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. 2026 Mar 16;13(3):e70465. doi: 10.1002/nop2.70465

Effectiveness of Virtual Reality Intervention on Anxiety and Vital Signs of Patients Before Colonoscopy: A Randomised Controlled Study

Seda Cansu Yeniğün Akbulut 1,✉, Hatice Merve Alptekin 2, Seher Ünver 3
PMCID: PMC13097404  PMID: 41840460

ABSTRACT

Aims

Patients undergoing colonoscopy often experience anxiety related to bowel preparation, procedural pain, and fear of cancer, which can adversely affect their vital signs. This study aimed to evaluate the effect of virtual reality intervention on anxiety and cardiac vital signs (including systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate) of patients before the colonoscopy procedure.

Design

This study was designed as a randomised, controlled, and double‐blind trial.

Methods

The sample of this study consisted of 70 patients undergoing colonoscopy in the endoscopy unit of the general surgery service of a public hospital. Patients were randomly assigned to the groups (intervention group or control group) and were evaluated twice before the colonoscopy procedure. Patients in the intervention group watched a relaxing video via virtual reality glasses for 15 min between the first and second evaluation stages. The Visual Analog Scale for Anxiety was used to evaluate the patients' anxiety levels before colonoscopy, while cardiac vital signs were evaluated using a digital sphygmomanometer.

Results

In the intervention group, anxiety level of the patients significantly decreased during the second evaluation stage compared to the control group (p < 0.001). Additionally, systolic blood pressure, diastolic blood pressure, and mean arterial pressure scores showed significant reductions in the intervention group at the same stage (p < 0.05). Although patients in the intervention group had lower heart rate scores at the second evaluation stage, there was no statistically significant difference between groups (p > 0.05).

Conclusion

Virtual reality intervention has an improving effect on patients' systolic blood pressure, diastolic blood pressure, and mean arterial pressure. It is also effective in reducing patients' anxiety levels. Virtual reality intervention can be used as a distraction method before colonoscopy procedure.

Patient or Public Contribution

In this study, patients actively participated in the process of evaluating their anxiety levels and vital signs.

Trial Registration

ClinicalTrials.gov identifier: NCT06407531

Keywords: anxiety, cardiac vital signs, colonoscopy, surgical nursing, virtual reality

1. Introduction

Colorectal cancer (CRC) is the third most common cancer worldwide, accounting for approximately 10% of all cancer cases, and is the second leading cause of cancer‐related deaths worldwide (WHO 2023). The American Cancer Society recommends people at average risk of CRC to start regular screening at age 45 (American Cancer Society 2024). The aim of the screening programs is to detect polyps before they turn into cancer and show symptoms. One of these screening programs is the colonoscopy procedure (Jayasinghe et al. 2023; Tonini and Zanni 2024). Colonoscopy is often perceived as an embarrassing and uncomfortable procedure by patients. Reports indicate that anxiety levels among patients before the procedure tend to range from moderate to high (Yang et al. 2018). The sources of this anxiety are attributed to several factors, including the bowel preparation process, the anticipated pain of the procedure, potential negative outcomes such as the fear of a cancer diagnosis, and the unfamiliarity with the hospital environment (Boustani et al. 2017; Peng et al. 2024).

2. Background

Anxiety is a condition in which an individual experiences intense worry, apprehension, and unease by perceiving future situations as threatening (Knowles and Olatunji 2020). In clinical settings, anxiety is generally considered as state anxiety, which reflects a temporary emotional response to a specific situation and can be measured using standard assessment tools (Boustani et al. 2017; Quevedo‐Bayona et al. 2025). As state anxiety refers to the anxiety felt at the moment, also known as personal anxiety, it primarily arises due to fear, the environment, and external stimuli (Boustani et al. 2017). Prior to the colonoscopy procedure, patients are held in the waiting room until their turn. This waiting period induces significant anxiety in patients, as they anticipate the procedure's completion to alleviate their uncertainty (Rosvall et al. 2021). Additionally, it has been determined that the extended waiting time for patients awaiting their turn for endoscopy (including colonoscopy) also increases their anxiety (Çelik et al. 2022). The anxiety felt by patients can trigger the stress response and stimulate the secretion of epinephrine‐norepinephrine. Activation of the neuroendocrine response to stress leads to increased catecholamine release, resulting in adverse physiological changes such as palpitations, sweating, and increased blood pressure and heart rate (Küçükakça Çelik et al. 2022; Ugras et al. 2023; Khalil et al. 2024). Consequently, increased anxiety before colonoscopy can cause measurable changes in cardiac vital signs such as heart rate and blood pressure.

Reducing patients' fears and anxiety contributes positively to the overall success of colonoscopy procedures (Boustani et al. 2017; Veldhuijzen et al. 2020). Numerous non‐pharmacological interventions are applied to reduce patients' stress and eliminate their negative emotions (Çelik et al. 2022; El‐Hassan et al. 2009; Ugras et al. 2023). In recent years, virtual reality (VR) has emerged as a distraction‐based non‐pharmacological intervention (Aydın Özkan and Akıncı 2024; Veldhuijzen et al. 2020). It is easily accessible, economical, and simple to use via VR‐glasses (VR‐G) (Cakir and Evirgen 2023). In their randomised controlled study, Yılmaz and Dinçer observed that VR intervention during colonoscopy resulted in reducing the anxiety levels among patients. Furthermore, the intervention group had notably lower pain, anxiety, systolic blood pressure (SBP), and higher peripheral oxygen saturation compared to the control group (Yılmaz and Dinçer 2023). Despite numerous studies on VR intervention during colonoscopy (Aydın Özkan and Akıncı 2024; Cakir and Evirgen 2023; Çakır and Evirgen 2021; Veldhuijzen et al. 2020), there is a lack of research evaluating VR intervention for patients before the colonoscopy procedure. This study is guided by a conceptual framework based on the stress–response model. Acute stress is generally short‐term stress resulting from immediate stressors or challenging situations. It triggers temporary physiological changes in the body, such as the fight‐or‐flight response, increased heart rate, and adrenaline release (Chu et al. 2024). Colonoscopy also increases situational anxiety, activating the sympathetic nervous system and leading to changes in cardiac vital signs, including heart rate and blood pressure (Çelik et al. 2022). Virtual reality has been conceptualised as a distraction‐based intervention that reduces anxiety by shifting attention away from stressful stimuli (Yılmaz and Dinçer 2023). A reduction in anxiety is expected to attenuate sympathetic activation, resulting in more stable cardiac vital signs prior to the procedure.

Therefore, this study aimed to evaluate the effect of VR intervention on the patients' anxiety and cardiac vital signs [including SBP, diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate] before colonoscopy procedure. To achieve these aims, the following hypotheses were evaluated.

2.1. Research Hypotheses

The anxiety level of the patients who watched a relaxing video through VR‐G is lower than the patients who did not.

The SBP scores of the patients who watched a relaxing video through VR‐G is lower than the patients who did not.

The DBP scores of the patients who watched a relaxing video through VR‐G is lower than the patients who did not.

The MAP scores of the patients who watched a relaxing video through VR‐G is lower than the patients who did not.

The heart rate scores of the patients who watched a relaxing video through VR‐G is lower than the patients who did not.

3. Methods

3.1. Study Design and Setting

A double‐blind randomised controlled study design was used in this study. In a double‐blind study, neither the participants nor the investigators responsible for monitoring participants, collecting data, and assessing outcomes are aware of the intervention assignment, a design feature that minimises bias and allows a more accurate evaluation of the treatment effect (Friedman et al. 2015). All phases of the study were conducted according to the Consolidated Standards for Reporting Trials (CONSORT) guidelines (Boutron et al. 2017) and the protocol of this study was recorded in the ClinicalTrials.gov Protocol Registration and Results System. Quantitative methodology was chosen because the purpose of this study was to measure the effect of a defined intervention on specific physiological and psychological outcomes using objective, numerical data. Quantitative approaches are particularly suitable when researchers aim to test hypotheses, examine causal relationships, and generate measurable, generalisable findings (Cathala and Moorley 2018).

This study was conducted with patients undergoing colonoscopy at the endoscopy unit of the general surgery service of a public hospital in the Mediterranean Region of Türkiye. It includes six beds, and approximately 250 colonoscopy procedures were performed during the year 2023. This endoscopy unit comprises 2 rooms. The first is a waiting/recovery room, where patients wait before the colonoscopy and rest after the colonoscopy procedure. The second is the endoscopy room, where the colonoscopy procedure is performed. On the day of the colonoscopy, patients are initially admitted to the waiting/recovery room of the endoscopy unit, where curtains are used to separate the beds.

3.2. Sample and Participants

The study sample consisted of 70 patients who were scheduled to undergo colonoscopy in the endoscopy unit between 25 November 2023 and 29 May 2024. The G*Power (version 3.1.9.6, Kiel University, Kiel, Germany) program was used to calculate the appropriate sample size for this study. The means and standard deviations in the study of Guerrier et al. were used, and the results obtained from the power analysis indicated that each group should comprise at least 30 patients (Guerrier et al. 2021). A total sample size of 60 patients was required to detect the large effects (d = 0.772) with a power of 95% by using a t‐test between means with α at 0.05. Anticipating a possible sample loss, the sample size was increased by 15%. Therefore, 35 patients were included in each group, and the total number of patients enrolled in the study was 70.

The inclusion criteria of this study were: (1) being volunteered to participate in the study, (2) undergoing colonoscopy procedure, (3) undergoing colonoscopy procedure for the first time, and (4) not having any disability to use VR‐G (such as having migraine, vertigo or epilepsy). Patients who had visual or hearing impairments, using analgesic or anxiolytics, and undergoing emergency colonoscopy were excluded from the study.

3.3. Sampling and Recruitment

In this study, a simple random sampling was used to ensure that all eligible patients had an equal probability of being selected for participation. Probability‐based sampling methods reduce the risk of selection bias and contribute to the representativeness and internal validity of the study sample (Shorten and Moorley 2014). The sampling frame consisted of all patients scheduled for colonoscopy in the endoscopy unit during the data collection period who met the inclusion criteria.

Eligible patients were identified daily from the endoscopy unit's appointment list and invited to participate in the study if they met the predefined inclusion criteria. After providing patients with verbal and written information about the study, they were given the opportunity to ask questions and were informed that participation in the study was entirely voluntary. Patients were also informed that they could withdraw from the study at any time up to the second evaluation phase without providing any reason and without affecting their clinical care processes. Participant recruitment continued until the required sample size of 70 was reached.

3.4. Randomisation and Blinding

To enhance the rigour of this study's double‐blind randomised controlled design, additional procedures were implemented to ensure allocation concealment and prevent bias throughout all stages of the study. Although participants were informed that two different care approaches were being compared, they were not provided with any information about which group (VR intervention or control) they had been assigned to. To minimise intervention leakage, all patients were assessed in physically separated areas based on their beds in the waiting/recovery room, and the intervention and control groups were approached at different times. The data collection process was conducted by a nurse researcher with seven years of surgical nursing experience; this researcher assessed patients' anxiety levels and cardiac vital signs but had no knowledge of group assignments. On the other hand, the VR intervention was administered by an independent assistant researcher specialising in VR‐G use; this researcher was not involved in the data collection and outcome assessment phases. Participants were assigned to the intervention or control group in a 1:1 ratio according to the randomisation list generated using www.randomization.org. An independent biostatistician who was not involved in the sample selection, intervention implementation, or data evaluation processes created and safely stored the randomisation sequence to guarantee assignment concealment. Assignment files with sequential numbers were created, and no researcher involved in patient evaluation had access to group codes. A blinded co‐investigator recorded all outcome measurements, and an independent statistician examined the data coded as Group A and Group B to perform statistical analyses. Until the primary analyses were finished, group identities were kept a secret. By keeping participants and outcome assessors in the dark about the intervention assignment, these procedures reduced performance and assessment bias and strengthened the double‐blind RCT design's methodological rigour. The flow chart of the study procedure is shown in Figure 1.

FIGURE 1.

FIGURE 1

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CONSORT flowchart of participant recruitment.

3.5. Data Collection Forms

The data of this research were collected using the “Descriptive Characteristics Form”, the “Visual Analog Scale‐Anxiety (VAS‐A)”, and the “Cardiac Vital Signs Form”.

3.5.1. Descriptive Characteristics Form

This form was created by the researchers in line with the literature (Grilo Bensusan et al. 2016; Kim et al. 2023; Ugras et al. 2023), and included 7 questions on descriptive characteristics of the patients (age, gender, educational level, hospitalisation history, surgery history, chronic disease history, and being informed about colonoscopy).

3.5.2. Visual Analog Scale‐Anxiety (VAS‐A)

In the study, the single item VAS‐A was used to determine the anxiety levels of the patients before colonoscopy. It was developed by Cline et al. in 1992 and determined by Davey et al. (2007) to be usable in the assessment of anxiety (Cline et al. 1992; Davey et al. 2007). The scale consists of a 10 cm long horizontal line with the left side indicating that there is no anxiety, and the right side indicating increasing levels of anxiety.

3.5.3. Cardiac Vital Signs Form

This form was created by the researchers to record cardiac vital signs (including SBP, DBP, MAP, and heart rate) of the patients before the colonoscopy procedure. These parameters, including anxiety and cardiac vital signs, were chosen for measurement because they have been standardised across clinical study settings and are directly related to the physiological outcomes being investigated. Oxygen saturation or sweating were not chosen for two reasons: first, the study hypothesis was focused on autonomic cardiovascular responses, not respiratory; second, because sweating is a subjective measurement and is difficult to assess for standardisation among clinical research settings.

3.6. Study Procedures

The data of the study were collected in two evaluation stages.

3.6.1. First Evaluation Stage (E1)

The patients who came to the endoscopy unit at 08:00 on the morning of the day of colonoscopy were visited at the bedside in the waiting/recovery room by the nurse researcher. Before any data collection began, all eligible patients received both verbal and written information about the purpose, procedures, potential risks, and voluntary nature of the study. Each participant was given an information sheet to keep, which included details about their rights, including the right to withdraw from the study at any time without providing a reason and without affecting the care they would receive. Participants were informed that they could withdraw at any point until the beginning of the colonoscopy procedure, as all data collection occurred prior to the intervention.

After verbal and written informed consent forms were obtained from the patients who volunteered to participate in the study, the descriptive characteristics form was filled out by the nurse researcher. Then, the nurse researcher evaluated the cardiac vital signs of the patients with a digital sphygmomanometer (OMRON M3w) and the results on the monitor were recorded on the cardiac vital signs form by the independent assistant researcher. In addition, the patients were asked to mark their current anxiety levels on the line by the nurse researcher, and the VAS‐A score was recorded by the independent assistant researcher. This process took approximately 10 min for each patient groups. The researchers then left the waiting/recovery room saying that they would be visited again before the turn is on to pass into the endoscopy room.

3.6.2. Second Evaluation Stage (E2)

3.6.2.1. Intervention Group

After the completion of the first evaluation stage, researchers returned to the waiting/recovery room. The independent assistant researcher informed patients about the VR‐G intervention procedure that includes watching a relaxing video for 15 min. To eliminate the factors preventing the patient from focusing on the video, the patient's relatives were asked to leave the room, and entry and exit to the room were restricted. The patients were asked to extend their feet on the bed and the patient's bed was placed in the semi‐fowler (30°–45°) position. Following this, the VR‐G device was customised to fit the patient's head structure by using its adjustable feature and was carefully positioned to prevent any pressure on the ears. Then patients were asked to focus only on the video. In case of any complication (headache, dizziness, nausea, vomiting, etc.), the nurse researcher waited in the room and recorded the start and end time of video viewing. After the VR‐G intervention was completed, the glasses were taken from the patients and they were informed that they were going to be visited by the endoscopy unit nurse for the colonoscopy procedure. Following this, their anxiety level and cardiac vital signs were evaluated by the nurse researcher and recorded by the independent assistant researcher. This process took approximately 20 min for each patient.

The VR‐G intervention utilised a video called “360° VR Forest Walk—8K Virtual Relaxation with Soothing Forest Sounds & Bird Song”. Through this video, patients experienced walking in a forest accompanied by bird sounds. All patients watched the same video, and the VR‐G group patients had an average video‐watching duration of 14.36 min during the intervention.

3.6.2.2. Control Group

After the completion of the first evaluation stage, the researchers returned to the waiting/recovery room and informed the patients that they were going to be visited by the endoscopy unit nurse for the colonoscopy procedure, without any intervention. Following this, the nurse researcher evaluated patients' anxiety level and cardiac vital signs 5–10 min before the colonoscopy procedure, and the independent assistant researcher recorded them on the cardiac vital signs form. This process took approximately 5 min for each patient. The researchers then left the waiting/recovery room.

3.7. Data Analysis

The statistical analyses were conducted using the SPSS software version 21.0 (IBM, Armonk, NY, USA) by an independent statistician to maintain the double‐blinded study protocol. Descriptive data were reported as median with minimum and maximum values, mean with standard deviations, and frequencies as percentages. The Shapiro–Wilk W test was used to analyse the normal distribution of the data, including age, VAS‐A, SBP, DBP, MAP, and heart rate. Non‐parametric tests were used to evaluate the study hypothesis when the data deviated from normally distribution. Descriptive characteristics of patients in the groups were assessed using the Mann–Whitney U test and Fisher's exact test to determine homogeneity. Additionally, the independent samples t‐test and the Mann–Whitney U test were used to compare mean anxiety and cardiac vital sign scores between groups. Within the first and second evaluation stages, the Wilcoxon test and paired samples test were used to compare anxiety and cardiac vital sign scores. The Spearman's correlation test was used to determine the relationship between VAS‐A and cardiac vital sign scores. For all tests, p < 0.05 was considered as the significance level. A post hoc power analysis was conducted using the G*Power 3.1.9.7 program (Kiel, Germany) with an error level of α = 0.05, an effect size of d = 1.33, df = 64.84, and a sample size of 35 for each group; the statistical power was calculated as 0.999.

3.8. Ethics Statement

The ethical permission for this study was obtained from the İstanbul University‐Cerrahpaşa Non‐Interventional Clinical Research Ethics Committee (number: 2023/100, date: 07.06.2023) and permission to conduct this study was obtained from Akdeniz Provincial Directorate of Health (number: E‐98360293‐604.01.02‐229686518, date: 20.11.2023). All study procedures were performed by the ethical standards of the Helsinki Declaration and verbal and written consent of the patients included in the study was obtained by informing them about the study. The video is available and accessible to everyone on the YouTube platform, so permission was not obtained for the video (Youtube 2024).

3.9. Rigour of the Study

The methodological rigour of this randomised controlled trial was ensured through the CONSORT guidelines and various strategies recommended in the clinical trial methodology literature. Credibility (internal validity) was enhanced by using a double‐blind design, which minimised performance and assessment bias by preventing participants and outcome assessors from knowing the group assignments. The application of standardised data collection protocols and the use of validated measurement tools, such as the Visual Analog Scale for Anxiety (VAS‐A) for assessing anxiety levels and digital measurement devices for recording cardiac vital signs, strengthened the accuracy and precision of the measurements.

Trustworthiness was ensured by having the intervention implementation, data collection, and statistical analysis processes conducted independently by separate researchers. Assignment confidentiality was maintained using a computer‐generated randomisation list and confidential assignment methods; this approach reduced selection bias by preventing prior knowledge of group assignments.

Dependability (methodological consistency) was supported by detailed documentation of all work procedures, strict adherence to the intervention protocol, and compliance with CONSORT reporting standards throughout all stages of the study. The intervention was applied identically to all participants in the experimental group; outcome assessments were conducted according to a standard sequence at predetermined time points.

Confirmability was ensured by coding the study groups as Group A and Group B during the statistical analysis process and by preventing the independent statistician from accessing group identities until the primary analyses were completed. This approach minimised researcher bias and strengthened the objectivity of the analytical process. Taken together, these strategies strengthened the methodological robustness and scientific integrity of the study, ensuring that the findings were reliable, reproducible, and consistent with international standards for randomised controlled trials.

4. Results

4.1. Descriptive Characteristics

It was determined that the descriptive characteristics of the patients in both groups were comparable, except for the mean age in the statistical comparison (p > 0.05). The median age of the patients in the control group was statistically significantly higher than that in the intervention group (p < 0.001) (Table 1).

TABLE 1.

The descriptive characteristics of the patients according to the groups (n = 70).

Variables Intervention (n = 35) Control (n = 35) Total (n = 70) Statistics, p value
Median [min–max] Median [min–max] Median [min–max]
Age (years) 51.05 61.11 56.08

U = 314.500

Z = −3.504

p < 0.001*

[31–75] [31–78] [31–78]
n % n % n % Test/p values
Gender
Female 18 51.4 17 48.6 35 50 p = 1.000 ‡
Male 17 48.6 18 51.4 35 50
Education level
Primary/secondary school 16 45.7 23 65.7 39 55.7 p = 0.148 ‡
High school/university 19 54.3 12 34.3 31 44.3
Hospitalisation history
Yes 20 57.1 24 68.6 44 62.9 p = 0.458 ‡
No 15 42.9 11 31.4 26 37.1
Surgery history
Yes 7 20.0 11 31.4 18 25.7 p = 0.413 ‡
No 28 80.0 24 68.6 52 74.3
Chronic disease history
Yes 16 45.7 17 48.6 33 47.1 p = 1.000 ‡
No 19 54.3 18 51.4 37 52.9
Being informed about colonoscopy
Yes 31 88.6 30 85.7 61 87.1 p = 1.000 ‡
No 4 11.4 5 14.3 9 12.9
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Note: *p < 0.05; U: Mann–Whitney U test.

‡

Fisher's exact test.

4.2. Anxiety

In the intervention group, the median VAS‐A score of the patients was 4.0 (min‐max: 1–8) at the first evaluation stage, and significantly decreased to 1.0 (min–max: 0–5) at the second evaluation stage (Z = −4.952, p < 0.001). In the control group, the median anxiety level of the patients was 4.0 (min–max: 1–9) at the first evaluation stage and remained unchanged at the second evaluation stage (Z = −0.289, p = 0.772). Additionally, the median VAS‐A score of the intervention group at the second evaluation stage was significantly lower than that in the control group (U = 220.000, p < 0.001) (Table 2).

TABLE 2.

The VAS‐A levels and cardiac vital sign scores of the patients among evaluation stages.

Variables Groups Evaluation stages Within groups statistics, p value
E1 E2
Median [min–max]/Mean [±SD] Median [min–max]/Mean [±SD]
VAS‐A

Intervention

Control

 4.0 [1–8] 1.0 [0–5] Z = −4.952, p < 0.001*
4.0 [1–9] 4.0 [1–9] Z = −0.289, p = 0.772
Between groups Statistics, p value

U = 520.000

Z = −1.098, p = 0.272

U = 220.000

Z = −4.696, p < 0.001*

SBP

Intervention

Control

 136.6 [±10.65] 128.25 [±9.17] t = 7.296, p < 0.001*, ,†
130.14 [±10.34] 134.02 [±9.36] t = −3.271, p = 0.002*, ,†
Between groups Statistics, p value t = 2.572 t = −2.604
df = 68, p = 0.012* df = 68, p = 0.011*
DBP

Intervention

Control

 84.0 [70–92] 75.0 [70–96] Z = −4.257, p < 0.001*
77.0 [67–92] 82.0 [68–95] Z = −2.658, p = 0.008*
Between groups Statistics, p value U = 386.000 U = 370.500
Z = −2.672, p = 0.008* Z = −2.858, p = 0.004*
MAP

Intervention

Control

 100.56 [±6.71] 93.97 [±6.30] t = 7.428, p < 0.001*, ,†
95.47 [±7.70] 98.79 [±6.88] t = −3.216, p = 0.003*, ,†
Between groups Statistics, p value t = 2.944 t = −3.055
df = 68, p = 0.004* df = 68, p = 0.003*
Heart rate

Intervention

Control

 80.8 [±7.69] 75.45 [±6.34] t = 5.986, p < 0.001*, ,†
76.0 [±9.54] 77.97 [±9.64] t = −3.973, p < 0.001*, ,†
Between groups Statistics, p value t = 2.316 t = −1.288
df = 68, p = 0.024* df = 68, p = 0.203
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Abbreviations: DBP, diastolic blood pressure; E1, first evaluation stage; E2, second evaluation stage; MAP, mean arterial pressure; SBP, systolic blood pressure; VAS‐A, visual analog scale‐anxiety.

*

p < 0.05; Z: Wilcoxon test; U: Mann–Whitney U test; t: Independent samples t‐test.

†

Paired samples test.

4.3. Cardiac Vital Signs

In the intervention group, the all cardiac vital sign scores (SBP, DBP, MAP, heart rate, respectively) of the patients were significantly decreased at the second evaluation stage (t = 7.296, p < 0.001; Z = −4.257, p < 0.001; t = 7.428, p < 0.001; t = 5.986, p < 0.001, respectively). Conversely, in the control group, all the cardiac vital sign scores of the patients were significantly increased at the second evaluation stage (t = −3.271, p = 0.002; Z = −2.658, p = 0.008; t = −3.216, p = 0.003; t = −3.973, p < 0.001, respectively) (Table 2).

Among the cardiac vital sign scores, except heart rate, all other second evaluation scores (SBP, DBP, MAP, respectively) for the intervention group were significantly lower than the control group (t = −2.604, p = 0.011; U = 370.500, p = 0.004; t = −3.055, p = 0.003, respectively) (Table 2). Although patients in the intervention group had lower heart rate scores at the second evaluation stage, there was no statistically significant difference between groups (t = −1.288, p = 0.203) (Table 2).

There was no correlation between the anxiety and cardiac vital sign scores of the intervention group patients at the first and second evaluation stages (p > 0.05). There was a positive and moderate correlation between the anxiety and blood pressure scores (including SBP, DBP and MAP) of the control group patients at the first and second evaluation stages (p < 0.05) (Table 3).

TABLE 3.

Correlation between VAS‐A, cardiac vital sign scores, and age.

Variables E1—VAS‐A E2—VAS‐A
Intervention Control Intervention Control
SBP r s 0.289 0.425 0.089 0.463
p 0.092 0.011* 0.612 0.005**
DBP r s 0.179 0.446 0.221 0.348
p 0.304 0.007** 0.201 0.041*
MAP r s 0.240 0.451 0.155 0.416
p 0.164 0.007** 0.374 0.013*
Heart rate r s −0.053 0.102 −0.031 0.171
p 0.764 0.559 0.860 0.326
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Abbreviations: DBP, diastolic blood pressure; E1, first evaluation stage; E2, second evaluation stage; MAP, mean arterial pressure; SBP, systolic blood pressure; VAS‐A, visual analog scale‐anxiety.

*

Correlation is significant at the 0.01 level (2‐tailed).

**

Correlation is significant at the 0.05 level (2‐tailed).

5. Discussion

This study represents the first investigation into the effects of VR intervention on anxiety and cardiac vital signs in patients before colonoscopy. Consequently, the results of this study were compared with the results from the studies on VR intervention effects in various patient groups concerning anxiety and cardiac vital signs. Existing literature reports that patients who are scheduled for colonoscopy experience a higher rate of anxiety on the day of colonoscopy than on previous days and that this may adversely impact colonoscopy tolerability, comfort, and procedural success (Arabul et al. 2012; Bytzer and Lindeberg 2007; Yang et al. 2018). Therefore, effective anxiety management is crucial before colonoscopy procedure (Grilo Bensusan et al. 2016; Ugras et al. 2023).

Virtual reality, a non‐pharmacological method in anxiety management and distraction, facilitates computer‐human interaction and simulation within a virtual system, fostering a sense of reality and providing communication between users and the virtual environment (Chiu et al. 2023; Kim et al. 2017). In the present study, although VAS‐A scores were initially higher in the intervention group, they decreased during the second evaluation stage, whereas anxiety levels in the control group remained unchanged. The first hypothesis of this study was confirmed in light of this finding. Similarly, Kim et al. investigated the effect of VR intervention on anxiety in patients before endoscopy and reported that it is effective in reducing anxiety levels (Kim et al. 2023). In their randomised controlled study, Keshvari et al. found that VR intervention before coronary angiography led to a significant decrease in VAS‐A scores during the second evaluation stage, while anxiety levels increased in the control group during the same stage. In the literature, some studies investigated the effects of VR intervention on the preoperative anxiety of patients (Keshvari et al. 2021). A study conducted by Ganry et al. investigated the effect of a VR intervention on anxiety in adult patients undergoing ambulatory skin cancer surgery and found that nature videos watched before surgery significantly reduced anxiety levels in the intervention group (Ganry et al. 2018). Despite the limitations of studies conducted on patients before the colonoscopy procedures, these findings emphasise the significance of adopting VR‐G interventions to reduce patients' anxiety prior to colonoscopy. Therefore, showing relaxing videos to patients through VR‐G in the endoscopy unit waiting room can be a beneficial non‐pharmacological intervention for patients' psychological readiness.

Interventional anxiety is known to activate the sympathetic nervous system, resulting in vasoconstriction in blood vessels and undesirable physiological responses including elevated blood pressure and heart rate (Ozhanli and Akyuz 2022; Ugras et al. 2023). In the present study, the intervention group experienced higher blood pressure (SBP, DBP, MAP) scores at the first evaluation stage, and these parameters decreased during the second evaluation stage, confirming the study's second to fourth hypotheses. Consistent with this finding, a VR intervention was employed on patients prior to open‐heart surgery, resulting in a decrease in SBP and DBP scores in the intervention group during both the first and second evaluations (Amiri et al. 2023). In another randomised controlled study, the impact of a VR intervention on patients scheduled for colorectal and abdominal wall surgery was evaluated. The results indicated that patients in the intervention group experienced a decrease in SBP and DBP scores while those in the control group experienced an increase (Ugras et al. 2023).

In this study, although the heart rate scores of patients significantly decreased at the second stage of evaluation, no significant difference between groups was observed; thus, the fifth hypothesis of the study was not confirmed. In contrast, studies by Amiri et al. and Altun Uğraş et al. reported that the use of VR intervention is associated with reduced heart rates during colonoscopy procedures (Amiri et al. 2023; Ugras et al. 2023). This discrepancy may be explained by the activation of the sympathetic nervous system in response to the surgical or procedural stress experienced by patients. Similarly, Keshvari et al. found that VR intervention before coronary angiography positively impacts heart rate, which may be attributed to differences in the patient populations studied (Keshvari et al. 2021). This suggests that the application of VR intervention prior to angiography might be more effective in influencing heart rate outcomes. While the effectiveness of VR intervention on heart rate reduction varies across different clinical scenarios, it can contribute to the management of anxiety and stabilisation of cardiac vital signs in patients before procedures like colonoscopy.

5.1. Strengths and Limitations

One of the strengths of this study is that it is the first to evaluate the effect of VR intervention on patients' anxiety levels and cardiac vital signs before colonoscopy. Moreover, these findings are expected to enhance existing literature and raise awareness about this issue. Secondly, a double‐blinded study design was utilised in this study. Anxiety levels and cardiac vital sign scores were recorded by an independent assistant researcher, while data analysis was conducted by an independent statistician. These measures helped minimise potential biases and enhance the objectivity of the study's findings.

This study has some limitations to be considered. Firstly, the study sample is limited to patients scheduled for a colonoscopy procedure, potentially limiting the generalisation for the whole entire colonoscopy procedure. Additionally, the anxiety scale evaluates the anxiety levels of the patients subjectively. In future studies, it is recommended to use objective measurement methods such as cortisol levels.

5.2. Clinical Impacts

The findings of this study offer a practical perspective on the use of non‐pharmacological strategies for before surgery anxiety management within surgical nursing practice. The VR‐based relaxation intervention appeared to reduce anxiety levels and improve selected cardiovascular parameters in patients awaiting colonoscopy.

These results suggest that nurses may consider VR as a supportive distraction technique to enhance patients' psychological comfort and psychological stability during the before pre‐procedural period, indicating its potential as a feasible adjunctive option for improving the overall pre‐procedural period experience in clinical settings.

6. Conclusions

The results of the present study showed that watching a relaxing video via VR‐G has a positive impact on patients' SBP, DBP, and MAP scores. Additionally, it effectively reduces anxiety levels of patients waiting to undergo a colonoscopy procedure. Consequently, it is recommended to use VR interventions as a distraction technique to manage anxiety and improve cardiac parameters prior to colonoscopy procedures. It is recommended that future research examine the effectiveness of VR‐G intervention in different age and patient groups, with different types of content, evaluate its long‐term effects, and compare it with other distraction methods.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

We would like to thank patients who supported us during the conduct of this study. We also thank Musa Akbulut for his technical support and for being an independent assistant researcher during the VR‐G intervention guidance.

Contributor Information

Seda Cansu Yeniğün Akbulut, Email: scyenigun@akdeniz.edu.tr.

Hatice Merve Alptekin, Email: merve.alptekin@kocaeli.edu.tr.

Seher Ünver, Email: seherunver@trakya.edu.tr.

Data Availability Statement

The datasets used to support the findings of this study are available from the corresponding author on reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used to support the findings of this study are available from the corresponding author on reasonable request.

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