Running head: USE OF VIRTUAL REALITY VIDEOS TO REDUCE ANXIETY

Use of Virtual Reality Videos to Reduce Anxiety for Radiation Oncology Patients
Deirdre Colao
Laurie Baker
Arizona State University

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Abstract
Purpose: To implement a non-pharmacologic approach to reduce anxiety in patients receiving
radiation treatment.
Background and Significance: Anxiety is a prevalent health problem affecting up to 30% of the
general population. Over 95% of radiation oncology patients report anxiety often related to not
knowing what to expect during treatments. The current guideline for management of anxiety is
the use of benzodiazepines; which can impose a risk to patients. Evidence demonstrates virtual
reality videos can be an effective non-pharmacologic approach to reduce anxiety..
Design: Observational cohort evidence based project.
Setting: Outpatient radiation oncology facility in the Southwest United States.
Sample: 40 patients who have not previously undergone radiation therapy, but have been
prescribed radiation treatments for malignant or non malignant conditions.
Methods: Patients who had not previously undergone radiation treatments were identified based
on chart review and consented for participation in the project. The patient's were assessed for
both their general (trait) anxiety and situational (state) anxiety using The State Trait Anxiety
inventory (STAI). They were then shown a virtual reality video that walked them through what
they would experience during their radiation treatment. The patient's were re-administered the
STAI questionnaire following the video to assess any change in anxiety levels.
Variables: Trait and State anxiety scores before and after the virtual reality video intervention.
Findings/Outcomes: A paired t-test was conducted to assess the data. There was a significant
difference in the state anxiety scores pre intervention (m = 32.65, SD = 11.47) and post
intervention (M = 25.50, SD 8.95), p =< 0.001.

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Conclusions: The use of virtual reality videos was an effective non-pharmacological approach to
reduce anxiety in patients receiving radiation treatment.
Implications for nursing: The results provide support for the use of a virtual reality intervention
as a non-pharmacologic option to reduce anxiety for patients.
Keywords: Radiation oncology, anxiety, virtual reality, patients

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The Use of Virtual Reality Videos to Reduce Anxiety
When a patient is diagnosed with cancer and presents for an initial consultation regarding
the role of radiation in their treatment, they often experience significant anxiety. Their new
diagnosis which is often grave, combined with the steep learning curve about the world of
oncology is certainly anxiety provoking. Physiological and psychological health issues, stemming
from anxiety, can have a negative impact on a cancer patient's well-being. Current guidelines
recommend only benzodiazepines for the management of anxiety; however, the use of these
medications can present a risk to the patient. Non-pharmacologic approaches such as the use of
virtual reality videos have been found to be an effective approach to manage situational anxiety
in many patients.
Background and Significance
Chen and Chang (2012) describe the significant emotional challenges and myriad of
emotions oncology patients experience, including: acceptance of illness, facing mortality, altered
financial and socioeconomic stability, self reproach, and changes in their perception of self. They
also recount patient self reports of negative feelings which they described as mental distress
manifested as worries, fear, bad anticipations, shock, hopelessness, and anger. The concepts of
mental distress, worries, and fear are defined as anxiety by the National Cancer Institute (2015).
The issue of anxiety in cancer patients can manifest at various times during their cancer diagnosis
and treatment. Anxiety can affect a patient's behavior and willingness to proceed with treatment.
The National Cancer Institute (2015) recommends addressing anxiety with cancer patients at all
stages of their treatment. Evaluation tools such as the State Trait Anxiety Inventory (STAI) are
recommended by the American Psychological Association (2017) to evaluate a patient's anxiety at
different times during an illness. Current guidelines from the National Comprehensive Cancer

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Network (NCCN) recommend evaluation of anxiety followed by treatment with, psychotherapy
with or without anxiolytic and with or without antidepressant. No non-pharmacological
interventions are recommended beyond psychotherapy (National Comprehensive Cancer Network,
2015). Dunn et al., (2012) used the STAI to evaluate the trajectory of anxiety in oncology patients
before, during, and after radiation treatments. Their results showed that 95% of the patients had
anxiety prior to their first radiation treatment.
A retrospective chart review of the electronic medical records at the clinical site
demonstrated 7- 8% of patients who have undergone radiation treatment in the past five years had
a co morbid diagnosis of anxiety. At the clinical site where this project was implemented patients
are currently assessed for anxiety in an informal manner. Patients are asked if they have anxiety
and or claustrophobia at the time of their initial consultation. A standardized tool for assessment of
anxiety is not used. If a patient reports anxiety, the current standard of care at the clinical site is to
prescribe a benzodiazepine for management of the patient's symptoms. Patients are not presented a
non-pharmacologic approach to help manage anxiety.
The use of benzodiazepines present potential side effects and risk to patients. Rosenberg
(2015) looked at the association between use of benzodiazepines and higher incidents of
Alzheimer's. Her research showed that patients who had used benzodiazepines for more than 180
doses had markedly higher rates of Alzheimer's disease; 33% versus the control group of 22%.
Furthermore, her research provided evidence that use of benzodiazepines at any time increased the
risk of Alzheimer's by 43% to 51%. Other concerning side effects of benzodiazepine use include
sedation in the first few weeks of therapy, unsteadiness, poor coordination, and disorientation
(Lader, 2011). In a retrospective study performed by van Strien, A. M., Koek, H. L., van Marum,
R. J., & Emmelot-Vonk, M. H. (2013) data was presented confirming that use of psychotropic

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medications including benzodiazepines significantly increase the frequency of falls in the
elderly. While the use of benzodiazepines can be effective in the management of situational
anxiety, the medication can have many unacceptable side effects for patients receiving care at an
outpatient radiation oncology center. Use of benzodiazepines prevent patients from driving to their
appointments, can effect cognitive functioning, and reduces a patient's ability to make important
decisions during a time that can be very tumultuous. This has lead to the following clinical
question: (P) In oncology patients undergoing radiation treatments, (I) how does a virtual reality
intervention, (C) versus use of benzodiazepines, (O) affect the level of anxiety (T) prior to
radiation treatments?
Search Strategy
To answer the clinical question, an extensive search of the literature was performed.
Three databases were searched including: Cumulative Index of Nursing and Allied Health
Literature (CINAHL), Public/Publisher MEDLINE PubMed, and Psychological Information
Database (PsychINFO). Search strategies included restricting the publication date to 2010-2016,
peer reviewed journals, and only those written in English.
The database searches were performed using key words, MeSH terms, and Boolean
Connectors. Key words used in combination for all search strategies were anxiety, radiation
oncology nursing, radiation oncology, virtual reality, VR, virtual reality exposure, virtual reality
therapy, cancer patients, education, treatment, anxiety disorders, simulation, quality of life,
intervention, and health (Appendix A).
A systematic search was conducted and studies were initially reviewed for relevance.

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Studies with virtual reality as an intervention and studies with anxiety as an outcome were
reviewed in greater detail. Ten studies that best addressed one or more component of the PICOT
question were identified.
Critical Appraisal and Synthesis of Evidence
Three of the studies chosen for relevance were systematic reviews (level I evidence), four
randomized control trials (level II evidence), one Quasi-experimental trial (level III evidence),
one qualitative study (level V evidence), and one mixed methods study (level IV). Nine of the
ten studies addressed anxiety as one of the dependent variables and all had non-pharmacological
interventions including music therapy, psychotherapy, and hypnosis as the independent variable.
All nine studies showed decreased anxiety after the intervention. Statistical analysis was
performed in all of the studies and every study showed statistically significant results with (p)
ranging from 0.05 to < 0.001 (Appendix B). Eight of ten studies evaluated cancer patients and
three studies specifically addressed cancer patients undergoing radiation therapy. Six studies
used virtual reality as the intervention to reduce anxiety. The instruments used to evaluate the
change in the dependent variables were predominantly validated tools including State Trait
Anxiety Inventory (STAI), Self Rating Anxiety Scale (SAS), Self Rating Depression Scale
(SDS) and Visual Analog Scales (VAS). Bias was not evident in the selected studies. Three
studies had government based grants, five studies did not have any financial assistance, and the
remaining two studies received financial assistance from private health foundations.
Purpose Statement
The purpose of the project is to demonstrate that virtual reality videos can be an effective
non-pharmacologic approach for managing anxiety for patients undergoing radiation treatments.

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The goal is to facilitate a practice change where the use of virtual reality videos would be
considered in place of benzodiazepines for patients prior to their radiation treatments.
Theoretical Framework

Roy's Adaptation Model (Roy, 1991) was selected to help guide an intervention to reduce
anxiety for oncology patients receiving radiation (Appendix C). The model has four essential
elements: the person receiving nursing care, the environment, health, and nursing. The model is
designed to assist with changes in nursing practice and nursing research. In the proposed
practice change, all of the elements are addressed; the person receiving care is the oncology
patient, the environment is the radiation oncology department, the health issue is anxiety, and
nursing is the nursing staff at the facility who will be working to evaluate the proposed practice
change following implementation of the non-pharmacological intervention with virtual reality to
decrease anxiety in patient's in place of benzodiazepines.
Evidence Based Model
The Rosswurm and Larrabee Evidence Based Model (1999), has been chosen to guide the
process towards creating a practice change (Appendix D). For the planned project, the need for a
practice change was identified after collection of internal and external evidence which identified
the need to evaluate possible non-pharmacological interventions for treatment of cancer patients
who have situational anxiety related to radiation treatments. A review of current evidence
helped identify possible interventions and evidence related to anxiety in cancer patients and
possible interventions were collected and synthesized. The details of the practice change
intervention were designed and the virtual reality videos were created for each treatment
modality. The project was then implemented and data was collected to determine efficacy.

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Methods
Approval for the project was obtained from Arizona State University Institutional Review
Board and permission to implement the project at the clinical site was obtained from the medical
director of the practice.
The setting for the project was an outpatient radiation oncology facility in the Southwest
United States with four physicians and one physician's assistant. The center has three different
radiation machines providing different modalities for delivering radiation. Evidence based
practice is at the core of every treatment and intervention discussion at the center. The providers
and center staff all expressed enthusiasm for the project and participated in making patients
aware of the opportunity to learn about the project details.
Inclusion criteria for eligible patients to participate in the project were English speaking,
adult patients who had been prescribed radiation by their radiation oncologist. The patients had not
previously received radiation treatments. Patients with both malignant and non malignant
conditions were included.
The instrument used to measure anxiety was the Spielberger State-Trait Anxiety
Inventories (STAI). The STAI instrument is an established assessment tool with construct validity
and internal reliability (Spielberger, 1983). The STAI instrument is a self evaluation tool that is
divided into two questionnaires. The first questionnaire is an assessment of Trait or general
anxiety. The second questionnaire is an assessment of State of situational anxiety. Each
questionnaire is comprised of 20 items which are scored on a Leikert scale from 1-4. The responses
were scored from 1 ("not at all") to 4 ("very much so"). The Trait anxiety questionnaire is a self
assessment of how a patient "generally feels" in day to day life. The State anxiety questionnaire is
a self assessment of how the patient feels "in that moment" or "right now".

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Patients who had not previously undergone radiation treatments were identified based on
chart review and consented for participation in the project prior to their first radiation treatment.
This was generally done on the day of their initial consultation with the radiation oncologist.
Once written consent was obtained patients were administered both the Trait and State anxiety
questionnaires. The patient then watched a virtual reality video of their specific planned
radiation treatment modality wearing specialized virtual reality glasses. The appropriate video
was chosen based on which treatment machine was ordered for the patient's radiation and based
on whether the patient would need to wear a face mask for their treatment. The video walked the
patient through what they would see, hear, and experience during their radiation treatment.
Immediately following the video the patient completed a second State anxiety questionnaire to
assess any change in anxiety levels following the intervention.
SPSS®, version 23 was used for statistical data analysis. Descriptive statistics and
frequency distributions were generated on the sample. A paired- samples t-test was conducted to
compare pre and post intervention anxiety scores. Pearson’s correlations were performed to
examine the relationship between anxiety scores and gender, treatment type, age and diagnosis.
Funding was not requested or obtained for the project. The project costs included the cost
to reproduce the STAI questionnaire which is copyrighted. The cost was 50c per questionnaire.
The Virtual reality videos were made at no cost and the virtual reality goggles cost $40. No other
costs were incurred for the project.
Results
The sample was composed of 40 adult patients, 23 men, and 17 women. The patient's age
ranged from 24 to 84 years, (M = 64.25, SD 13.74). Twenty six (65%) of the patients had a cancer
diagnosis with the remaining 18(35%) having non malignant conditions including meningiomas,

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vestibular schwannomas and trigeminal neuralgia. The number of patients requiring a face mask
for immobilization for their treatment was 15 (37.5%). Two different treatment machines were
used by the participating patients, 12 (30%) patients were treated on the Truebeam machine, and
the remaining 28 patients were treated on the Cyberknife machine.
A paired t-test was conducted to compare the patient's state anxiety scores prior to the
virtual reality intervention and their state anxiety score following the intervention. There was a
significant difference in the state pre intervention anxiety scores (m = 32.65, SD = 11.47) and the
state post intervention scores (M = 25.50, SD 8.95). There was a significant difference in the
anxiety scores pre and post the virtual reality intervention t(39) = 6.03, p = < 0.001. (Appendix
E)
Bivariate correlations were run and demonstrated that there was no statistical correlation
between patient's age and trait anxiety levels. There was no correlation between patients needing
to wear a mask and state anxiety levels. There was also no correlation between gender and state
anxiety levels.
Discussion
The results demonstrate that using a virtual reality video intervention is an effective way
to reduce anxiety in patients prior to receiving radiation treatment. The findings from the project
are consistent with the evidence found in the available literature.
Strengths of the project include the inclusion of patients with multiple diagnoses and
patients receiving treatments with different modalities of radiation. The project was not cost
prohibitive and the intervention can be carried on at no additional cost to the clinical site.
Limitations of the project are the relatively small sample size of 40 patients and that the project
was only carried out at one site.

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Conclusions
The results of the project provide support for the use of a virtual reality intervention as a
non pharmacologic option to manage anxiety and potentially reduce patients' use of
benzodiazepines.
All patients should be screened for anxiety using a standardized tool as part of routine
care for patients prior to radiation treatments. Virtual reality videos can be considered as a nonpharmacologic therapeutic option in the place of benzodiazepines for patients with anxiety
therby reducing risk to the patient resulting from side effects related to those medications.

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References
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Baños, R. M., Espinoza, M., García-Palacios, A., Cervera, J. M., Esquerdo, G., Barrajón, E., &
Botella, C. (2013). A positive psychological intervention using virtual reality for patients
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Chirico, A., Lucidi, F., De Laurentiis, M., Milanese, C., Napoli, A., & Giordano, A. (2016).
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(2012). Trajectories of anxiety in oncology patients and family caregivers during and
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Guo, Z., Tang, H. Y., Li, H., Tan, S. K., Feng, K. H., Huang, Y. C., ... & Jiang, W. (2013). The
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Lader, M. (2011). Benzodiazepines revisited—will we ever learn?. Addiction,106(12), 20862109.
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McCann, R. A., Armstrong, C. M., Skopp, N. A., Edwards-Stewart, A., Smolenski, D. J., June, J.
D., ... & Reger, G. M. (2014). Virtual reality exposure therapy for the treatment of
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nges.aspx
Opriş, D., Pintea, S., García‐Palacios, A., Botella, C., Szamosközi, Ş., & David, D. (2012).
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van Strien, A. M., Koek, H. L., van Marum, R. J., & Emmelot-Vonk, M. H. (2013). Psychotropic
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USE OF VIRTUAL REALITY VIDEOS TO REDUCE ANXIETY
Appendix A Data base search results

Key words

Yield

CINAHL
anxiety
+ radiation oncology
anxiety + cancer patients or oncology patients
cancer patients + anxiety + radiation
education + virtual reality + anxiety
cancer patients + virtual reality
cancer patients + virtual reality + radiation

54, 848
2,146
6,241
137
7
30
5

PubMed
anxiety
radiation therapy
cancer patient
cancer patient + oncology + radiation/radiation therapy
cancer patient + oncology + radiation/radiation therapy + anxiety
anxiety + cancer patients + oncology + radiation
+ reality therapy/augmented reality/virtual reality

63,000
151, 412
3,281
375, 713
1,293
78

PsychINFO
anxiety + radiation
anxiety + cancer patients
anxiety + radiation + cancer patients
anxiety + radiation + cancer patients + situational anxiety
anxiety + radiation + cancer patients + virtual reality
anxiety + radiation + cancer patients + alternative therapies

357
43
82
2
2
4

16

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Appendix B Synthesis Table
Year of

Level of

Type of Study

Instrument

Control

N

n

IV

Study

Evidence

Banos

2013

II

RCT

VAS

No

NA

19

VR

Chen

2013

III

Quasi-Experimental

STAI

Yes

NA

200

Chirico

2016

I

Systematic Review

STAI

Yes

19 RCT

Gou

2013

II

RCT

SDS & SAS

Yes

Li

2012

II

RCT

STAI

McCann

2014

I

Systematic Review

Opris

2012

I

Shimotsu

2010

Sule-Suso

2015

Anxiety

Radiation

Cancer

patients

patients

Dec

No

Yes

Music

Dec

Yes

Yes

NA

VR

Dec

No

Yes

NA

178

Psycho-therapy

Dec

No

Yes

Yes

NA

120

Music

Dec

No

Yes

NA

Yes

27 RCT

1080

VR

Dec

No

No

Meta-Analysis

NA

Yes

23 RCT

397

VRET

Dec

No

No

VI

Mixed methods

RCAS

No

NA

382

NI

N/M

Yes

Yes

V

Qualitative

Open- Ended

No

NA

150

VR/VI

Dec

Yes

Yes

Yes

NA

49

Hypnosis &

Dec

No

No

Questionnaire
Zhao

2015

II

RCT

SAS

AR/VR

AR: Artificial Reality, Dec: Decrease, Inc: Increase, Info: Information Provided to Patients, IV: Independent Variable, NA: Not
Applicable, N: Number of Studies Reviewed, n:Number of Patients in study, NI: No Intervention, N/M: Not Measured, RCAS: Radiation
Categorical Anxiety Scale, RCT: Randomized Control Trial, SAS: Self Rating Anxiety Scale, SDS: Self Rating Depression Scale, STAI:
State Trait Anxiety Inventory, VAS: Visual analog scale, VI: Virtual Imaging, VR: Virtual Reality, VRET: Virtual Reality Exposure
Therapy

Running head: USE OF VIRTUAL REALITY VIDEOS TO REDUCE ANXIETY

Appendix C Roy's Adaptation Model

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USE OF VIRTUAL REALITY VIDEOS TO REDUCE ANXIETY

Appendix D Evidence Based Model (EBP) figure.

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USE OF VIRTUAL REALITY VIDEOS TO REDUCE ANXIETY

Appendix E t-test results

State anxiety scores before and after virtual reality video intervention.
Variable
State anxiety score
p ≤ 0.001

Pre virtual reality video
n
m(SD)
40
32.65(11.47)

Post virtual reality video
n
m(SD)
40
25.50(8.95)

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