PICOT: Quantitative Systematic Review

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PICOT: Quantitative Systematic Review Picot question: In children and adolescents with burn-related, is virtual reality distraction more effective than standard treatment in reducing pain intensity during wound dressing change?

Population: children and adolescents with burn injuries Intervention: virtual reality distraction Comparison: standard wound care Outcome: reduced pain intensity Time: during wound dressing

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Quantitative Systematic Review Chapter 4: RESULTS 4.1 Chapter Introduction Wound dressing procedures are painful and can negatively affect patient satisfaction with care.

Healthcare providers pay close attention to the patient’s pain, but their ability to reduce pain is still insufficient. Pharmacological products dominate pain management strategies in many clinical settings. However, clinicians are increasingly using virtual reality and other nonpharmacological interventions to reduce pain perception among patients. VR technology, in particular, is becoming prominent in wound care settings with good results in clinical nursing.

However, there is a knowledge gap, and many practitioners are reluctant to use this intervention due to limited knowledge concerning its efficacy, safety, and sustainability. Some practitioners argue that it is unclear whether distraction intervention using virtual reality can relieve pain during medical procedures. This chapter presents the systematic review's findings, starting with the search strategy results, then a description of the included studies and their findings.

Objective: The objective of this review is to determine if distraction using virtual reality technology during painful procedures such as wound dressing can reduce the experience of pain.

4.2: Results of the Search The literature search generated 527 articles, n=404 articles from the COCHRANE Central database, and the rest from the CINAHL (n=42), PubMed (n=19), (appendix 3), and Medline (27). Reviewing the abstracts and article titles revealed that only 80 articles contained information relevant to the study topic. Four hundred forty-seven articles were excluded since they did not satisfy the inclusion criteria. The full articles were retrieved for further review.

However, further comparison of the full-text articles with the eligibility criteria excluded fifty-

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nine articles. Twenty studies were excluded since they were conducted in designs other than randomized control trials. Twenty articles were excluded since they only contained abstracts.

The full-text versions of these articles were inaccessible. Two studies were written in languages other than English and were excluded from the review. One study needed a control arm and could not be included in the review. Nine articles were excluded since they were dissertations, conference papers, and grey literature. Twenty studies fulfilled the inclusion criteria and were considered for further review. However, two independent reviewers assessed the quality of these studies and excluded nine due to weak design and failure to satisfy specific aspects of the inclusion criteria. The reviewers agreed that nine studies should be incorporated into the final review.

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527 articles

447 articles not relevant

20 articles reviewed

11 articles were excluded since they had weak study designs 4.3 Descriptions of the Studies

80 articles relevant

59 articles were excluded for several reasons

One article available in full text is not retrieved

9 articles appraised Figure 1: search results

Although the selected studies utilized the randomized controlled trial design, they used different study attributes. However, the investigators in all studies were qualified health professionals adequately trained in virtual reality equipment use. Further, the studies were conducted in different settings. For instance, n-7 studies were conducted in the United States, whereas one was conducted in Canada. One study was conducted in Brisbane, Australia. The participant’s demographics, including age, differed significantly from one study to another. The minimum age of the participants in all studies was four years, and the mean ages ranged between 7.5 and 12. The proportion of the participants was approximately 1.6 times more likely to be male than female, and the sample size varied significantly from one study to another. The study

by Ali et al. (2021) had the least number of participants (n=22), whereas Xiang et al. (2021) and Kipping et al. (2012) had significantly large sample sizes of (n=90) and (n=132), respectively.

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Kaya and Özlü (2023) described a study where the researchers used n=65 participants to determine the effectiveness of virtual reality in reducing pain in children undergoing burn dressing. The participants had a total body burn percentage of approximately 0.8%. Kaya and Özlü (2023) compared the virtual reality outcomes against standard care.

The type of virtual reality technology varied from one study to the other. For instance, Kipping et al. (2012) used off-the-shelf VR, whereas Jeffs et al. (2014) used passive distraction involving a movie and a tripod-arm device virtual reality. Conversely, Xiang et al. (2021) compared smartphone VR games with passive VR games, while Le May et al. (2022) used immersive VR involving the video game Dreamland. Ali et al. (2022) used the Oculus Rift DK2, Armstrong et al. (2022) used mobile phone VR and Brown et al. (2014) used the Ditto VR. None of the studies used the same number of participants from the same ethnic group. An independent observer assessed the participants' pain and found similar child pain rates before the study. All studies used subjects who were going through various forms of wound treatment. For instance, Le May et al. (2022) used (n=20) participants aged between 7 and 17 going through a burn care process and were provided with both experimental and standard care in a randomized manner. Le May et al. (2022) conducted their research in Montreal, Canada. The study setting was a surgical trauma burn unit at CHU Saint-Justine Centre. On the other hand, Armstrong et al.

(2023) used (n=35) participants aged 5-17 years who were scheduled for one week of daily dressing changes.

Brown et al. (2014) investigated the impact of play on healing using (n=99) participants aged between 4 and 12. This study was conducted at the Royal Children’s Hospital in Brisbane.

Conversely, Xiang et al. (2021) conducted a study using (n=90) participants aged between 6 and 17 to investigate the impact of smartphone virtual reality games on pain. The studies used

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different pain scales to gather data from the subjects. For instance, Xiang et al. (2021) used the FLACC-R scale to gather data on the pain scores of the participants. The study was conducted in an ABA-verified US pediatric burn center, and the participants were followed up for about 15 months.

Ali et al. (2021) and Blokzijl et al. (2023) conducted their research in pediatric burn units to determine if distracting children with virtual reality gadgets could decrease their pain during dressing. Ali et al. (2021) used (n=22) participants between 9 and 16 years, whereas Blokzijl et al. (2023) used (n=38) burn patients as highlighted in Appendix 2. Unlike the other studies, Jeffs et al. (2014) conducted a single-blinded, randomized controlled study using n=28 participants to determine if virtual reality was more effective than passive distraction in reducing pain during wound care. Jeffs et al. (2014) conducted their study in a large children’s hospital based in the mid-south U.S. 4.4 Critical Appraisal Using JBI The demographics of the participants at baseline differed significantly across studies.

However, all participants were undergoing treatment for burn-related injuries. The subjects in these studies were below 18 years. All studies (n=9) used children and adolescents between 4 and 17 years as the subjects. The variations in the participants could threaten the internal validity of studies exploring causal relationships. However, in all studies, the participants were randomly allocated to the treatment and control groups, thus reducing the risk of known attributes of the participants influencing the allocation and distorting the comparability of the groups. The review shows that the participants were assigned to groups based on chance, not personal characteristics.

In 90% of the studies, the allocation to groups was concealed, implying that the researchers were unaware of the next group in the allocation process, as indicated in Appendix 2. Concealment of

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allocation meant that the researchers could not deliberately and purposefully influence the allocation of participants to the control or the treatment group.

The studies did not blind the participants to the treatment. The participants in the treatment group engaged in VT technology. Also, they wore headphones during VR tasks.

Therefore, they were aware of the intervention. The failure to blind the participants was a severe problem since the participants could have behaved differently to the intervention, thus distorting the study results. However, the researchers minimized the risk of bias by providing standard wound care to the subjects in both groups.

Many studies are needed to provide adequate details of those delivering the treatment.

However, the review shows that the studies did not blind those delivering the treatment. These parties were aware that patients using the VR technology were in the treatment arm of the study, whereas those that only used standard treatment were in the control group. For instance, Jeffs et al. (2014) noted that the investigators were extensively trained in using VR equipment. The investigators were also present during wound care and participated in setting up and guiding patients to use the IVR gadgets. Failure to blind the clinicians could have introduced bias to the study results.

The studies did not blind the outcome assessors. Only Jeffs et al. (2014) blinded the participants. In n=8 studies, the assessors participated in wound care procedures, as highlighted.

However, the assessors used semi-structured interviews to ensure the information gathered from the participants focused on the treatment interventions rather than the biased opinions of the assessors. Other than the interventions of interest, the studies ensured that the subjects were treated the same way. For instance, the standard burn treatment given to the treatment group was

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also given to the control group (Brown et al., (2014); Blokzijl et al., 2023). The similar treatment of these groups ensured that external factors did not influence treatment outcomes.

4.5 Summary JBI Checklist Questions

Number of studies

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Was true randomization used for the assignment of participants to treatment groups?

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Was allocation to treatment groups concealed?

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Were treatment groups similar at the baseline?

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Were participants blind to treatment assignment?

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Were those delivering treatment blind to treatment assignment?

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Were outcomes assessors blind to treatment assignment?

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Were treatment groups treated identically other than the intervention of interest?

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Was follow-up complete, and if not, were differences between groups in terms of

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their follow-up adequately described and analyzed?

Were participants analyzed in the groups to which they were randomized?

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10 Were outcomes measured in the same way for treatment groups?

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11 Were outcomes measured reliably?

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12 Was appropriate statistical analysis used?

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4.6 Reported Outcomes The review disclosed that the outcomes in each study were measured using the same instruments for the treatment and the control groups. This approach to outcome measurement helped reduce the threat of internal validity. Also, it increased the tests' reliability and the outcomes' validity. All studies (9) reported positive results of the VR interventions that reduce

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pain during wound treatment. Moreover, the studies had no methodological or statistical issues, and the findings were justifiable.

The positive outcomes included distraction during wound dressing (Ali et al., 2022) and reduced experience of pain during burn dressing (Kaya & Özlü, 2023). Also, the RTCs reported that virtual reality creates intense cognitive distraction during painful procedures (Shahar et al., 2014; Blokzijl et al., 2023). The studies consistently report that virtual reality is logistically safe and effective in lowering the pain experienced in different settings of post-burn pain (Le May et al., 2022; Shahar et al., 2014; Armstrong et al., 2023).

Over 75% of the subjects reported that VR helped improve their experience of pain during the painful wound dressing procedure. These subjects reported being satisfied with the VR use during burn care and would use it in future wound care procedures. Only less than 25% of the respondents in these studies stated they would not use VR during future dressing changes.

Also, the reports on the providers' perceptions of VR technology show that they were satisfied with its effectiveness in reducing the experience of pain among burn patients. Care providers recorded pain scores at different points during wound care procedures. Although the studies noted that pain scores remained relatively low during dressing changes, healthcare providers stated that average pain scores were lower in VR than in standard wound care procedures. About 60% of the care providers reported that VR technology created some distraction that helped patients focus their attention elsewhere during dressing changes. Further, the care providers reported that VR did not negatively influence their ability to deliver quality standard care to patients (Kaya et al., 2023).

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Further, procedural pain outcomes were better in VR than in standard care groups. Brown et al. (2014), for instance, reported that pain levels dropped significantly when the subjects were distracted by VR technology.

4.7 A Critical Review of Results The findings support the hypothesis that VR technology can relieve the pain of burnrelated injuries in adolescents and children during wound dressing and other painful wound care procedures. The studies revealed significant changes in pain scores when VR technology was applied during wound dressing. Most subjects believed that VR technology generated pain relief during wound care procedures. However, a critical evaluation of some responses did not reveal significant differences between the VR technology and standard wound care procedures (Kaya et al., 2023). Nonetheless, the groups that received VR interventions experienced less pain intensity than the control groups. These findings show that VR technology was more effective in reducing pain among children. Several studies concluded that the distraction caused by VR helped children give less attention to wound care procedures and associated pain (Kaya et al., 2023; Ali et al., 2021; Le May et al., 2022; Jeffs et al., 2014).

Most studies focused on the impact of VR on pain intensity. However, some studies focused on other health parameters, such as the range of motion of the extremities. Ali et al.

(2022), for instance, revealed that adding VR to the rehabilitation program created a distraction from pain, thus increasing the patient’s range of motion during dressing change. Ali et al. (2022) explained that distraction reroutes an individual’s concentration from the agonizing stimulant.

Armstrong et al. (2023) pointed out that though virtual reality is a significant distraction mechanism for patients with burn-related injuries, few studies have investigated the usefulness of this distraction in home settings. Further, Armstrong et al. (2023) noted that Virtual Reality is

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easier to implement besides effectively reducing pain. In the study, children astonishingly reported increased pain intensity in the first week of the experiment. However, in the subsequent dressing, they reported less pain. The caregivers also reported significant changes in pain intensity in the intervention and the control groups. However, the child-reported and caregiverreported pain differed significantly. Nonetheless, VR increased the participants’ distraction, reducing their pain experience during dressing.

Chapter 5: DISCUSSION 5.1 Chapter Introduction This chapter highlights the review's findings, including a comparison and summary. Also, the chapter contains the strengths and limitations of the review and implications for practice. It outlines an important area for clinical practice for the potential to integrate an effective intervention into available treatments for procedural pain among children undergoing burnrelated wound care. This paper is pegged on a systematic review of VR as a pain reduction tool in burn injury care. The review identified 9 RCTs that satisfied the recommended methodological rigor. Over 500 articles were generated, but only nine that met the inclusion/exclusion criteria were selected for review. The lower-rated studies were excluded since they lacked details of allocation concealment, had incomplete information about randomization procedures, revealed limited binding of subjects, and showed sample attrition.

Painful procedures to manage burn injuries and improve recovery have received significant attention recently. This review focuses on randomized controlled trials investigating the effectiveness of virtual reality in reducing pain during burn injury dressing. Searching for randomized studies generated many articles, some containing irrelevant information. These studies were excluded to ensure that only relevant studies were reviewed. Scrutiny of the study

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abstracts and full texts of some studies helped identify the articles with appropriate information to answer the research question. The inclusion/exclusion criteria helped reduce the number of articles from 527 to 9. The review focused on the change in pain scores among patients treated for burn injuries.

Researchers face a massive challenge in comparing and generalizing results from studies that use an active arm and a placebo. In such situations, obtaining crucial information about the actual and placebo effect of specific interventions is hard. However, the reviewed RCTs used an active arm and standard treatment to determine the actual effect of VR. Using standard treatment as the control in the RCTs created a platform for making practical treatment effect estimations.

5.2 Summary of the Findings The findings revealed significant pain score differences among patients with virtual reality devices integrated into their wound care. However, all studies reported a drop in pain scores among the subjects. Although the studies reported different pain scores among patients treated with virtual reality, these findings provided critical information to answer the study question. Nonetheless, some findings were more convincing than others. For instance, Xiang et al. (2021) and Blokzijl et al. (2023) reported that virtual reality could safely be integrated into painful wound management procedures to relieve pain in children and adolescents. Le May et al.

(2018) reported that virtual reality distraction in burn care was more effective in relieving burnrelated pain than standard treatments. These findings were more convincing than Brown et al.

(2014), who reported that virtual reality achieves better outcomes when combined with pain medications. Virtual reality provides a more significant pain relief effect, thus reducing a patient’s experience of pain. These gadgets deter patients from concentrating on the source of pain during wound dressing and other painful procedures (Armstrong et al., 2023; Alashram et

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al., 2022; Ali et al., 2021). The studies further revealed that VR technology does not affect the delivery of standard burn care. These findings suggest that VR could be an adjunct intervention for managing acute pain in routine burn care.

The high-quality empirical support for VR technology in relieving situational pain among pediatric burn patients, as highlighted in the studies, underscores the significance of these interventions (Smith et al., 2023; Armstrong et al., 2023; Brown et al., 2014). Smith et al. (2023) clarified that various aspects of hospitalization, including medical jargon, unfamiliarity with healthcare providers, unpopular routines, and exposure to strangers, increase anxiety among children. Anxiety decreases a person’s ability to cope with pain (Kaya et al., 2023). Therefore, preparing patients with VR before wound care procedures helps familiarize them with the healthcare environment, thus reducing situational foreignness.

The studies revealed that VR technology is a tangible tool clinicians use to create a procedural distraction, thus reducing a person’s concentration on pain. Pain has a cyclical relationship with anxiety, whereby high pain intensity worsens anxiety and often augments the severity of pain (Smith et al., 2022). This relationship helped researchers investigate the feelings of anxiousness among the subjects once the VR technology was introduced. The findings further supported the moderate correlation between anxiousness and pre-procedural pain. Adolescents treated with standard wound care were not distracted from the process and hence experienced a higher intensity of pre-procedural anxiety and subsequent pain (Smith et al., 2022).

Further, RCTs revealed that combining virtual reality with other interventions, such as hydrotherapy, decreases pain scores (Le May et al., 2012). The studies identified virtual reality as an innovative intervention that could be integrated into care processes for children and adolescents undergoing painful medical procedures.

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This review sought to identify published and unpublished trials of VR as a pain reduction instrument in wound care. The reviewed sample comprised nine published RCTs which helped explore the scope and quality of research on this topic. This review differs from others in that it only included RCTs. These studies are essential since they offer concrete insight into unique directions for a complex study area. Although the review differs from other systematic reviews on VR as a medical intervention, the results are consistent with the findings that this tool distracts patients, thus reducing their experience of pain during painful procedures.

5.3 Comparison with Literature Children and adolescents with burn-related injuries require several medical and nursing interventions to improve recovery (Lauwens et al., 2020; Alashram et al. (2018). These interventions are painful, making them unwelcome among patients. Studies have proposed virtual reality technology to reduce pain during wound care (Lauwens et al., 2020; Kipping et al., 2012). Qualitative and quantitative analysis of patient data concerning the effects of using VR technology to relieve patients of acute pain related to burn injuries provided an indirect measure of effectiveness. Similar to the findings of other studies, participants in the reviewed studies experienced significant distractions when using VR technology. Over 60% of the participants achieved meaningful pain relief (Armstrong et al., 2023; Lauwens et al., 2020; Brown et al., 2014; Xiang et al., 2021). These results align with the growing literature indicating that VR technology can safely and effectively relieve acute burn injury-related pain.

Literature highlights that burn patients using VR technology have positive burn care experiences (Alashram et al., 2018; Kipping et al., 2012). The studies concurred with de Araúj et a. (2021), who concluded that VR positively impacted pain relief during wound dressing. Also, they noted that VR distracted patients from pain perception during wound care (de Araújo et al.,

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2021; Lauwens et al., 2020; Jeffs et al., 2014). Moreover, VR did not cause discomfort. Rather patients were satisfied with its use. In studies focusing on non-burn-related conditions, researchers confirmed that distractions caused by virtual reality technology decreased pain during dressing changes (Ding et al., 2019). However, some studies reported that VR technology does not achieve the intended pain relief (Blokzijl et al., 2023). In such cases, as clarified by Alashram et al. (2018), likely, VR technology did not generate sufficient distraction. Therefore, increasing the level of distraction could improve outcomes for the patients.

Further, the review revealed that the magnitude of interactivity could influence how VR technology influences pain experience in burn patients (Blokzijl et al., 2023). Increasing the immersion and distraction of VR technologies gives patients to engage in an environment that demands more attention than burn-related pain. Although VR may not achieve pain relief instantaneously, it gradually captures the patient’s attention, significantly decreasing pain over time (Ding et al., 2019; Kipping et al., 2012; Lauwens et al., 2020). Further, studies demonstrated that virtual reality reduced pain intensity even in patients treated with standard care (Ding et al., 2019; Blokzijl et al., 2023; Phelan et al., 2023).

Individuals with burn injuries engage in repetitive therapeutic interventions like wound debridement, dressing change, and other procedures that increase pain intensity (Phelan et al., 2023; Xiang et al., 2021). Despite the associated pain, these procedures are critical to recovery.

Whereas pharmacologic interventions have commonly been used to reduce pain, these interventions have some side effects and might sometimes be ineffective. Therefore, clinicians should integrate non-pharmacological interventions into wound care to reduce the risk of side effects and improve outcomes (Kipping et al., 2012; Phelan et al., 2023). Literature shows that virtual reality technology effectively treats procedural pain. This intervention can minimize

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persistent disabilities attributable to burn injuries and improve the patient’s participation in their therapies (Phelan et al., 2023).

5.4 Strengths of the Review A comprehensive literature search was a major strength of this review. A database search of RCTs helped generate many peer-reviewed articles addressing the research topic. Electronic databases also enabled the detection and elimination of duplicates and other studies that did not satisfy the inclusion criteria. Also, the databases helped narrow and widen the search accordingly and generate quality articles. Using strict inclusion/exclusion criteria also helped strengthen the review. The review focused on studies using the RCT design and excluded other studies due to limited design strength.

Further, the review only included the pediatric and adolescent populations. This population has a high risk of burn injuries than other groups. They experience burns in different body parts, including the face, neck, and extremities, making them suitable candidates for the study. Irrespective of how well-designed a randomized controlled trial is, its effectiveness is reflected in its outcome assessment. Therefore, another significant strength of this review is that all studies used validated outcome assessment tools, increasing the validity of the studies.

Further, the validated pain assessment instruments increased the assessment accuracy and reduced investigator bias.

Moreover, the validated tools improved the researcher’s ability to translate the findings across settings. The studies revealed that VR researchers are committed to utilizing validated outcome metrics to improve the accuracy and clarity of measurements in this field.

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5.5 Limitations of the Review The main problem of the current review is that the RTCs needed bigger sample sizes.

Only one (n=1) study had more than 50 participants (Xiang et al. (2021), which had 90 subjects.

The other studies had less than 100 participants. The small sample sizes made it difficult to generalize the findings to a larger diverse population (Carnaby & Madhavan, 2013). Further, using simple randomization strategies may lead to imbalanced covariate distributions between the study groups. Also, small sample sizes contribute to power limitations that hamper the study analysis. The application of alternative randomization strategies to support balance in studies involving smaller samples still needs to be improved within the VR intervention literature.

Moreover, the reviewed RCTs demonstrated little concordance in timing, duration, and frequency of VR application during wound care. The review does not show whether this intervention's duration influenced VR's effectiveness in reducing pain. Therefore, RCTs exploring the impact of VR on pain during wound care would benefit immensely from procedures that reduce variability and enhance comparisons across studies.

Another challenge discovered in the review is that the researchers used virtual reality games created by expert collaborators (Le May et al., 2022). The studies used games that were easy to implement and engaging for the target subjects. Notably, the games were easier to use within the scope of the studies. Therefore, conclusions from the studies might be difficult to generalize outside the controlled settings of the studies.

5.6 Implications for Future Practice The RCTs evaluated the impact of VR on burn wound care and provided consistent findings. The review shows that most studies (90%) reported positive results relating to the impact of VR technology on pain relief. The positive outcomes included decreased experience of

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pain, increased distraction during wound care, and improved wound care. The findings show that VR technology is a beneficial intervention that could be used across medical care settings. For instance, since VR technology has a better acute pain relief effect during wound care than standard treatment, healthcare professionals can integrate them into wound care procedures in the future to enhance outcomes.

Armstrong et al. (2023) reported that most clinicians agree they could use VR frequently to relieve their patients of acute pain during future burn care procedures. Clinicians also indicated that they were satisfied with the VR effect on pain experience among patients (Le May et al., 2022; Shahar et al., 2014). Therefore, health professionals could use this protocol to guide the implementation of VR as part of pain distraction tools used in acute burn units.

Virtual reality technology is well adapted for use in adolescents and children, who comprise the most challenging populations of burn injury victims to treat. Therefore, in the future, healthcare providers could encourage patients with burn injuries to use VR during wound care. Care providers may work with developers to create VR technologies that suit individuals' needs, interests, and preferences. In the future, healthcare professionals could extend this intervention to treat other victims of burn-related injuries (Shahar et al., 2014). Further, the VR intervention could be integrated into treatment plans for other conditions affecting different populations.

5.7 Implications for advanced nurse practice The realization that VR technology can greatly enhance wound care by relieving pain could significantly impact the four pillars of advanced nurse practice, including education, leadership, research, and management. These pillars are designed to transform and modernize care pathways, thus enabling safe and effective care (Kerr & Macaskill, 2020). Also, they

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enhance skills sharing across different professional boundaries. Therefore, nurse leaders could create novel programs to facilitate the implementation of VR technology in wound care settings.

Further, nurses could perform evidence-based studies to identify VR technologies that could effectively reduce pain during wound care. Education and training are vital APN practices. They equip these professionals with crucial information about best practices to resolve health challenges. APNs could initiate an education and training program to increase awareness of VR as a pain-relieving tool during wound care.

5.8 Recommendations for Further Research Research on VR's impact on pain during wound dressing could be enhanced with various interventions. For instance, most RCTs presented data based on pre-and post-intervention comparisons in this review. All of the studies provided outcome data at the post-intervention time point. Therefore, in the future, researchers need to evaluate the outcome data over an extended period. Also, the researchers should create a follow-up and inclusion plan to manage study sample attrition. Moreover, using statistical methods that align with the trial design and the sample size could help improve study outcomes and analysis.

Many researchers need to comply with statistical reporting standards for publication (Carnaby & Madhavan, 2013). For instance, they provide only the p-values without accurate information about the direction and variability of the effect. Using insufficient statistical reporting in trials could affect the ability to synthesize data across VR studies. Therefore, researchers should utilize adequate statistical reporting to facilitate data synthesis and inform effect size computation for future research protocols.

Although all studies separated the participants into standard care control and VR intervention groups, they used varied VR technologies. For instance, whereas some studies used

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VR music, others used video games. However, these interventions were classified under the broad class of VR distractions. Therefore, different VR distractions might have produced varied pain relief results. This made it difficult to draw a definite conclusion identifying a specific VR technology as the most effective distraction. Further research focusing on specific VR technologies could help identify their degree of provided pain relief.

5.9 Chapter Summary Systematic reviews of randomized controlled trials assess the volume and relevance of research on a specific issue. The review is an organized, structured, and comprehensive investigation that assists researchers in highlighting the benefits of particular interventions and offers guidance for future direction. It revealed that painful wound care experiences could be relieved using VR technology.

6.0 Reflection on personal learning The review provides valuable information regarding VR technology and its role in providing pain relief to burn patients. While working in a burn unit in Saudi Arabia, I realized that patients are treated with standard care during dressing changes. For instance, patients are just given pain relievers which might not achieve the anticipated impact (Almutlaq et al., 2020).

Therefore, it is necessary to implement interventions that could reduce pain during wound care and improve satisfaction with care among patients. As an MSc student, I have identified VR technology as a reliable intervention to reduce this pain. Studies have shown clinicians can integrate this novel intervention into wound care to enhance patient experience and improve burn care outcomes. Burn rehabilitation is a critical component of burn injuries treatment. This continuous process occurs from initial contact with care providers to when the injured section heals. Wound care procedures, including cleaning and dressing, are painful. Therefore,

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integrating into care an intervention that generates pain relief by distracting patients could improve wound care significantly.

7.0 Conclusion Evidence demonstrates that virtual reality technology relieves pain from dressing changes in children and adolescents with burn injuries. Burn patients treated with VR technology and standard wound care experience lower pain intensity and better wound care outcomes than those treated with standard care alone. This technology provides an intense cognitive distraction to patients during painful procedures. Patients who use VR during wound care pay less attention to pain and the environment. Studies suggested that VR could be integrated into wound care across different settings to relieve pain and improve wound care outcomes. VR technology offers pain relief and would particularly benefit children and adolescents, who constitute a significant portion of burn cases. It also improves pain relief among patients with chronic burn-related wounds. Studies have revealed that VR is helpful in wound dressing changes and is not associated with side effects. Clinicians can consider VR a non-pharmacologic companion for wound and pain management in burn patients. Furthermore, VR applies to different settings and is particularly well adapted for adolescents and children, constituting the most challenging burn populations to treat.

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Effect of virtual reality on adolescent pain during burn wound care. Journal of Burn Care & Research, 35(5), 395–408. https://doi.org/10.1097/BCR.0000000000000019 Kaya, M., & Özlü, Z. K. (2023). The effect of virtual reality on pain, anxiety, and fear during burn dressing in children: a randomized controlled study. Burns, 49(4), 788-796. https://doi.org/10.1016/j.burns.2022.06.001 Kerr, L., & Macaskill, A. (2020). The journey from nurse to advanced nurse practitioner: applying concepts of role transitioning. British Journal of Nursing, 29(10), 561-565. https://doi.org/10.12968/bjon.2020.29.10.561 Kipping, B., Rodger, S., Miller, K., & Kimble, R. M. (2012). Virtual reality for acute pain reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial. Burns, 38(5), 650-657. https://doi.org/10.1016/j.burns.2011.11.010 Lauwens, Y., Rafaatpoor, F., Corbeel, K., Broekmans, S., Toelen, J., & Allegaert, K. (2020).

Immersive virtual reality as analgesia during dressing changes of hospitalized children

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and adolescents with burns: A Systematic Review with Meta-Analysis. Children, 7(11), 194. https://doi.org/10.3390%2Fchildren7110194 Le May, S., Genest, C., Francoeur, M., Hung, N., Guingo, E., Khadra, C., ... & Roy, A. A. (2022). Virtual reality mobility for burn patients (VR‐MOBILE): A within‐subject‐ controlled trial protocol. Pediatric and Neonatal Pain, 4(4), 192-198. https://doi.org/10.1002/pne2.12086 Phelan, I., Furness, P. J., Matsangidou, M., Babiker, N. T., Fehily, O., Thompson, A., ... & Lindley, S. A. (2023). Designing effective virtual reality environments for pain management in burn-injured patients. Virtual Reality, 27(1), 201–215. https://doi.org/10.1007/s10055-021-00552-z Sharar, S. R., Miller, W., Teeley, A., Soltani, M., Hoffman, H. G., Jensen, M. P., & Patterson, D. R. (2008). Applications of VR for pain management in burn-injured patients. Expert review of neurotherapeutics, 8(11), 1667–1674. https://doi.org/10.1586/14737175.8.11.1667 Smith, K. L., Wang, Y., & Colloca, L. (2022). Impact of VR technology on pain in pediatric burn patients: a systematic review and meta-analysis. Frontiers in Virtual Reality, p. 160. https://doi.org/10.3389/frvir.2021.751735 Xiang, H., Shen, J., Wheeler, K. K., Patterson, J., Lever, K., Armstrong, M., ... & Fabia, R. B. (2021). Efficacy of smartphone active and passive virtual reality distraction vs standard care on burn pain among pediatric patients: a randomized clinical trial. JAMA Network Open, 4(6), e2112082-e2112082.

25

Appendices Appendix 1: Included Studies Matrix Study

Method

Armstrong et

A randomized

al. (2023)

controlled trial.

Country

-U.S

Participants

Children with

Number of

Participant’s

Duration of the

Participants Age

study

n=35

September 1,

5-17 years

burn injuries

2019, to May 30, 2021

Kipping et al.,

Prospective

-U.S

Children and

2012)

Randomized

adolescents

Controlled Trial

undergoing

n = 132

11-17 years

-

n=28

10 -17 years

October 2013

burn-related wound care Jeffs et al.

single-

Mid-south

children and

(2014)

blinded, three-arm,

U.S

adolescents

to March

with burn

2015.

experimental

injuries Xiang et al.

A randomized

(2021)

controlled study.

Le May et al.

within‐subject‐

(2022)

controlled trial

U.S

Canada

Children

n=90

6 to 17 years

December

undergoing

2016 to

wound care

January 2019.

Children and adolescents with burn-

n= 40

7 to 17 years

-

26

related injuries Ali et al.

Randomized

-U.S

Pediatric

(2021).

control trial

Blokzijl et al.

pilot Randomized

U.S

burn-injured

(2023)

Controlled Trial

City Hospital

children

(RCT

Burn Center

Brown et al.

Randomized

Brisbane,

Burn injured

(2014)

Controlled Trial

Australia

children

Kaya, M., &

A randomized

-U.S

Burn injured

Özlü, Z. K.

between-groups

(2023).

study

n=22

9 to 16 years

-

n=38

7-12 years

April 2019 to

patients

September 2020.

Children

n= 75

4–12 years

August 2011 to August 2012

n=65

7-12 years

-

27

Appendix 2: JBI Critical Appraisal Checklist for Randomized Controlled Trials Reviewer

______________________________________

Date_________19/Junre/2023______________________ Author_______________________________ Year_________ Record Number_________ Author name Armstro

Xiang Le

Ali et

Jeffs

Blokzijl

Brown

Kipping et

Kaya, M.,

and year ng et al.

et al.

May

al.

et al.

et al.

et al.

al., 2012)

& Özlü, Z.

(2023)

(2021

et al.

(2021

(2014

(2023)

(2014)

)

(2022

).

)

(2023).

) Was true

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

randomizatio n used for the assignment of participants to treatment groups?

Was allocation to treatment groups concealed?

Were

28

treatment groups similar at the baseline?

Were

No

No

No

No

Yes

No

No

No

No

No

No

No

No

Yes

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

participants blind to treatment assignment?

Were those delivering treatment blind to treatment assignment?

Were outcomes assessors blind to treatment assignment?

Were treatment groups

29

treated identically other than the intervention of interest?

Was follow-

Yes

No

Yes

Yes

No

No

Yes

Unclear

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

up complete, and if not, were differences between groups in terms of their follow-up adequately described and analyzed?

Were participants analyzed in the groups to which they were

30

randomized?

Were

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

outcomes measured in the same way for treatment groups?

Were outcomes measured in a reliable way?

Was appropriate statistical analysis used?

Comments: All RCTs were critically appraised. The appraisal revealed that the participants and the researchers were not blinded. However, participants were treated per the intervention of their group.

31

Appendix 3: Search Results From PubMed Search

32

Appendix 4: Search Results From Cochrane