Virtual Reality–Based Intervention to Reduce Preoperative Anxiety in Adults Undergoing Elective Surgery

Key Points Question Compared with standard care, can a virtual reality–based intervention with preoperative education improve preoperative anxiety in adult patients undergoing elective surgery? Findings This randomized clinical trial of 74 adult patients undergoing elective surgery found that a virtual reality–based intervention was effective in reducing preoperative anxiety. Meaning The findings of this study suggest that virtual reality–based interventions can improve preoperative anxiety in adult patients undergoing elective surgery, but more randomized clinical trials with larger samples are needed to further confirm its effects.


Primary outcome: Pre-operative anxiety
Pre-operative anxiety was measured using the Amsterdam Pre-operative Anxiety and Information Scale (APAIS). 1 The scale consists of six items divided into two subscales: the anxiety scale and the need-for-information scale.Higher scores indicate higher anxiety levels or greater information needs.Moerman et al. suggested that patients scoring 11 or higher on the anxiety scale should be considered anxiety cases.A previous study indicated that APAIS is a valid instrument for assessing pre-operative anxiety and is highly correlated with the state scale of the State-Trait Anxiety Inventory (STAI-S; > 0.60) and specific to pre-operative assessment. 2 This study used the translated and validated Chinese version of the APAIS, 3 with Cronbach's alphas of 0.862 and 0.830 for the anxiety and the need-for-information subscales, respectively.

Secondary outcomes: Pain
The visual analogue scale (VAS) was used to assess the subjective pain levels of the participants.It is a simple yet effective tool consisting of a continuous scale, a horizontal line 100 mm long anchored by two distinctive verbal descriptors of a symptom on a scale of 0 mm (none) to 100 mm (maximum).The VAS is quick to administer and widely adopted in similar studies 4-6 and is more sensitive for identifying fine changes than solely numerical scales and four-point scales, especially for assessing pain. 7

Stress
The VAS was used to assess the participants' self-reported stress levels.The stress VAS consisted of a 100mm horizontal line with the descriptors "none" at 0 mm and "maximum" at 100mm.Participants indicated their stress level by marking a vertical line along the horizontal scale.

Preparedness
Preparedness for surgery refers to the understanding of risks, benefits, alternatives, potential complications, and expected outcomes of upcoming surgery. 8In this study, the operational definition of preparedness refers to the extent of the participants' feeling ready and equipped to undergo surgery. 9The VAS was used to assess the subjects' preparedness on a scale of 0 mm (none) to 100 mm (maximum).

Simulation sickness
Simulation sickness refers to a syndrome similar to motion sickness that is often experienced during exposure to simulators or virtual reality (VR) environments. 10In this study, the simulation sickness of the participants was assessed using the Simulation Sickness Questionnaire (SSQ) developed by Kennedy et al. 11 The SSQ is a self-report questionnaire comprising of 16 items related to simulator sickness.Respondents rate their level of discomfort or symptoms using a 4-point rating scale for each item: 0 (none), 1 (slightly), 2 (moderate) and 3 (severe).The items are grouped into three subscale clusters: Nausea (N), Oculomotor (O) and Disorientation (D), each reflecting the impact of that aspect of simulation sickness on the participant.A weighted score representing the Total Severity (TS) of simulation sickness experienced by the participant can be calculated.A higher score represents a greater level of simulation sickness.The SSQ has been adopted by numerous studies on VR. 12 The Cronbach's alpha was 0.84 for nausea, 0.91 for oculomotor and 0.88 for discomfort. 11The translated Chinese version 13,14 was used for data collection in this study after undergoing content validation by an expert panel.

Satisfaction
Satisfaction refers to the fulfilment or gratification of a desire, need or appetite. 15In this study, the operational definition of satisfaction refers to the fulfilment or gratification of the participant by the pre-operative services.The self-report VAS was used to assess the participant's satisfaction on a scale of 0 mm (none) to 100 mm (maximum).

Postoperative length of stay
The length of stay refers to the duration of hospitalization between admission and discharge 16 and is an important metric for assessing the quality of care. 17In this study, to minimize the confounding effects arising from varying pre-operative waiting times, the postoperative length of stay was operationally defined as the time from the end of surgery and anesthesia and transfer to the Post-Anesthetic Care Unit (PACU) to discharge from the surgical in-patient episode.Using the interval from the end of anesthesia and surgery, rather than initial hospital arrival or admission, provides a more standardized measure of the postoperative recovery time.The PACU admission marked the endpoint of the intraoperative period and the beginning of the postoperative recovery period.Defining the endpoint of the postoperative period as discharge from the surgical in-patient episode also provides a consistent measure across patients.The postoperative length of stay was measured in hours, rounded to the nearest whole number.The periods were calculated

eFigure 6 .
Graphical Comparison of the Satisfaction of the Study Groups at T3 eFigure 7. Graphical Comparison of Postoperative Length of Stay Between Study Groups © 2023 Chiu PL et al.JAMA Network Open.