024)
      ISSN: 2785-7263                                                                                  DOI: 10.54103/dn/20520




         DISSERTATION NURSING®
         Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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     Corresponding author:                                  14
                                                                                              Submission received: 30/06/2023
     Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                      End of Peer Review process: 09/11/2023
     ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                   Accepted: 09/11/2023
     Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                    This work is licensed under a Creative Commons
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                                                                                              Submission received: 30/06/2023
     Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                      End of Peer Review process: 09/11/2023
     ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                   Accepted: 09/11/2023
     Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                    This work is licensed under a Creative Commons
        Dissertation Nursing V.3, N.1 (01/2024)
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         Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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                                                                                              Submission received: 30/06/2023
     Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                      End of Peer Review process: 09/11/2023
     ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                   Accepted: 09/11/2023
     Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
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                                                                                              Submission received: 30/06/2023
     Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                      End of Peer Review process: 09/11/2023
     ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                   Accepted: 09/11/2023
     Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
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     Corresponding author:                                  18
                                                                                              Submission received: 30/06/2023
     Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                      End of Peer Review process: 09/11/2023
     ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                   Accepted: 09/11/2023
     Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                    This work is licensed under a Creative Commons
        Dissertation Nursing V.3, N.1 (01/2024)
                ISSN: 2785-7263                                                                                                                  DOI: 10.54103/dn/20520




                  DISSERTATION NURSING®
                  Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



APPENDIX 1: Search strategy (e.g. MEDLINE)
#1                AND   #2 "Emergency Service,               AND   #3 “Virtual Reality”[MeSH]                AND   #6 “Infant”[MeSH]     AND   #10"Randomized Controlled Trial" [Publication Type]
"Pain"[MeSH]            Hospital"[Mesh]

                                                                   OR                                              OR                          OR
                                                                   #4 “Virtual Reality Exposure                    #7 “Child”[MeSH]            #11"Randomized Controlled Trials as Topic"[Mesh]
                                                                   Therapy”[MeSH]
                                                                   OR                                              OR
                                                                   #5 “Exergaming”[MeSH]                           #8
                                                                                                                   “Adolescent”[MeSH]
                                                                                                                   OR
                                                                                                                   #9 “Minors”[MeSH]
OR
#12 Pain          AND   #15 “Hospital Emergency Services”    AND   #32 “Virtual Reality Immersion Therapy”   OR    #67 Child*            AND   #78 "randomizedcontrolled trial"
OR                      OR                                         OR                                              OR                          OR
#13 Suffering           #16 “Emergency Hospital Service”           #33 “Virtual Reality Therapy”                   #68 Infant*                 #79 "randomizedcontrolled study"
OR                      OR                                         OR                                              OR                          OR
#14 Ache                #17 “Emergency Hospital Services”          #34 “Virtual Reality Therapies”                 #69 Newborn                 #80 “randomisedcontrolled trial”
                        OR                                         OR                                              OR                          OR
                        #18 “Hospital Service Emergency”           #35 “Educational Virtual Realities”             #70 Neonat*                 #81 “randomisedcontrolled study”
                        OR                                         OR                                              OR                          OR
                        #19 “Hospital Service Emergencies”         #36 “Educational Virtual Reality”               #71 Baby                    #82 rct
                        OR                                         OR                                              OR
                        #20 “Hospital Emergency Service”           #37 “Instructional Virtual Realities”           #72 Babies
                        OR                                         OR                                              OR
                        #21 “Emergency Units”                      #38 “Instructional Virtual Reality”             #73 Adolescen*
                        OR                                         OR                                              OR
                        #22 “Emergency Unit”                       #39 “User-Computer Interfaces”                  #74 Youth*
                        OR                                         OR                                              OR
                        #23 “Accident and Emergency                #40 “User Computer Interface”                   #75 Teen*
                        Department”

                        OR                                         OR                                              OR
                        #24 “Emergency Ward”                       #41 “User Computer Interfaces”                  #76 Teenager*
                        OR                                         OR                                              OR
                        #25 “Emergency Wards”                      #42 “Virtual Systems”                           #77 Minor*
                        OR                                         OR                                              OR
                        #26 “Emergency Departments”                #43 “Virtual System”                            #78 Pediatric*
                        OR                                         OR
                        #27 “Emergency Department”                 #44 “Computer Simulations”
                        OR                                         OR
                        #28 “Emergency Room”                       #45 “In silico Simulation”
                        OR                                         OR
                        #29 “Emergency Rooms”                      #46 “Computerized Models”
                        OR                                         OR
                        #30 “Emergency Outpatient Unit”            #47 “Computerized Model”
                        OR                                         OR
                        #31 “Emergency Outpatient Units”           #48 “Computer Models”
                                                                   OR
                                                                   #49 “Computer Model”
                                                                   OR
                                                                   #50 “In silico Models”
                                                                   OR
                                                                   #51 “In silico Model”
                                                                   OR
                                                                   #52 “ComputationalModelling”
                                                                   OR
                                                                   #53 “ComputationalModeling”
                                                                   OR
                                                                   #54 “In silico Modeling”
                                                                   OR
                                                                   #55 “Video Game”


           Corresponding author:                                                                       19
                                                                                                                                           Submission received: 30/06/2023
           Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                                             End of Peer Review process: 09/11/2023
           ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                                                          Accepted: 09/11/2023
           Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                                              This work is licensed under a Creative Commons
                  Dissertation Nursing V.3, N.1 (01/2024)
 ISSN: 2785-7263                                                                                                      DOI: 10.54103/dn/20520




    DISSERTATION NURSING®
    Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing


                                            OR
                                            #56 “Computer Games”
                                            OR
                                            #57 “Computer Game”
                                            OR
                                            #58 “Character User Interface”
                                            OR
                                            #59 “Command-line Interface”
                                            OR
                                            #60 “Command-line User Interface”
                                            OR
                                            #61 “Computer User Interface”
                                            OR
                                            #62“Graphic User Interface”
                                            OR
                                             #63 “Graphical User Interface”
                                            OR
                                            #64 “Text User Interface”
                                            OR
                                            #65 “Text-based User Interface”
                                            OR
                                            #66 “User-computer Interface”




Corresponding author:                                                         20
                                                                                                             Submission received: 30/06/2023
Luca Re: lucagiuseppe.re@ospedaleniguarda.it                                                          End of Peer Review process: 09/11/2023
ASST GOM Niguarda, Padiglione 6, ala C, Piano 1°                                                                       Accepted: 09/11/2023
Piazza dell’Ospedale Maggiore 3, 20162, Milan, Italy
                                                                                   This work is licensed under a Creative Commons
   Dissertation Nursing V.3, N.1 (01/2024)
