Virtual reality as a non-pharmacological intervention for pediatric preoperative anxiety: A quality improvement initiative and retrospective analysis

Abstract

ABSTRACT Preoperative anxiety affects 50-75% of pediatric surgical patients and can lead to adverse perioperative outcomes including difficult anesthesia induction, emergence delirium, and prolonged recovery. Virtual reality has emerged as a promising non-pharmacological intervention, yet evidence from real-world clinical implementation remains limited. We conducted a nine-month quality improvement initiative at VCU Children’s Hospital from October 2023 through June 2024, implementing custom-designed virtual reality interventions for pediatric patients aged 6-15 years undergoing elective surgical procedures. The intervention was refined through five iterative Plan-Do-Study-Act cycles before retrospective analysis of prospectively collected data from 80 pediatric patients, 65 parents or caregivers, and 29 preoperative nurses. Primary outcomes included distress measured via 0-10 Numerical Rating Scale and fear assessed using the 0-4 Children’s Fear Scale, both measured pre- and post-intervention. Secondary outcomes included physiological parameters, parent anxiety, and stakeholder satisfaction. VR intervention demonstrated significant reductions in both patient distress (median change: -2.0 points, 95% CI [-2.00, -1.00], p<0.001) and fear (median change: -1.0 point, 95% CI [-1.00, 0.00], p<0.001). A majority of patients achieved a clinically significant reduction (≥30%) in both distress (66.2%) and fear (52.5%). Physiological markers demonstrated significant reductions in heart rate (mean decrease 5.8 beats per minute, p<0.001) and systolic blood pressure (mean decrease 4.1 mmHg, p<0.0001). Baseline anxiety levels predicted treatment response, with higher initial scores associated with greater likelihood of improvement. Stakeholder satisfaction was consistently high across patients (91.2% willing to use virtual reality again), parents (95.4% would recommend), and nurses (100% endorsement, zero workflow disruption). Virtual reality intervention significantly reduces pediatric preoperative anxiety with high stakeholder acceptance and minimal workflow disruption, supporting integration into routine preoperative care protocols. AUTHOR SUMMARY We developed and implemented a custom virtual reality intervention to reduce anxiety in children before surgery. Preoperative anxiety is extremely common in pediatric patients and can negatively affect their surgical experience and recovery. Over nine months, our team created child-friendly virtual reality environments and systematically integrated this technology into routine care at a busy pediatric surgical unit, refining our approach based on continuous feedback from patients, families, and healthcare providers. Our findings demonstrate that children using virtual reality showed substantial reductions in both self-reported anxiety and objective physiological measures like heart rate and blood pressure. Importantly, children who were most anxious before surgery experienced the greatest benefit from the intervention. Nearly all children expressed willingness to use virtual reality again in future procedures, and parents overwhelmingly recommended it for other families facing similar situations. Nursing staff found the technology easy to incorporate into their workflow without causing procedural delays or disrupting standard care. This work demonstrates that virtual reality can be successfully implemented in real-world clinical settings as a safe, effective, non-pharmacological approach to managing surgical anxiety in children. By reducing fear and distress during one of the most challenging moments in a child’s healthcare journey, virtual reality has significant potential to improve the preoperative experience for pediatric patients and their families.

The authors' abstract, as published at the source. PLOS Digital Health, 2026 · DOI ↗