Published July 1, 2022 | Version 1
Project deliverable Open


  • 1. California State University, Los Angeles


Project leader:

Project member:

  • 1. California State University, Long Beach


Background: Anticipatory pain and anxiety related to children’s fear of the unknown aspects of procedures and their association with a prior incident leading to fracture care may impact future healthcare interventions. Purpose: The overarching goals of this project were to optimize orthopedic care by decreasing children’s perceptions of pain and anxiety during a percutaneous bone pin removal and/or cast procedure and increase the child’s and parent’s overall satisfaction with the experience. Therefore, the purpose of this Doctor of Nursing Practice (DNP) Quality Improvement (QI) project was to develop, implement, and evaluate the effectiveness of virtual reality (VR) protocol for use with pediatric orthopedic patients undergoing a cast or percutaneous bone pin removal procedure. Methods: This evidence-based quality improvement project used the Plan, Do, Study, Act (PDSA) Framework. Participants received care at an outpatient pediatric orthopedic clinic in a Southern California magnet children’s hospital and included a convenience sample of 30 children ages 7-18 years, with no neurologic deficits, hearing impairment, or vertigo. Children’s perceptions of pain and anxiety related to the procedures and the children’s and parent’s overall satisfaction with the VR distraction technology were the four outcomes measured. The clinic’s registered nurses used the Wong-Baker Faces Pain Rating Scale (WBFPRS) and the Child Fear Scale (CFS) anxiety level to assess the child’s pre-and post-procedural pain and anxiety levels. Child and parent satisfaction surveys were used to assess overall satisfaction with the VR distraction experience. Results: Thirty-seven children were asked to participate in the VR experience until a sample size of 30 was obtained. Only one of the 30 children reported pain pre-procedure; she reported a level 2 pain score and was scheduled for pin removal. A total of three children reported pain post-procedure: the same child who underwent a pin removal and two others who described their pain as arm stiffness noted after the cast removal. Reduction of anxiety levels post-procedure was statistically significant (p<.001). Twenty-nine (96.67%) children reported they would use VR again. Similarly, twenty-nine (96.67%) parents agreed or strongly agreed they would use VR again if their child had to undergo similar procedures. Conclusion: VR distraction effectively reduced children’s perceptions of anxiety during cast and/or percutaneous pin removal. Parents and their children overwhelmingly rated VR as an effective distraction technique when used for cast or pin removal procedures. Development of guidelines for the use of VR, as well as enhanced teamwork and interdisciplinary collaboration, were essential to the success of this project. Future studies should focus on using VR as a distraction technique to reduce anxiety and pain for children undergoing other brief medical procedures in ambulatory centers.


Cunningham, Carol_C9_Effect of Virtual Reality Distraction on Children’s Anxiety and Pain Perceptions During Cast and Pin Removal.pdf