Nursing Interventions for Reducing Procedural Pain and Anxiety in Hospitalized Children

Introduction

Hospitalized children commonly undergo repeated painful procedures over the course of a single admission, including venipuncture, peripheral intravenous catheter insertion, and immunization, and prior research has documented that inadequately managed procedural pain is associated not only with acute distress but also with heightened anticipatory anxiety for subsequent procedures and, in some studies, longer-term needle-related fear extending beyond the hospitalization itself (Duff, 2003; MacLaren & Cohen, 2005). Nurses are typically the clinicians both performing these procedures and responsible for selecting and delivering accompanying nonpharmacological comfort strategies, positioning nursing practice as the primary point of intervention for procedural pain and anxiety reduction in most pediatric inpatient settings (Wente, 2013).

A range of nonpharmacological intervention categories has been evaluated in the pediatric procedural pain literature, including distraction techniques such as bubbles, kaleidoscopes, and interactive books; virtual reality-based distraction; comfort positioning and facilitated parental holding, which replace restraint-based positioning with a supportive, upright hold; and multicomponent interventions combining several of these elements (Koller & Goldman, 2012; Pillai Riddell et al., 2015). Prior systematic reviews, including Cochrane reviews focused on psychological interventions for needle-related procedural pain and distress, have generally supported a beneficial effect of nonpharmacological intervention relative to standard care, though these reviews have often pooled a broad and heterogeneous range of intervention types together, or have focused on outpatient and emergency department settings rather than specifically nurse-delivered intervention within pediatric inpatient care (Birnie et al., 2018; Uman et al., 2013).

Given the continued expansion of virtual reality-based distraction as a comparatively newer intervention category, and the practical importance for inpatient nursing units of understanding which specific intervention types offer the greatest benefit relative to their resource and training requirements, an updated, nursing-focused synthesis directly comparing effect sizes across intervention categories is warranted. The purpose of this systematic review and meta-analysis was to synthesize randomized controlled trial evidence evaluating the effect of nurse-delivered, nonpharmacological interventions on procedural pain and anxiety among hospitalized children undergoing acute needle-related procedures, with a pre-specified subgroup analysis comparing effect magnitude across distraction, virtual reality, comfort positioning, and multicomponent intervention categories.

Methods

Protocol and reporting. This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement (Page et al., 2021). The review protocol was registered prior to data extraction.

Search strategy. A systematic search of MEDLINE, CINAHL, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted from database inception through December 2024, using a combination of controlled vocabulary and free-text terms for pediatric population, procedural pain, anxiety, and nonpharmacological or nurse-delivered intervention. Reference lists of included studies and relevant prior systematic reviews were hand-searched for additional eligible trials.

Eligibility criteria. Eligible studies were randomized controlled trials evaluating a nurse-delivered, nonpharmacological intervention against standard care, no intervention, or an attention control condition, during an acute needle-related procedure (venipuncture, peripheral intravenous catheter insertion, or immunization) among hospitalized children aged 2 to 17 years, reporting at least one validated pain or anxiety outcome measure. Studies evaluating pharmacological intervention exclusively, studies conducted solely in outpatient or community settings, and non-randomized or single-group designs were excluded.

Study selection and data extraction. Two reviewers independently screened titles and abstracts, then full texts of potentially eligible records, with disagreements resolved through discussion or, where necessary, adjudication by a third reviewer. Data extraction, including study design, sample characteristics, intervention and comparator description, outcome measures, and results, was performed independently by two reviewers using a standardized extraction form, with discrepancies resolved by consensus.

Risk of bias assessment. Risk of bias was assessed independently by two reviewers using the Cochrane Risk of Bias 2 (RoB 2) tool, evaluating five domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported result (Sterne et al., 2019). Each study received an overall judgment of low risk, some concerns, or high risk of bias.

Data synthesis. Random-effects meta-analysis (restricted maximum likelihood estimation) was used to pool standardized mean differences (Hedges’ g) with 95% confidence intervals for pain and anxiety outcomes separately, consistent with Cochrane Handbook guidance for combining outcomes measured on different validated instruments across studies (Higgins et al., 2023). Statistical heterogeneity was quantified using the I² statistic. Pre-specified subgroup analysis stratified the pain outcome by intervention category (distraction, virtual reality, comfort positioning, multicomponent), with between-subgroup differences evaluated using a chi-square test. Publication bias was assessed through visual inspection of funnel plot asymmetry.

Results

The search identified 1,842 records, of which 1,405 remained after duplicate removal. Following title and abstract screening, 96 full-text articles were assessed for eligibility, and 14 randomized controlled trials, comprising 1,247 children, met inclusion criteria (Figure 1). Included studies were conducted across a range of countries and inpatient pediatric units and evaluated four intervention categories: standard distraction (5 studies), virtual reality (4 studies), comfort positioning or facilitated parental holding (3 studies), and multicomponent interventions (2 studies), as summarized in Table 1. Risk of bias was judged low in 5 studies, some concerns in 6 studies, and high in 3 studies, with the deviations-from-intended-intervention domain most frequently responsible for downgrading, reflecting the inherent difficulty of blinding participants and bedside staff to a behavioral intervention.

The pooled anxiety outcome, drawn from 9 studies (n = 812), similarly favored intervention (SMD −0.71, 95% CI −0.95 to −0.47, p < .001; I² = 54%), with a subgroup pattern broadly consistent with the pain outcome: virtual reality-based studies again showed the largest anxiety-reduction effect among the four categories, though the smaller number of studies contributing to the anxiety outcome within each subgroup limited the precision of subgroup-specific anxiety estimates relative to the pain outcome. Visual inspection of the funnel plot for the pain outcome showed mild asymmetry, with some indication of smaller studies reporting larger effects, though the modest number of included studies (k = 12) limits the reliability of formal publication bias assessment.

Discussion

This systematic review and meta-analysis found that nurse-delivered nonpharmacological interventions produced a moderate to large, statistically significant reduction in both procedural pain and anxiety among hospitalized children undergoing needle-related procedures, with an overall pooled effect for pain (SMD −0.68) consistent in direction and comparable in magnitude to effects reported in prior, broader systematic reviews of psychological intervention for pediatric needle-related distress (Birnie et al., 2018; Uman et al., 2013). The present review extends this literature by focusing specifically on nurse-delivered intervention within the inpatient setting and by directly comparing effect magnitude across four distinct intervention categories within a single synthesis.

The comparatively large pooled effect observed for virtual reality-based distraction (SMD −0.89) is consistent with a growing body of literature suggesting that the immersive, multisensory engagement offered by virtual reality may produce a stronger attentional shift away from the painful stimulus than more traditional distraction techniques, a mechanism proposed within cognitive-behavioral models of attention and pain perception (Chan et al., 2019; Gerçeker et al., 2018). This finding has practical relevance for inpatient units considering which nonpharmacological intervention to prioritize when resources do not permit universal implementation of all intervention categories, though the comparatively small number of virtual reality trials contributing to this subgroup (k = 4) warrants some caution in over-interpreting the precision of this specific estimate.

The comparatively smaller, though still statistically significant, effect observed for comfort positioning (SMD −0.51) should not be interpreted as indicating lesser clinical value, given that this intervention category requires substantially less specialized equipment or training investment than virtual reality and addresses a distinct mechanism, replacing restraint-based positioning with a supportive, less physically coercive hold, rather than attentional distraction specifically (Pillai Riddell et al., 2015). A comprehensive procedural comfort approach may reasonably combine comfort positioning as a low-resource baseline practice with distraction or virtual reality as an additional, resource-permitting enhancement, consistent with the larger effect observed here for multicomponent interventions combining multiple strategies.

The risk of bias pattern observed across included studies, generally low risk in the randomization, missing data, and outcome-selection domains, with more frequent concerns in the deviations-from-intended-interventions domain, reflects a structural limitation common to behavioral intervention trials rather than a correctable methodological weakness specific to this literature, since blinding of participants and bedside staff to a distraction or positioning intervention is rarely feasible. This should be considered when interpreting the overall risk of bias profile, as the field’s methodological ceiling for this specific domain differs meaningfully from pharmacological intervention trials.

Several limitations of this review should be considered. The moderate to substantial statistical heterogeneity observed for both outcomes (I² = 61% for pain, 54% for anxiety) indicates genuine variability in effect magnitude across studies that subgroup analysis by intervention category only partially explained, and likely reflects additional unmeasured variation in procedure type, child age, baseline anxiety, and specific implementation fidelity across studies. The modest number of studies within each intervention subgroup, particularly for virtual reality (k = 4) and multicomponent interventions (k = 2), limits the precision of subgroup-specific estimates and the ability to conduct more granular analyses, such as by specific procedure type or child age band. Finally, mild funnel plot asymmetry raises some possibility of small-study or publication bias, though the relatively small total number of included studies limits confidence in this assessment.

Future research should prioritize larger, adequately powered trials directly comparing virtual reality against standard distraction and comfort positioning within the same study design, which would allow more precise head-to-head effect comparison than the indirect, between-study subgroup comparison possible in the present review. Cost-effectiveness research comparing the resource investment required for virtual reality implementation against its incremental benefit over lower-resource alternatives would further support inpatient nursing units in intervention selection. Taken together, these findings support the routine integration of nurse-delivered nonpharmacological intervention into standard pediatric procedural care, with virtual reality-based distraction offering the largest observed benefit where implementation resources permit, and comfort positioning offering a lower-resource, still clinically meaningful foundation applicable across virtually all inpatient pediatric settings.

References

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