Introduction

The International Association for the Study of Pain (IASP) [1] defines pain as an unpleasant feeling, emotional experience, or similar experience related to actual or potential tissue damage. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has identified pain as the fifth vital sign after body temperature, pulse, respiration and blood pressure [2]. In clinical work, nursing puncture operations, such as intravenous infusion, injection, blood collection and vaccination, can cause patients, especially children, to feel pain, but nurses often do not pay enough attention to such pain [3]. Because children’s cognitive function is not yet mature, their pain threshold is lower than that of adults [4]. Especially during medical procedures that involve pain, children often encounter unpredictable and potentially distressing stimuli. These experiences can have significant adverse effects both in the short and long term. Immediate physiological responses may include an increased heart rate and elevated blood pressure. Psychologically, there can be a lasting impact, such as the development of fear and distrust towards medical and healthcare professionals. It is therefore essential to address these concerns to ensure the overall well-being and positive health outcomes for children in medical settings [5, 6]. For their caregivers, seeing children experience pain will also bring traumatic experience to parents, increase work pressure for pediatric nurses and easily lead to nurse patient conflicts. Furthermore, Children, due to their immature physical and mental development and relatively poor cognitive abilities, tend to experience anxiety more readily than adults when confronted with unfamiliar environments and strangers [7]. As high as 86.82% of pediatric patients have experienced severe fear and anxiety during venipuncture [8]. Consequently, effective management of pain and anxiety is a crucial component of the clinical nursing care provided during venipuncture in pediatric patients.

With the development of information technology, visual reality (VR) technology, as a new intervention method based on distraction, plays an important role in reducing patients’ pain [9]. VR technology provides a rich, multisensory experience by engaging multiple senses simultaneously. It presents a range of stimuli such as captivating visual images, three-dimensional (3D) spatial audio, and interactive tactile and olfactory feedback. This comprehensive sensory environment significantly enhances the user’s sense of immersion and engagement [10]. By strategically leveraging the finite cognitive resources of attention, the technology effectively redirects individuals’ focus from the “real world” to the captivating realm of the virtual. This transition moves the spotlight away from potentially harmful stimuli and towards more benign or even enjoyable events, consequently alleviating the burden of pain that individuals may be experiencing [11]. At present, VR technology has been widely used in cancer patients’ symptom management, post stroke rehabilitation training, chronic pain and other fields, and has achieved good results [12, 13], but the role of VR technology in children undergoing puncture operations remain unclear. In recent years, many studies [14,15,16] have explored the potential of virtual reality (VR) technology to mitigate pain symptoms in patients undergoing puncture operations. However, the sample sizes across these studies have varied significantly, leading to a range of findings. Given this context, the aim of this meta-analysis is to conduct a systematic evaluation of the effectiveness of VR technology in reducing pain and anxiety associated with venous puncture procedures in pediatric patients, to contribute valuable evidence to inform clinical nursing practices and enhance patient care.

Methods

We performed this meta-analysis in accordance to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement [17].

Literature search

Two investigators searched Pubmed, Web of Science, Scopus, The Cochrane Library, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Medline, China National Knowledge Infrastructure (CNKI), Wanfang, Weipu and China biomedical databases on the randomized controlled trials (RCTs) of virtual reality technology on relieving pain and anxiety related to venous puncture for children. The search time set in the databases was from the inception to July 6, 2024. The search strategy (supplementary file 1) of this meta-analysis was as follows: (“virtual reality” OR “digital technology” OR “VR” OR “immersi*” OR “distract*”) AND (“child” OR “pediatric” OR “children”) AND (“intramuscular injection” OR “vaccination” OR “venipuncture” OR “intravenous” OR “injection” OR “invasive procedure " OR “vascular access” OR “ blood draw” OR “port access” OR “needle–related procedurel” OR “subcutaneous injection” OR “intravenous cannulation” OR “intradermal injection” OR “intravenous line” OR “IV”). Besides, we had traced the references of the included RCTs and related reviews to avoid any missing literature. During the course of this study, the expertise and guidance of a librarian were actively sought to facilitate research and information gathering.

Inclusion and exclusion criteria

The inclusion criteria of this meta-analysis were as following: The study was RCT design; the study population were children aged 3–12 years who needed nursing puncture related procedures; The intervention group received virtual reality technology intervention during puncture related operation, while the control group received routine nursing intervention during puncture related operation; The primary outcome measure was the self-reported pain and anxiety score of the children, and the secondary outcome measure was the pain and anxiety score of the children reported by the primary caregiver. The pain and anxiety assessment tools mainly included Wong Baker Faces Pain Scale (WBFPS), Visual Analogue Scale (VAS), Revised Face Pain Scale (FPS-R), Children’s Fear Scale (CFS) and Facial Affective Scale (FAS). The scope of our review was restricted to publications documented in Chinese and English languages. In the process of compiling the literature, we meticulously excluded any studies that were found to be duplicates, as well as those deemed of low quality due to significant flaws in their research design or the presence of incomplete data.

Literature screening and data extraction.

Two researchers independently conducted the literature screening process, adhering strictly to the predefined inclusion and exclusion criteria. They initially reviewed the titles and abstracts of identified studies, followed by a full-text review to assess eligibility. The information was extracted from the selected literature. The screening results were then cross-verified to ensure consistency. Any discrepancies that arose between the two researchers were resolved through discussion to reach a consensus. The information extracted from this meta-analysis mainly included the first author, publication time, country, sample size, study population, age, gender, intervention measures, outcome indicators.

Quality evaluation

This meta-analysis employed the Risk of Bias Tool for RCTs, as recommended by the Cochrane Library, to assess the quality of the included literature [18]. The quality assessment tool encompasses several key domains: the method of random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, completeness of outcome data, selective reporting, and other potential sources of bias. Each domain was rated as having either a “high risk of bias,” a “low risk of bias,” or being “unclear.” The quality evaluation was conducted independently by two researchers. In instances where discrepancies arose, a third researcher was engaged to reach a consensus on the final evaluation. This rigorous approach ensures the reliability and integrity of the findings within the meta-analysis.

Statistical methods

EndNote 21 software was employed to efficiently manage data and references throughout the research process. This meta-analysis used RevMan 5.3 software for statistical analysis. If there was no heterogeneity among the results (P > 0.1, I2 < 50%), the fixed effect model was used for synthesized analysis. If there was heterogeneity (P ≤ 0.1, I2 > 50%), we used the random effect model to perform synthesized analysis. The outcome indicators analyzed in this meta-analysis were continuous variables, and the evaluation tools of each test indicator might be different, the standardized mean difference (SMD) was used as the effect indicator, and 95% confidence interval(95%CI) was calculated as the effect statistic. Sensitivity analyses was conducted on all outcomes after excluding studies with an uncertain or high risk of bias. Funnel plots and Egger regression test were used to evaluate the Publication bias of included RCTs. P < 0.05 indicated that the difference between groups was statistically significant.

Results

Study inclusion

The initial search yielded a total of 715 pertinent articles. Upon the elimination of duplicates, 696 publications were subjected to initial screening. Following a review of the titles and abstracts, 643 articles were excluded, leaving 62 for further assessment through full-text evaluation. Adhering to the defined inclusion and exclusion criteria, a total of 10 RCTs [19,20,21,22,23,24,25,26,27,28], were ultimately included in this meta-analysis. The study selection process is visually depicted in Fig. 1.

Fig. 1
figure 1

The flow diagram of study selection

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Characteristics of included RCTs

Of the included 10 RCTs [19,20,21,22,23,24,25,26,27,28], a total of 874 children involved, 429 children received VR intervention during vein puncture, 445 children received routine care during vein puncture. The included RCTs were conducted and reported from different countries. The characteristics of included RCTs are shown in Table 1.

Table 1 The characteristics of included studies
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Quality of included RCTs

The quality included in RCTs was generally good. All RCTs reported specific random grouping methods, and 4 studies [22,23,24, 28] did not report allocation hiding, which might cause researchers to report tendentiously. 6 studies [20, 21, 23, 24, 27, 28] reported no blind design. All studies clearly defined the inclusion and exclusion criteria, and described the gender, age and other baseline data of the two groups of children. The quality of included RCTs is shown in Figs. 2 and 3.

Fig. 2
figure 2

Risk of bias graph

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Fig. 3
figure 3

Risk of bias summary

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Synthesized outcomes

Children’s self-reported needle-related pain level All 10 studies [19,20,21,22,23,24,25,26,27,28] reported the self-reported pain scores for children. There was no heterogeneity among the studies (P = 0.06, I2 = 45%), and the fixed effect model was used for analysis. The results showed that VR technology was beneficial to reduce the children’s self-reported pain scores [SMD=-0.48, 95% CI (− 0.61, − 0.35), P < 0.001], as shown in Fig. 4a.

Fig. 4
figure 4

The forest plots for pain level

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Children’s caregivers reported needle-related pain level 5 studies [20, 22, 24, 26, 27] reported the children’s caregivers reported pain scores for children. There was heterogeneity among the studies (P < 0.001, I2 = 86%), and the random effect model was used for analysis. The results showed that VR technology was beneficial to reduce the children’s caregivers reported needle-related pain level [SMD=-0.93, 95% CI (-1.45, − 0.42), P < 0.001], as shown in Fig. 4b.

Children’s self-reported needle-related anxiety level 4 studies [20, 21, 24, 28] reported the children’s self-reported needle-related anxiety level. There was no heterogeneity among the studies (P = 0.12, I2 = 49%), and the fixed effect model was used for analysis. The results showed that VR technology was beneficial to reduce the children’s self-reported anxiety scores [SMD=-0.45, 95% CI (− 0.65, − 0.25), P < 0.001], as shown in Fig. 5a.

Fig. 5
figure 5

The forest plots for anxiety level

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Children’s caregivers reported needle-related anxiety level 2 studies [20, 24] reported the children’s caregivers reported needle-related anxiety level. There was no heterogeneity among the studies (P = 0.67, I2 = 0%), and the fixed effect model was used for analysis. The results showed that VR technology was beneficial to reduce the children’s caregivers reported needle-related anxiety level [SMD=-0.47, 95% CI (− 0.73, − 0.21), P < 0.001], as shown in Fig. 5b.

Publication biases and sensitivity analyses

The funnel plots for synthesized outcomes are shown in Fig. 6. The dots were evenly distributed in the funnel plots, and Egger regression test results indicated there were no publication biases in the synthesized outcomes (all P > 0.05).

Fig. 6
figure 6

The funnel plots for synthesized outcomes

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Sensitivity analyses, which evaluate the influence of one study on the overall risk estimate by removing study one by one, indicated that the overall risk estimate results were not substantially changed by any single RCT.

Discussions

At present, the pain management in children is usually inadequate, and the presence of pain may have a negative impact on children’s future pain response [29]. Previous studies [30,31,32] have pointed out that pain assessment should be carried out during admission, operation or invasive operation, department transfer, and disease development. The appropriate pain assessment scale should be selected before, during and after the puncture operation and the pain should be assessed accordingly [33]. It is necessary for pediatric nurses to provide comfortable care for foreseeable painful operations or diagnosis and treatment methods to minimize the adverse effects of pain on children [34, 35]. The results of this study have found that VR technology reduces the pain and anxiety of children undergoing vein puncture, which should be promoted in clinical nursing care of children.

At present, the mechanism of VR technology to alleviate pain is still under exploration. Relevant research [36] uses the attention theory or gate theory to explain, that is, the perception of pain requires attention. Effective engagement with VR can significantly divert the brain’s attentional resources, which are usually directed towards processing pain, thereby leading to a decrease in the perceived intensity of pain. In medical procedures like punctures, the strategic use of VR technology can encourage children to become deeply immersed in a captivating, engaging, and realistic digital environment. This is facilitated by multisensory stimulation that encompasses sight, sound, and touch. This stimulation not only piques the child’s interest but also serves to effectively reduce their awareness and sensitivity to pain, enhancing the overall comfort and ease of the procedure [37,38,39]. Previous researches [40, 41] have elucidated the neuroanatomical underpinnings of pain perception, demonstrating that exposure to painful stimuli is correlated with increased activity in pain matrix areas, such as the insula and thalamus. When patients undergo VR intervention, functional magnetic resonance imaging (fMRI) has revealed a significant reduction in the activity of these individual pain matrix areas—by more than 50%. This neuroimaging evidence aligns well with the subjective reports of decreased pain scores from patients who have received VR interventions. Additionally, several studies [40, 41] has highlighted the potential of virtual reality (VR) technology to enhance patients’ pain tolerance. This is achieved by mitigating the negative emotions associated with the experience and by shortening the duration it takes for patients to perceive pain. The immersive nature of VR serves as a distraction, effectively redirecting the patient’s attention away from the source of discomfort, thereby reducing the overall sensation of pain. This approach represents a promising avenue for improving the patient experience, particularly in pediatric populations where the management of pain and anxiety during medical procedures is of paramount importance. Therefore, the intervention of VR technology is of great significance to the management of puncture related pain in nursing care of children.

VR technology is helpful the pain management and care of children undergoing puncture operations. Untreated pain may lead to negative psychology in children, and severe pain may have a destructive impact on their future pain perception, so pain management is particularly important [42]. Previous study [43] has found that if children’s attention is focused on events other than nursing puncture operations, the pain signals transmitted to their brain will be reduced accordingly, and children will temporarily forget the pain they are experiencing. This study has demonstrated that VR technology can effectively alleviate the pain experienced by children during nursing punctures, as perceived from the viewpoints of both the children and their primary caregivers. Notably, children, being the direct subjects of pain perception, provide the most pertinent insights through their self-reported pain scores. However, it is important to recognize that their individual experiences of pain can vary significantly due to differences in age, cognitive abilities, and levels of understanding. Furthermore, the primary caregiver, who is well-acquainted with the child’s baseline condition and typical responses to pain, offers a valuable perspective when reporting on the child’s experience of pain. Their observations complement the child’s self-assessment and provide a more comprehensive understanding of the child’s pain and anxiety levels during the procedure. Overall, the study underscores the importance of considering multiple perspectives when evaluating the effectiveness of interventions like VR technology in pediatric pain management. By incorporating the viewpoints of both children and their caregivers, a more holistic and accurate assessment of the intervention’s impact can be achieved.

The results of this study have shown that VR technology can alleviate puncture related anxiety of children. A recent study [44] has shown that compared with the control group, the anxiety scores of children with anxiety disorder who received VR intervention are significantly lower. Some studies [45,46,47] have shown that high anxiety levels may worsen individual pain experience, lead to lower pain threshold, and further stimulate children’s pain response and anxiety symptoms. VR technology enables children to maintain a sense of pleasure, achieve a state of physical and mental relaxation, and eliminate anxiety through visual images and auditory stimulation [48,49,50]. By obstructing the child’s view of the clinical environment, the VR devices can mitigate the fear and anxiety that children may experience due to the unfamiliar and often intimidating surroundings. Additionally, VR headsets effectively block out adverse auditory stimuli from the environment, such as the sounds of medical equipment or procedures, which can be distressing for young patients [51, 52]. Therefore, VR intervention effectively alleviates the anxiety of children caused by nursing puncture operations.

The limitations of this study are worth considering. First of all. Given the rapid evolution of VR technology, the pertinence of findings from Gold in the year of 2006 [23] is questionable, particularly in light of the significant technological advancements that have occurred since then. The VR equipment type, intervention content, basic diseases of children and nursing puncture received are different, which may increase the heterogeneity of combined results. Secondly, this meta-analysis only includes Chinese and English reported literature, there may be articles published in other language that could not be included for analysis. Thirdly, we do not have information or data regarding that if the children have exposure to venipuncture prior to this event, this can significantly influence the pain level and other outcomes of children, more studies on this issue in the future are needed. Fourthly, different research tools for anxiety and pain assessment may have different effects on the results of meta-analysis. Even if we chose MD for data synthesis, there was still a potential risk of bias. Finally, it is noteworthy that the safety of VR interventions has not been explicitly reported in the studies reviewed. Consequently, there is a clear need for future research to delve into both the application effects and the safety profile of VR technology within the context of clinical venipuncture nursing. This should be approached through large-scale, high-quality studies that can provide more definitive insights into the potential benefits and risks associated with VR use in this setting.

Conclusions

In summary, VR technology has demonstrated the potential to effectively alleviate the pain and anxiety associated with pediatric venipuncture procedures. It is recommended that future research include a comprehensive safety report on VR interventions to ensure patient well-being. Future studies could benefit from incorporating a broader range of evaluation metrics, such as heart rate, blood pressure, respiration rate, and patient satisfaction surveys. These indicators can provide a more holistic assessment of the intervention’s impact. Besides, there is a pressing need for more high-quality, multicenter, and large-sample studies to further evaluate the clinical utility and efficacy of VR technology in pediatric nursing. Such research endeavors will be instrumental in establishing evidence-based guidelines for VR use, ensuring that this promising tool is employed in a manner that is both safe and maximally effective in managing pain and anxiety during pediatric venipuncture procedures.