This material is protected by U.S. copyright law. Unauthorized reproduction is prohibited. To purchase quantity reprints,
please e-mail reprints@ons.org or to request permission to reproduce multiple copies, please e-mail pubpermissions@ons.org.
Effects of Distraction Using
Virtual Reality Glasses During
Lumbar Punctures in Adolescents With Cancer
Suzanne Sander Wint, RN, BSN, CPON, Debra Eshelman, RN, MSN, CPNP,
Jill Steele, RN, MSN, and Cathie E. Guzzetta, RN, PhD, HNC, FAAN
Key Points . . .
Purpose/Objectives: To determine the effects of virtual
reality (VR) glasses on adolescents with cancer undergoing
lumbar punctures (LPs).
Virtual reality (VR) glasses are a feasible, age-appropriate,
Design: Pilot study using an experimental, control group
nonpharmacologic adjunct to conventional care in managing
pain associated with lumbar punctures (LPs) in adolescents
Setting: In-hospital oncology clinic.
with cancer.
Sample: 30 adolescents with cancer (17 in the VR and 13
in the control group) undergoing frequent LPs.
Visual analogue scale pain scores tended to be lower in the VR
Methods: Subjects were randomly assigned to groups.
Both groups received standard intervention during the LP, but
the experimental group also wore VR glasses and watched a
The majority of adolescents who received the VR glasses felt
video. Following the LP, both groups rated their pain using a
the glasses distracted them from the LP and wanted to use them
visual analog scale (VAS) and were interviewed to evaluate
their experience.
More research is needed to explore novel distraction techniques
Main Research Variables: Pain, subjective evaluation
of experience.
for managing pediatric pain associated with procedures.
Findings: Although VAS pain scores were not statistically
different between the two groups (p = 0.77), VAS scores
the bedside, nurse clinicians at a pediatric cancer center have
tended to be lower in the VR group (median VAS of 7.0,
range 048) than in the control group (median VAS of 9.0,
observed that adolescents who frequently undergo this pro-
range 059). 77% of subjects in the experimental group said
cedure during their cancer treatment continue to experience
the VR glasses helped to distract them from the LP.
pain and anxiety.
Conclusions: VR glasses are a feasible, age-appropri-
An individual approach is recommended for managing
ate, nonpharmacologic adjunct to conventional care in
p r o c e d u r a l pain using behavioral and pharmacologic
managing the pain associated with LPs in adolescents.
Implications for Practice: The clinical application of
various age-appropriate distracters to reduce pain in adoles-
Suzanne Sander Wint, RN, BSN, CPON, is a staff nurse at Children's
cents undergoing painful procedures should be explored.
Hospital of Oklahoma in Oklahoma City. At the time that this article
was written, she was the clinical manager of outpatient services at the
Children's Medical Center of Dallas in Dallas, TX. Debra Eshelman,
RN, MSN, CPNP, is an advanced practice nurse and program coordi-
dolescents diagnosed with cancer must undergo fre-
nator of "After the Cancer Experience;" and, at the time that this ar-
quent painful procedures, such as lumbar punctures
ticle was written, Jill Steele, RN, MSN, was a clinical research nurse,
(LPs), during their therapy, and many describe such
both at the Center for Cancer and Blood Disorders at the Children's
procedures as the most distressing aspect of their disease (U.S.
Medical Center of Dallas. Cathie E. Guzzetta, RN, PhD, HNC, FAAN,
Department of Health and Human Services, 1992). Unfortu-
is a nursing research consultant at the Children's Medical Center of
Dallas and director of Holistic Nursing Consultants in Dallas. (Sub-
nately, LPs must be performed frequently throughout the
mitted December 2000. Accepted March 1, 2001.) This study was
course of treatment. Despite the use of standard therapy that
funded by the Oncology Nursing Foundation Novice Researcher and
includes conscious sedation, eutectic mixture of local anes-
Mentorship Grant.
t h e t i c s (EMLA  , [AstraZeneca Pharmaceuticals, LP,
Wilmington, DE]) applied at the LP site, and one parent at
Digital Object Identifier: 10.1188.02/ONF.E8-E15
WINT VOL 29, NO 1, 2002
ONF VOL 29, NO 1, 2002
interventions for children with cancer (Zeltzer et al., 1990).
mine the effectiveness of distraction on pain perception and
Distraction is thought to be an effective strategy for coping
the subjective evaluations of the experience in adolescents
with pain-produced distress (McCaul & Malott, 1984). When
with cancer undergoing frequent LPs. A convenience sample
used in the management of pain, distraction has been referred
of 30 subjects undergoing LPs was studied; subjects were
to as cognitive refocusing, which directs attention away from
randomly assigned to the experimental VR distraction group
the pain (McCaffrey & Pasero, 1999) to a non-noxious event
or the standard care comparison group. Subjects were be-
or stimulus in the immediate environment (Fernandez, 1986).
tween the ages of 1019 years, male and female, being
Many researchers who used distracters, such as blowing
treated for cancer, receiving LPs as part of therapy, undergo-
bubbles (French, Painter, & Coury, 1994), viewing kaleido-
ing at least a second LP, of any ethnic origin, able to under-
scopes (Carlson, Broome, & Vessey, 2000; Vessey, Carlson,
stand and communicate in English, and able to hear and see.
& McGill, 1994), using relaxation/guided imagery (Broome,
Informed written consent was obtained from each parent, and
Lillis, McGahee, & Bates, 1992), and using party blowers
assent was obtained from the adolescent before the start of the
(Manne, Bakeman, Jacobsen, Gorfinkle, & Redd, 1994) have
study. The study, conducted in a private, in-hospital clinic
demonstrated the effectiveness of distraction. These studies
treatment room within a 322-bed pediatric teaching hospital
have shown an overall reduction in pain and anxiety but
i n the southwest United States, was approved by the
have been evaluated primarily in nonadolescent patients. In-
hospital's institutional review board.
stead of using such simple distracters, virtual reality (VR)
glasses, a more novel distracter, could be an excellent
diversional strategy and an effective nonpharmacologic inter-
Six certified oncology nurses performing the LPs received
vention for reducing LP pain in adolescents.
standardized instruction on (a) how to use and teach subjects
McCaul and Malott (1984) postulated that the effective-
about the VR glasses, (b) methods for obtaining informed
ness of distraction in relieving the distress associated with
consent, and (c) collecting demographic data. The adoles-
painful procedures depends on the interpretation of the pain
cents in the comparison group received standard nursing
experience and the attentional capacity of the distracter. For
care for an LP, including (a) weight-based conscious sedation
distraction to be effective, one must assume that the percep-
using fentanyl and midazolam, (b) 2.5 grams of EMLA cream
tion of painful stimuli is not completely autonomic but can
applied at the spinal injection site, (c) a full explanation of
be (at least partially) controlled cognitively (McCaul &
the LP given to the patient and parent, and (d) parental pres-
Malott). If the attentional capacity of a distracter is high, thus
ence at the patient's side for support. Although subjects re-
consuming most of one's cognitive energies, less cognitive
ceived sedation, they were cognitively aware of the environ-
capacity for processing painful stimuli exists (Vessey et al.,
ment and able to respond, move, and verbalize discomfort
1994). Because the pain experience has both a sensory com-
and anxiety during the LP.
ponent (what the pain feels like) and an affective component
Members of the experimental group wore VR glasses
(how distressing it is), authors have hypothesized that the use
(manufactured by i-O Display Systems LLC, Menlo Park,
of distraction could be an effective strategy for reducing sen-
CA) during their LPs, in addition to receiving standard nurs-
sory and affective components of pain and for decreasing the
ing care. The glasses were similar to oversized sunglasses
attentional capacity left to process the pain, thereby reduc-
with earphones attached. They were secured on the patient
ing the adolescent's pain and distress (Vessey et al.).
with a hook and loop strap around the crown of the head.
Each patient adjusted the earphones and volume prior to the
start of the LP. Subjects were placed in the standard side-ly-
ing position for their LPs with a videocassette recorder/tele-
Although the benefits of distraction have been docu-
vision placed at eye level. They all watched the same video
mented for managing pain and distress in younger children,
through the glasses, which provided three-dimensional (3-D)
these authors are unaware of any studies that described the ef-
viewing, and listened to music in stereo sound. The VR
fectiveness of simple distraction with adolescents undergoing
video, which was 32 minutes long, was recorded in succes-
major painful procedures. To achieve a broader understand-
sion to provide a total of 64 minutes of footage. The video
ing of distraction in this group of patients, a pilot study was
was titled "Escape" and was distributed by VIRTUAL i-O
conducted to determine the effects of using VR glasses as a
(Portland, OR) (Atkins, 1996). It contained experiences of
developmentally appropriate distraction technique on pain
skiing down the Swiss Alps, explosive drag racing, a stroll
perception and subjective evaluations of effectiveness in ado-
down Paris sidewalks, and visions of quiet mountain streams.
lescents with cancer undergoing frequent LPs. This study
According to the distributor, the video is a multidimensional
explored whether differences exist in the level of self-re-
sight and sound experience that allows subjects to see and
ported pain between adolescents with cancer who wear VR
hear images "up close, all around, and in their face" (Atkins).
glasses for distraction when undergoing frequent LPs and
Because of the 3-D glasses, some of the video events ap-
adolescents who receive standard nursing interventions, the
peared to jump out of the screen to bring a new sense of real-
experiences of adolescents with cancer during LP, and sub-
ity to the video. Prior to conscious sedation, nurses used a
jective evaluations of the VR glasses.
standardized script to explain the purpose of the VR glasses
to subjects and the need to focus their attention on what they
were hearing and seeing instead of on the discomfort of the
procedure (see Figure 1). The subjects started watching the
Design, Sample, Setting
video when placed on the procedure table at the beginning
of the LP and finished when the sedation recovery criteria
This study used an experimental control group design, as
were met.
well as a qualitative evaluation of the experience, to deter-
WINT VOL 29, NO 1, 2002
You get to wear virtual reality glasses during your spinal tap today.
1. Tell me what your spinal tap (lumbar puncture [LP]) was like to-
These glasses have worked for some people by distracting them
and may help you to concentrate on something other than the
2. What were you thinking about during the spinal tap (LP)?
discomfort of the procedure. If you are really distracted, it is nearly
3. What do you remember during your spinal tap (LP)?
impossible for you to think of something else like the spinal tap. You
4. Did anything help make the spinal tap (LP) better for you?
can help the glasses work even better by focusing all of your at-
a. If so, what made it better for you?
tention on the video and listening to the music. If you find yourself
b. If no, could anything have made this spinal tap (LP) better?
feeling discomfort or being nervous about the procedure, try to
refocus your attention to the video. Concentrate all of your atten-
5. Compared to your last spinal tap (LP), was this spinal tap
tion on what you are seeing--the sights, colors, and action. Listen
(please circle)
to the sounds, noises, and music. Try to completely focus all of
Extremely difficult
your attention on what you see and what you hear. Again, if you
find yourself thinking about the spinal tap, just let go of those
Less difficult
thoughts and return your attention to the video.
Much less difficult
If patient wore VR glasses, continue questionnaire.
6. What was it like wearing the VR glasses?
Figure 1. Script for Teaching Subjects About Virtual
7. Was there anything you liked about the VR glasses?
Reality Glasses
If yes, what?
Instrumentation and Procedure
8. Was there anything you didn't like about the VR glasses?
To evaluate pain in adolescents undergoing LPs, a visual
analog scale (VAS) was used. The VAS used a 100-mm verti-
If yes, please describe.
cal line with end points anchored as "no pain" at the bottom
9. Would you like to use the VR glasses during your next spi-
of the scale and "pain as bad as it could possibly be" at the
nal tap (LP)?
top. The VAS pain scores range from 0 to 100. The VAS is a
10. Did the VR glasses take your mind off the spinal tap (LP)?
widely used pain measurement with well-established validity
Very much
and reliability for adults and children 915 years old (Abu-
Saad & Holzemer, 1981; Downie et al., 1978; Price, McGrath,
Not much
Rafii, & Buckingham, 1983; Reading, 1980; Vessey et al.,
Not at all
1994). Among the numerous tools available for assessing
Figure 2. Virtual Reality Questionnaire
pain, direct scaling procedures, such as VAS, are popular be-
cause of their simplicity, versatility, relative insensitivity to
thoughts during the LP. In addition, experimental subjects
bias effects, and the assumption that the procedures yield
were asked five additional questions dealing with the evalu-
numerical values that are valid, reliable, and on a ratio scale
ation and effectiveness of the VR glasses as a distracter.
(Price et al.). These researchers also demonstrated that the
To establish content validity of the VR questionnaire, a
VAS can be used as a valid and reliable measure for both the
four-member content expert panel was asked to judge the rel-
intensity and the unpleasantness of human pain.
evance of each question in measuring the patient's perceived
The nurse performing the LP assessed the subject's seda-
experience during a LP and their evaluation of the VR
tion level following the LP using the Sedation Assessment
glasses. In addition, content experts were asked to determine
Scale, an institutional scale used to monitor the safety of se-
the readability and clarity of the questionnaire and to recom-
dated patients. The scale ranged from 0, indicating the high-
mend any additions, changes, or deletions of questions.
est level of sedation, to 11, indicating complete recovery
Based on their recommendations, the questionnaire was re-
from sedation. Before rating their pain after the procedure,
vised accordingly.
subjects had to score a minimum of eight on the Sedation
Assessment Scale, which usually occurred in about 30 min-
Data Analysis
utes following the LP. This score indicated the minimum
Data were entered into Microsoft Access and analyzed us-
level of recovery from sedation. At this time, subjects in both
ing SPSS, version 10. Two-tailed p values of less than 0.05
groups were asked to draw a line on the VAS that best de-
scribed the level of pain experienced during the LP.
were considered to be significant. Comparisons between sub-
In addition to measuring the level of pain, an investigator-
jects in the experimental and control groups based on demo-
developed questionnaire was used to determine the experi-
graphic characteristics, as well as clinical and procedural vari-
ences during the LP of both groups and the subjective evalu-
ables (e.g., whether EMLA cream was applied to the LP site,
ations of the VR glasses by those in the experimental group
whether a parent was present during the LP, ease of the LP,
(see Figure 2). The 10-item VR questionnaire consisted of a
level of sedation, mix of nurses performing the LP) and the
combination of open-ended questions (e.g., What were you
categorical responses from the VR questionnaire, were per-
thinking about during the spinal tap (LP)?) and response set
formed by using the Fisher's exact test. Because the continu-
questions (e.g., Compared to your last spinal tap, was this
ous variables were not found to be normally distributed, the
spinal tap extremely difficult, difficult, less difficult, or much
nonparametric Mann-Whitney U test was used to compare
less difficult). After rating their pain, all subjects were inter-
age, medication dosages, and the VAS pain scores between
viewed using the VR questionnaire and their responses were
the experimental and control groups.
audiotaped. Subjects in both groups verbally responded to
Taped interviews following the LP using the VR question-
the first five questions related to their experience and
naire were transcribed verbatim. Responses to each of the
ONF VOL 29, NO 1, 2002
age of 13.6 years. Just over half (53%) of the subjects were
questions were analyzed individually to present summary
findings. Each of the responses then was analyzed for con-
male, and the majority of subjects (80%) were either Cauca-
sian or Hispanic. Overall, 67% of the subjects had a diagnosis
tent by identifying the frequency, order, or intensity of the
of acute lymphoblastic leukemia (ALL) (see Table 1).
occurrence of words, phrases, or sentences to understand the
LP experience for the total group and to determine the experi-
In most instances, EMLA cream was applied to the site of
the needlestick prior to the LP (77%) and a parent was
mental group's evaluation of the effectiveness of the inter-
vention as a distraction technique. Reliability of the content
present with the patient during the procedure (80%). Subjects
analysis was established through consensus (verbal agree-
in both groups received a median of 77.5 mcg (range 0140)
of fentanyl and 3.0 mg (range 015) of midazolam during the
ment after discussion) between three of the researchers after
independent analysis of the data.
LP. Nearly all of the LPs were rated by the nurses as easy to
perform (90%). All subjects reached a minimum sedation
level of eight prior to rating their pain and being interviewed
following the LP, with the majority (90%) reaching a seda-
A total of 30 subjects was admitted to the study with 13
tion level of 11. A total of six certified oncology nurses per-
(43%) in the control and 17 (57%) in the experimental group.
formed all 30 of the LPs.
All subjects had at least one LP prior to enrollment in the
No significant differences were found between the experi-
study. The subjects ranged in age from 1019 with a median
mental and control groups based on age, gender, or ethnicity.
Table 1. Demographic, Clinical, and Procedural Characteristics
Control Group
E x p e r i m e n t a l Group
( n = 13)
( n = 17)
( n = 30)
Age in years
Acute lymphoblastic leukemia (ALL)
B-cell lymphoma
T-cell ALL
T-cell lymphoma
Parent at bedside
E a s e of lumbar puncture
Sedation assessment score
F e n t a n y l dose in mcg
M i d a z o l a m dose in mg
* p < 0.05
WINT VOL 29, NO 1, 2002
Significantly more subjects in the control group than in the
experimental group had a diagnosis of ALL (p = 0.02). Sub-
jects in both groups were statistically comparable based on
clinical and procedural characteristics including use of
EMLA, whether a parent was present during the LP, amount
of fentanyl and midazolam administered, ease of performing
the LP, sedation assessment score prior to interviewing the
patient, and the mix of nurses performing the LP.
To determine the effects of the VR glasses, VAS pain
scores were measured in both groups. The median pain score
on the VAS for the total group was 8.0 with a range of 059,
indicating a large degree of variability in patient responses.
Although no statistical difference was found (p = 0.77) on
the VAS pain scores between the control and experimental
groups, those in the VR group reported a trend toward lower
Figure 4. Median Pain Scores of Subjects Who Reached a
pain scores (median VAS of 7.0, range of 048) than did sub-
Score of 11 on the Sedation Assessment Scale
jects in the control group (median VAS of 9.0, range of 059)
(see Figure 3). For those subjects who reached an 11 on the
sedation assessment scale (indicating complete recovery from
despite probing by the interviewer. For example, "I didn't
conscious sedation), the VAS pain scores tended to be lower
have a lot of pain;" "Everything was good today;" "I didn't
in the VR group than in the control group (see Figure 4).
feel nothin' " (sic); "It was okay. My mom said I didn't know
Moreover, for each of the procedural strategies used by both
it was happening;" "I hardly felt it at all;" "It was okay;" "It
groups of subjects to reduce psychophysiologic pain and
was fast and easy;" and "Normal."
distress during the LP, including EMLA being used at the LP
Responses to the question "What were you thinking
site and parents being present for the procedure, subjects in
about during the spinal tap (LP)?" clearly showed that the
the VR group consistently reported lower VAS scores than
majority of the subjects in the VR group (13 of 17; 77%)
did subjects in the control group although the differences
were distracted by the intervention. For example, the VR
were not statistically significant (see Figures 5 and 6). De-
subjects reported they were "watching the video most of the
spite the lack of statistical significance, the consistent pat-
time" and made references to the 3-D glasses. One noted
tern across all the variables indicates that a nonrandom pro-
"The movie was nice." In contrast, the responses in the con-
cess was occurring.
trol group were vague and without reference to any distracter.
Subjects in both groups were interviewed to gain an un-
Eleven out of 13 subjects (85%) reported they were thinking
derstanding of their experiences during the LP using the first
about "nothing" or "sleeping" or they offered no response.
five questions on the questionnaire. Their responses to each
One focused on the previous spinal tap and worried about
of these questions were summarized. When asked, "Tell me
current pain and the other said she thought about food.
what your spinal tap was like today," almost all (29; 97%) of
In response to the question "What do you remember dur-
the patient responses in both the experimental and control
ing your spinal tap?", 13 (77%) subjects in the experimental
groups were indicative of a favorable experience. Only one
group clearly identified scenes from the VR video. For ex-
patient in the VR group reported a less favorable experience,
ample, they reported "3-D effects," "skiing," "motorcycles,"
stating "I think the EMLA cream was in the wrong place so I
"robots," "the Eiffel Tower," "skating," and "a bunch of dif-
was poked twice." The remaining 29 responses included
short, concise answers with very little elaboration or detail
Figure 5. Median Pain Scores of Subjects Who Received
Figure 3. Median Pain Scores
EMLA at the Lumbar Puncture Site
ONF VOL 29, NO 1, 2002
indicating that the multimodal pharmacologic and nonphar-
macologic approach of using conscious sedation, EMLA at
the LP site, and having parents at the bedside during the pro-
cedure was successful in managing the subjects' procedural
pain. Although no significant difference existed in the VAS
scores between the two groups, VAS scores tended to be
lower in the experimental than the control group. For sub-
jects who reached the highest level of recovery or a score of
11 on the sedation scale prior to rating their pain, those in the
VR group tended to report less pain than control group sub-
jects. Even for subjects in both groups who had EMLA ap-
plied to the LP site and who had a parent present during the
procedure, the VAS pain scores in the VR group were lower
than in the controls. Although these differences did not reach
statistical significance, likely because of the small sample
size, any multimodal approach to procedural pain manage-
ment that consistently lowers the perception of pain can be
considered clinically meaningful.
Figure 6. Median Pain Scores of Subjects Who Had Parents
In the past, the major focus on pediatric pain research has
Present During the Lumbar Puncture
centered on pharmacologic strategies for pain management.
In contrast, Lambert (1999) suggested that the literature pub-
lished between 19881997, which examined nonpharma-
ferent things in the movie." Subjects in the control group re-
cologic pain management interventions or studied the use of
ported remembering either "nothing," made reference to con-
these intervention by nurses, demonstrated that all of the in-
versation in the room, or offered no response.
terventions provided some degree of pain relief. The present
When asked the question, "Did anything help make the
study supports the growing body of nursing and psychologi-
spinal tap better for you?," overwhelmingly, 15 (88%) sub-
cal literature that identifies distraction techniques as a prom-
jects in the VR group indicated that the "video" or "the
ising nonpharmacologic approach to pain management for
glasses" helped their LP experience. One in the VR group
pediatric patients.
mentioned "the medicine" in response to this question, in
Most studies suggest that simple distraction techniques,
contrast to the control group respondents who stated that se-
such as kaleidoscopes (Carlson et al., 2000; Vessey et al.,
dation helped (5), nothing helped (5), or did not respond (3).
1994), party blowers (Blount et al., 1992; Manne et al.,
More subjects in the VR group (69%) than in the control
1990), distracting toys (Smith, Barabasz, & Barabasz, 1996),
group (42%) said that the current LP was much less difficult
blowing out air (French et al., 1994; Manne et al., 1994),
than their last LP, although this difference was not statisti-
music via earphones (Fowler-Kerry & Lander, 1987), cartoon
cally significant (p = 0.42).
w a t c h i n g (Cohen, Blount, & Panopoulos, 1997), or
Subjects in the VR group also were interviewed using five
nonprocedural talk (Gonzales, Routh, & Armstrong, 1993)
additional qualitative questions from the questionnaire to de-
are effective or trend toward effectiveness in decreasing self-
termine their evaluation of the VR glasses and its effective-
reported pain in younger children for procedures such as
ness as a distraction technique during the LP. Their responses
venipuncture or immunization. However, one recent study of
to these last five questions supported the answers they pro-
children and adolescents undergoing venipuncture or IV in-
vided to the first five questions on the VR questionnaire.
sertion reported no differences in pain, fear, or distress be-
Seventy-seven percent of the subjects in the experimental
tween the distraction-kaleidoscope group and the control
group said that the VR glasses took their mind off the LP.
group (Carlson et al.). Little data exists that evaluates other
They reported that the video helped them to focus their
kinds of distraction for pain reduction during more painful
thoughts and distract them from the procedure. Subjects con-
procedures, such as LPs in the older child or adolescent. Our
tinued to vividly describe their recollections of the sights
study is the first to suggest that a more novel distracter (VR
and sounds on the video during the LP. They depicted the
glasses) may be effective in reducing perceived procedural
music, scenes, movement, and action experience in the video
pain. The VR glasses are easy-to-use in older children and
as "neat," "cool," "fun," and "interesting." Several subjects
adolescents and require little training for nurses. In addition,
recounted the real-life sensations they felt during the ses-
these study results support the work of Kazak et al. (1996)
sion: "I thought I was in there." "It's like you move with [the
who successfully demonstrated the benefits of combining
video]." "It's like you're there."
nonpharmacologic and pharmacologic approaches of pain
One patient, who had previously visited the Eiffel Tower
management in pediatric subjects. The current study results
and who was uncomfortable with heights, commented that he
also support the descriptive findings from Schneider and
did not like the Eiffel Tower scene on the video. Nearly all
Workman (2000) who found that VR glasses were beneficial
of the subjects (94%) said they wanted to use the VR glasses
in helping adolescents cope with their chemotherapy.
again during their next LP.
The results of the qualitative data demonstrate that the
majority of adolescents in the VR group perceived the ben-
efits of using VR glasses to help divert their thoughts from
the LP experience and refocus their attention on another
The results of this study demonstrate that the level of pain
event. Subjective evaluations of the VR glasses support the
reported by both groups of subjects undergoing LPs was low,
WINT VOL 29, NO 1, 2002
elicit the lived experience during procedures from adolescent
theoretic postulation that the perception of painful stimuli
can be, to some degree, cognitively controlled. Although
the mechanism that enables distraction to be an effective
I m p l i c a t i o n s for Nursing Practice
strategy for managing pain is not known, some hypothesize
that the perception of pain can be controlled because indi-
Distracters, such as VR glasses, appear to be indicated for
viduals possess a limited capacity for processing of infor-
patients who are undergoing painful procedures that are mild
mation (Johnson & Petrie, 1997). If one's attention is pre-
to moderate in intensity and are time limited (a few minutes
dominately engaged in a specific task, then the attention
to an hour). The start-up costs for the equipment is minimal
available for another task is limited (Kahneman, 1973).
and includes VR glasses (about $500 a pair), television (vari-
When a distracter is capable of capturing a subject's atten-
able), videocassette recorder (variable), cart for equipment
tion, the individual has less cognitive ability to process
mounting (variable), and videotapes (about $25 each).
painful stimuli. In applying these postulates to the current
For adolescents undergoing LP, the VR glasses were prac-
study, the cognitive energies of the subjects in the VR
tical to use in a side-lying LP position and provided an age-
group appear to have been successfully occupied by the
appropriate, socially acceptable, diversional strategy in deal-
sights, movement, and sounds of the VR video, leaving less
ing with a painful procedure. Candidates for this type of
energy to interpret the sensory and affective components of
distraction technique include adolescents who are interested
in using distraction, can understand that distraction is used
The evaluations of the experimental group also indi-
to alter their perception of pain, have the mental ability to re-
cated that VR glasses were successful as a novel distracter.
focus their attention from the LP to the sights and sound on
The glasses were practical to use in the side-lying position
the VR video, and have the physical energy to concentrate.
necessary for the LP. Despite conscious sedation, subjects
Patients should know what is involved with the LP, what will
were able to experience the sights and sounds of the VR
be done, the length of time involved, and the sensations that
video and vividly recall specific details associated with the
will occur (McCaffery & Pasero, 1999). Based on the re-
experience. McCaffery and Pasero (1999) postulated that
searchers' experience with the subject who was uncomfort-
such distraction furnishes patients with a sensory shield that
able with the Eiffel Tower scene on the video, patients also
protects them from painful stimuli because of the increased
should be instructed to simply close their eyes for a few mo-
sensory stimulation that the distracter provides. A distracter
ments if any image on the video becomes unpleasant for
that furnishes the most effective level of sensory shielding,
therefore, is probably one that includes as much sensory
In conclusion, the pain scores in both the VR and the con-
input as possible (i.e., auditory, visual, tactile, kinesthetic,
trol groups were low, indicating the success of a multimodal
and olfactory) (Bush, 1987; McCaffery & Pasero). In con-
approach to procedural pain. Less pain was reported by those
trast, the sensory shielding provided by a distracter prob-
in the VR group than in the control group and although this
ably subsides as the strategy and stimuli become boring to
difference was not found to be statistically significant, it may
the patient. Although the VR glasses provided only audi-
represent a clinically important trend. The majority of the
tory and visual input, the scenes, events, and action on the
subjects in the VR group said that they believed that the VR
video were so diverse and changed so quickly that subjects
glasses helped to distract them from the LP, and almost all
had little time to process and recognize an event before the
wanted to use them again.
next input appeared. The multidimensional sight and sound
Multimodal approaches that combine pharmacologic and
experience included in the VR video, combined with the
nonpharmacologic interventions have been recommended
sense of "being there," furnished by the 3-D glasses, created
for managing procedural pain in infants, children, and ado-
constantly changing experiences that sustained novelty and
lescents (US Department of Health and Human Services,
required a high attentional capacity to process the incom-
1992). The results of this study demonstrate that VR glasses
ing stimuli.
have the potential to be a feasible, age-appropriate, easy to
This study has limitations. The applicability of these find-
use, nonpharmacologic adjunct to conventional standards of
ings to other populations is limited because of the small
care in managing the pain associated with painful procedures
sample size. Recommendations include that this study be
of adolescents with cancer. Based on the findings demon-
replicated and expanded to include a larger sample, focusing
strated in this study and the need to establish research-based
on outcomes with different adolescent populations undergo-
practices for managing procedural pain, future research in-
ing a variety of procedures in various settings. Also, the six
vestigating the clinical application of distraction is war-
nurses who performed the LPs were all experts who were
highly skilled in performing this procedure. Their proficiency
likely played a role in the resultant low pain levels experi-
Special acknowledgment is given to Barbara Foster, PhD, for her
enced in general by both groups of subjects. In addition, most
statistical consultation and the Center for Cancer and Blood Disorders
of the subjects in both groups had little to say about negative
nurse clinicians for their support and assistance in collecting data. We
experiences during the procedure, although they had mul-
are especially grateful to the patients and families who participated in
tiple opportunities during the interview to voice their con-
this study, to Janice Meeker for her time and dedication in typing and
consultation, and to Brenda Boggan, RN, for assisting in the develop-
cerns, fears, and discomfort. In general, we found that the ado-
ment of the proposal.
lescents were reluctant to talk during the interview despite
extensive probing from the interviewer. Many of their re-
sponses were "thin" (minimal) and did not yield the more de-
Author Contact: Debra Eshelman can be contacted at
veloped perceptions about the experience that was antici-
deshel@childmed.dallas.tx.us with copy to editor at rose_mary@
pated. Future researchers should explore other strategies to
ONF VOL 29, NO 1, 2002
M.K., Blackall, G.F., Daller, R., & Johnson, K. (1996). A random-
Abu-Saad, H., & Holzemer, W.L. (1981). Measuring children's self-as-
sessment of pain. Issues in Comprehensive Pediatric Nursing, 5, 337
ized controlled prospective outcome study of a psychological and
pharmacological intervention protocol for procedural distress in pe-
diatric leukemia. Journal of Pediatric Psychology, 21, 615631.
Atkins, C. (Director) (1996). Escape [Video]. (Available from Virtual i-
Lambert, S.A. (1999). Distraction, imagery, and hypnosis: Techniques
O, 1553 SE Spokane Street, Portland, OR 97202).
for management of children's pain. Journal of Child and Family
Blount, R.L., Bachanas, P.J., Powers, S.W., Cotter, M.C., Franklin, A.,
Nursing, 2(1), 515.
Chaplin, W., Mayfield, J., Henderson, M., & Blount, S.D. (1992).
Manne, S.L., Bakeman, R., Jacobsen, P.B., Gorfinkle, K., & Redd,
Training children to cope and parents to coach them during routine
immunizations: Effects on child, parent, and staff behaviors. Behavior
W.H. (1994). An analysis of a behavioral intervention for children
undergoing venipuncture. Health Psychology, 13, 556566.
Therapy, 23, 689705.
Manne, S.L., Redd, W.H., Jacobsen, P.B., Gorfinkle, K., Schorr, O., &
Broome, M., Lillis, P., McGahee, T., & Bates, T. (1992). The use of
distraction and imagery with children during painful procedures. On-
Rapkin, B. (1990). Behavioral intervention to reduce child and par-
ent distress during venipuncture. Journal of Consulting and Clinical
cology Nursing Forum, 19, 499502.
Psychology, 58, 565572.
Bush, J.P. (1987). Pain in children: A review of the literature from a de-
velopmental perspective. Psychology and Health, 1, 215236.
McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd ed.). In
M. McCaffery & C. Pasero, Practical nondrug approaches to pain
Carlson, K.L., Broome, M., & Vessey, J.A. (2000). Using distraction to
(pp. 399427). St. Louis: Mosby.
reduce reported pain, fear, and behavioral distress in children and
McCaul, K., & Malott, J. (1984). Distraction and coping with pain. Psy-
adolescents: A multi-site study. Journal Society of Pediatric Nursing,
chological Bulletin, 95, 516533.
5, 7585.
Price, D., McGrath, P., Rafii, A., & Buckingham, B. (1983). The vali-
Cohen, L.L., Blount, R.L., & Panopoulos, G. (1997). Nurse coaching
dation of visual analogue scales as ratio scale measures for chronic
and cartoon distraction: An effective and practical intervention to
and experimental pain. Pain, 17, 4556.
reduce child, parent, and nurse distress during immunizations. Jour-
Reading, A.E. (1980). A comparison of pain rating scales. Journal of
nal of Pediatric Psychology, 22, 355370.
Psychosomatic Research, 24, 119124.
Downie, W.W., Leatham, P.A., Rhind, V.M., Wright, V., Branco, J.A.,
& Anderson, J.A. (1978). Studies with pain rating scales. Annals of
Schneider, S.M., & Workman, M.L. (2000). Virtual reality as a distrac-
tion intervention for older children receiving chemotherapy. Pediat-
the Rheumatic Diseases, 37, 378381.
ric Nursing, 26, 593597.
Fernandez, E. (1986). A classification system of cognitive coping strat-
egies for pain. Pain, 26, 141151.
Smith, J., Barabasz, A., & Barabasz, M. (1996). Comparison of hypno-
sis and distraction in severely ill children undergoing painful medical
Fowler-Kerry, S., & Lander, J.R. (1987). Management of injection pain
procedures. Journal of Counseling Psychology, 43, 187195.
in children. Pain, 30, 169175.
U.S. Department of Health and Human Services. (1992). Acute pain
French, G.M., Painter, E.C., & Coury, D.L. (1994). Blowing away shot
management in infants, children, and adolescents: Operative and
pain: A technique for pain management during immunization. Pedi-
medical procedures. [Agency for Health Care Policy and Research
atrics, 93, 384388.
Publication No. 92-0020]. Rockville, MD: U.S. AHCPR, Public
Gonzalez, J.C., Routh, D.K., & Armstrong, F.D. (1993). Effects of ma-
Health Service.
ternal distraction versus reassurance on children's reactions to injec-
tions. Journal of Pediatric Psychology, 18, 593604.
Vessey, J.A., Carlson, K.L., & McGill, J. (1994). Use of distraction with
children during an acute pain experience. Nursing Research, 43,
Johnson, M.H., & Petrie, S.M. (1997). The effects of distraction on ex-
ercise and cold pressor tolerance for chronic low back pain sufferers.
Pain, 69, 4348.
Zeltzer, L.K., Altman, A., Cohen, D., LeBaron, S., Munuksela, E.L., &
Kahneman, D. (1973). Attention and effort. Englewood Cliffs, NJ:
Schechter, N.L. (1990). Report of the subcommittee on the manage-
ment of pain associated with procedures in children with cancer. Pe-
diatrics, 86, 826831.
Kazak, A.E., Penati, B., Boyer, B.A., Himelstein, B., Brophy, P., Waibel,
WINT VOL 29, NO 1, 2002