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

Preoperative anxiety affects a majority of children undergoing surgery and is associated with adverse perioperative and psychological outcomes. Virtual reality (VR) is a promising non-pharmacological option, but real-world implementation data remain limited. We report a nine-month quality-improvement (QI) initiative that implemented a custom VR intervention in a pediatric preoperative holding area, followed by retrospective analysis of prospectively collected data. Using a single-arm, pre-post design without a comparison group, we evaluated within-subject changes in self-reported distress and fear, physiological indicators, and stakeholder experience in 80 children aged 6–15 years. Between the pre-VR and immediately post-VR assessments, distress (0–10 Numerical Rating Scale) decreased by a median of 2.0 points (median 3.0 to 1.0; p < 0.001) and fear (0–4 Children's Fear Scale) by a median of 1.0 point (1.0 to 0.0; p < 0.001). Heart rate fell by a mean of 5.8 beats/min and systolic blood pressure by 4.1 mmHg (both p < 0.001). Acceptance was high: 91% of children were willing to use VR again, 95% of parents would recommend it, and all participating nurses endorsed it, with few, minor adverse effects (3 of 80). In this uncontrolled QI initiative, VR was feasible and safe to implement and was accompanied by clinically meaningful within-subject reductions in anxiety and physiological arousal. Because the design included no comparison group, these changes cannot be attributed to VR alone and may partly reflect natural settling, acclimation, non-specific attention, or regression to the mean. Controlled trials are needed to establish comparative effectiveness before routine adoption.