Virtual Reality intervention for burns dressing changes; efficacy, implementability and predictors of success.

Patients will be present in the Liminal VR (https://liminalvr.com/) environment or the Furness et al. (2019) basketball simulation, previously shown to be effective in burns patients and healthy controls undergoing cold pressor stimulation (Phelan et al., 2019). They will do so using a Meta Quest 3 headset with the addition of an Elite head strap for additional stability and comfort. A pilot period will determine how these Virtual Reality (VR) experiences will work with patients and how the length of dressing change may impact what can be delivered. As the length of burns inpatient dressings are dependent on size of burn and complexity of dressing the duration of each VR session will be recorded. Each session will be monitored by the lead researcher in conjunction with burns nursing staff to ensure patient adherence to the intervention. To assess how immersive patients found the VR experience to be (a key indicator of effective VR intervention) a brief 5 question VR immersiveness scale will be given after the intervention to assess how patients experienced the VR world they were in. The Slater-Usoh-Steed (Slater et al., 1994; SUS) questionnaire will be used as it is brief and has been shown previously to be a good measure of presence in a VR world (Nystad & Sebok, 2004). Procedures Participants in both groups who are not part of the exclusion criteria will be approached prior to their second dressing change, likely the previous afternoon when there is a break in their other multidisciplinary treatments such as physio exercises. At this point they will be asked if they would like to participate in their randomised group, VR or treatment as usual (control). Potential participants will be given some time to consider, should they agree to participate the relevant consent form will then be completed. The VR group will then be offered a brief 5-10 minute trial of the VR program, and asked if they experienced any symptoms of nausea, vertigo or motion sickness. If they do experience these symptoms, they will be excluded. This trial period will also serve as a calibration point to ensure best fit and vision whilst in the VR environment. Participants will be asked to complete the Multidimensional Health Locus of Control (MHLC) or Internal-External 4 scale (IE-4) the brief-COPE scale and the general self-efficacy (GSE) scale. Patients will then be informed of the plan for intervention during their next dressing change and how the intervention will be employed to assist with their intra-dressing change pain. At the second dressing change, participants will be provided with their standard pre-dressing analgesia approximately 30 minutes prior to the onset of their dressing. Depending on day, patients may be showered before their in-bed dressing change. As the VR equipment is not waterproof, VR will be provided to the patient after showering prior to full dressing change. Typically, patients will be set up with the VR headset during their 30 minutes of waiting for analgesia to take effect. During this waiting period, an initial baseline Visual Analogue Scale (VAS) will be conducted to establish patients' pain prior to any additional stimuli (showering/dressing removal etc.). Once the patient has entered the VR environment, nurses will perform their standard dressing change procedure. Patients are able to use Entonox (on demand breakthrough analgesia; 50% oxygen in nitrous oxide; inhaled through hand-held tube) as needed (when patient requires additional pain control, or when senior burns nurses suggest they may require it) in both control and intervention groups. At the conclusion of the dressing, patients will remove the VR headset and once again be asked to complete a VAS for their pain. They will then be asked to complete the Burn Specific Pain Anxiety Scale (BSPAS) and SUS questionnaire. Patients in the control group will follow the same general procedure excepting the VR immersion scale and the VR itself. Based on senior nurse reported averages, 3-4 dressing changes are carried out daily on the Burns ward. Consequently, this may necessitate the lead researcher being unable to stay in the room for the full duration of a session in order to facilitate another VR participant or collect control measures. As patients can often be fatigued by dressing changes, post-dressing measures will be recorded as soon as the patient is able to complete them. Repeated measure At the conclusion of their dressing change, the VR group will be asked if they would like to continue using VR as part of their dressing changes. If they do not wish to continue they will only have data from one dressing recorded and nil further experimental intervention. Participants continuing with VR during their dressing change will have the procedure and measures above repeated at each subsequent dressing change, and results recorded. Consequently, this trial will continue to measure standard dressing change pain and anxiety over time to see if there is a continued benefit to using VR compared to standard care. The state adult burns service has an average of 4.8 dressings recorded per inpatient admission, giving this project the ability to see if VR’s analgesic effects persist across up to 4 dressings (not including first). Due to researcher availability, there will most likely be some patients in both control and VR groups who will undergo dressing changes on weekends, and that their data will not be able to be collected at this time. We acknowledge the limitation this imposes and will inform patients at the first consent that this may occur. At each patient's routine six-week post discharge consultant clinic appointment they will be provided a debrief pack informing them that they were part of a wider trial, with intervention and control groups.