In the Week 7 Learning Resources, on page 3, you will sample sets of papers for WRTG 391 from previous students. These sets of papers are grouped into topic areas, with three (3) papers in each set. Please download one set of three papers. Peruse the Six-Source Essay and Multi-Source Essay/Literature Review papers in the set. Then answer the following questions:

1. Did the student expand his or her topic from the Six-Source essay to the Multi-Source essay? Or did the student narrow his or her topic from the Six-Source Essay to the Multi-Source Essay/Literature Review?
2. Compare the Six Source Essay to the Multi-Source Essay. What challenges do you think the student encountered as he or she proceeded from the initial essay to the final paper?
3. In the literature review, did the student cite more than one source in each category? Comment on one of the categories and describe how the student synthesized the sources.

Assignment: Annotated Bibliography :

Annotated Bibliography Baos, R. M., Espinoza, M., Garca-Palacios, A., Cervera, J. M., Esquerdo, G., Barrajn, E., & Botella, C. (2012). A positive psychological intervention using virtual reality for patients with advanced cancer in a hospital setting: A pilot study to assess feasibility. Supportive Care in Cancer, 21(1), 263-270. https://doi.org/10.1007/s00520-012-1520-x The focus of this study is to present data on the benefits of virtual reality use to induce positive emotions in the setting of hospitalization for adult oncology patients. Researchers took a sampling of 19 patients of mixed ages and followed them through four 30-minute appointments while they wore virtual reality devices to see if joy and relaxation were induced. Mood and pain satisfaction were assessed before and after each session. The study confirmed that there were increases in levels of pleasantness and benefits of distraction, entertainment, promotion of relaxation, and a decrease in negative emotions. The study concludes that virtual reality use had a positive experience on patients. It notes also that future studies need to be done and take into account patients' medical states and physical discomfort level when disease is at an advanced state. Chow, H., Hon, J., Chua, W., & Chuan, A. (2020). Effect of virtual reality therapy in reducing pain and anxiety for cancer related medical procedures: A systematic narrative review. Journal of Pain and Symptom Management, 60(52), 309- 502. https://doi.org/10.1016/j.jpainsymman.2020.08.016 This research study reviews the use of virtual reality to treat pain and anxiety in oncological medical procedures and chemotherapy. This journal article gave a systematic review of nine studies that met the review criteria. A systematic review was performed on multiple sites, such as Ovid MEDLINE, PubMed and, Google Scholar 3 from years ranging from 1999 to December 2019. Researchers conducting the study used search terms such as oncology, pain, and anxiety to narrow down scholarly articles for review. In conclusion, based on all the studies reviewed, researchers were not able to identify conclusive evidence on the positive effects of virtual reality on reducing pain or anxiety in oncology patients undergoing procedures or chemotherapy. The authors conclude only two out of nine studies reached statistical significance and further research is required to prove that the use of virtual reality goggles provides escape from pain and anxiety during oncological medical procedures. Glennon, C., McElroy, S., Connelly, L., Mische Lawson, L., Bretches, A., Gard, A., & Newcomer, L. (2018). Use of virtual reality to distract from pain and anxiety. Oncology Nursing Forum, 45(4), 545-552. https://doi.org/10.1188/18.onf.545-552 The objective of this study is to analyze if there is a correlation between the use of virtual reality on the effects of pain and anxiety. The patient population studied were patients undergoing bone marrow aspiration and/or bone marrow biopsies. The researchers studied 97 patients receiving treatment at an outpatient cancer center in the midwestern United States. The study separated patients equally into control and experimental groups. The experimental group were the patients using the virtual reality glasses in the study, and the control group was compromised of the patients who did not receive virtual reality glasses during procedures. The study compared the two groups in a few main categories, such as, their demographic data, pain threshold, anxiety level, and total amount of medication used during the procedure. The research done in this article shows that the patients studied in this article did not experience a significant decrease in pain or anxiety during procedures, but it did decrease the frequency of pharmacological 4 interventions needed during the procedure. The researchers conclude that more research is necessary, but that the use of virtual reality goggles during this procedure may be an attainable, noninvasive alternative to the standard of care now. Tennant, M., Youssef, G. J., McGillivray, J. A., Clark, T., McMillan, L., & McCarthy, M. C. (2020). Exploring the use of immersive virtual reality to enhance psychological wellbeing in pediatric oncology: A pilot randomized controlled trial. European Journal of Oncology Nursing. https://doi.org/10.1016/j.ejon.2020.101804 The objective of this study is to research the use of virtual reality goggles in pediatric oncology patients and their effectiveness in procedures and daily cares. The study also further went on to study the effectiveness of the glasses, highlighting what made them more/less effective and compared them to other digital distractions such as iPads. The study followed 90 pediatric patients with their parents, separated the children into control groups, and gave them either virtual reality goggles or iPads as distractions for procedures or symptom distress. Researchers visually observed patients' pre-procedure and post-procedures as well as measured vitals for signs of excitability. Post-procedure, participants reported their emotions on enjoyment, sickness and level of distractedness. At the close of the study, it was found that virtual reality goggles did not significantly change the feelings after the procedures. What the study did find was that virtual reality goggles did outperform iPads, giving increased positive moods and reduction of negative symptoms. The outcome of the study proved that virtual reality goggles were indeed the superior intervention for reducing symptom distress and increasing patient well-being. Zeng, Y., Zhang, J., Cheng, A. S., Cheng, H., & Wefel, J. S. (2019). Meta-analysis of the efficacy of virtual reality-based interventions in cancer-related symptom 5 management. Integrative Cancer Therapies, 18, 1- 8. https://doi.org/10.1177/1534735419871108 This research article is a meta-analysis of multiple articles that examined the use of virtual reality interventions on symptom distress in oncology patients. Researchers used scholarly websites such as Medline, PubMed and Google Scholar to search the terms virtual reality, virtual environment, head mounted display, oncology and cancer. This combination of terms yielded 6 credible research studies. From the six research articles studied, the authors concluded that virtual reality-based interventions had a significant effect on reducing symptom distress in oncology patients. Researchers found that virtual reality therapy reduced anxiety, depression, pain, fatigue and cognitive function. The authors note that virtual reality-based therapies are helpful in acute cancer care but are also equally as important in long term symptom management. The researchers conclude that further research needs to be conducted to further explore the effectiveness of virtual reality therapy in cancer rehabilitation.

Six Source Essay:

Six Source Essay 2 Does Virtual Reality Therapy Alleviate Symptom Distress in Oncology Patients? Given all the ways we have to treat cancer today, why is the global survival rate for individuals with cancer is only 67% after five years (Zeng et al., 2019, p1)? There are many pharmacological interventions being used today to help treat cancer, such as chemotherapy, radiation, surgery, and bone marrow transplants, yet the five-year survival rates are not higher. The use of medicine is the preferred choice of treatment thus far; however, there are new alternatives to medicinal treatment, one being virtual reality therapy. New studies have shown that the use of virtual reality therapy has proven successful in relieving pain and anxiety during and after cancer treatments. The purpose of this paper is to synthesize research on the use of virtual reality therapy in relieving pain and anxiety in physically and psychologically impaired oncological patients and to show what sources reveal about the topic. This paper will consolidate the arguments from six different journal articles that compare the effectiveness and limitations of implementation of virtual reality therapy in treating acute symptom distress in oncological patients. Virtual reality therapy is a programmable, individual treatment, which allows the patient to control environmental stimuli to create an interactive distraction to their current environment. Banos et al., (2011) conducted a study of nineteen patients with metastatic cancer in measuring their mood, relaxation level, and distractedness during inpatient hospitalization while using virtual reality therapy. What the study found was significant increases in pleasantness, distraction from procedures, relaxation, and positive emotions. The study did conclude that while the outcomes were positive, therapy should be carried out in a timely manner, paying attention to stages of advanced disease. Zeng et al., (2019) conducted a meta-analysis study from multiple scholarly articles found on Medline, PubMed, and CAJ Database using search terms such as Six Source Essay 3 virtual environment, head mounted display, oncology, and cancer. Zeng et al., (2020) did not conduct their own study, but they analyzed multiple studies and summarized their findings from previously conducted research studies. Zeng et al., (2019) state that "the long-term side effects of cancer and cancer treatment may include a number of physical and psychological consequences, such as pain, fatigue, anxiety, depression, and cognitive dysfunction" (p. 1). After conducting their research analyzation, it was theorized that the use of virtual reality therapy improved cancer patients' physical, emotional, and cognitive well-being. Like Banos et al., (2011), Zeng et al., (2019) concluded that the use of virtual reality therapy improved the acute effects of treatment on the individual patient. Both articles mention the importance of furthering research into therapeutic use of virtual reality on the long-term side effects experienced by cancer survivors. Glennon et al., (2018) conducted a randomized study of 100 adult cancer patients scheduled to receive bone marrow biopsies/aspirations on the effectiveness of implementing virtual reality goggles to reduce symptom distress. Participants were able to watch multiple distractive scenes during the bone marrow biopsy procedure, including, undersea life, a rushing brook, or a swaying palm tree background. In the study, "participants who wore virtual reality goggles during the bone marrow aspiration and biopsy procedure did not experience a statistically significant decrease in pain and anxiety. However, participants in the experimental and control groups did report a decrease in pain and anxiety levels overall pre to post procedure" (Glennon et al., 2018, p549). It was concluded that the measurement of pain and anxiety would have yielded more accurate results if the research patients had the procedure done by the same medical staff (Glennon et al., 2018). The research of Glennon et al., (2018), found similar outcomes to the previous two studies from Banos et al., (2011), and Zeng et al., (2019). All three Six Source Essay 4 articles synthesized that patients can benefit from the use of virtual reality therapy during treatment. Pediatric patients have also been studied in the experimental research of virtual reality therapy. A study compromised of 90 pediatric patients, ranging in age from 7-18, was performed to analyze if virtual reality could replace physical activity and play in patients who could no longer participate in group activities (Tennant et al., 2020, p1). Through their research, Tennent et al., (2020) state that the use of virtual reality goggles "found increases in overall child emotional wellbeing that was indicated by improvements in scores across all subjective wellbeing measures (i.e., enhanced positive mood state; reduction in anxiety and anger; and lowered nausea and pain perception)" (p7). A limitation found in this study noted that improvements in comfort, weight of devices, and device resolution could hinder long term use, especially in pediatrics (Tennent et al., 2020, p7). Similar findings of increased emotional wellbeing were found in this study as well as the other studies reviewed previously. As the study conducted by Tennent et al., (2020) is one of the first pediatric studies to involve virtual reality therapy, further research is needed to determine the overall effectiveness of virtual reality therapy in pediatrics. Garrett et al., (2020) introduce the issue of chronic pain management in oncology patients. In this study, twenty-three participants were sent home with virtual reality devices and asked to use them as a tool for self-management of chronic cancer pain. The most common effect reported was that virtual reality was beneficial in their pain management. Garrett et al., (2020) noted "Overall, the effectiveness of these interventions compared to other adjunctive chronic pain therapies such as massage, acupuncture, mindfulness relaxation, music therapy, or even placebo therapeutics remains to be established and well-controlled large randomized clinical trials are Six Source Essay 5 necessary to establish the size of any analgesic effect of VR as an adjunctive tool in chronic pain management". Unlike conventional oncology treatment programs, virtual reality therapy allows patients an at home option to pain and anxiety treatment control without the use of medications. This study agrees with the findings of Tennent et al., (2020) on the point of further research being needed, especially in age groups not considered young adult. Tennent et al., (2020) researched pediatrics in a pilot study and it is found in Garrett et al., (2020) the same outcomes can be concluded in their research of long-term care across the age spectrum Cimpean (2019) conducted a research study in which a sampling of 20 adult patients diagnosed with cervical cancer were treated with virtual reality therapy. In the study, patients were separated into two equal groups, one participating in virtual reality therapy, the other participating in other forms of cognitive behavioral therapy conducted by psychotherapists. For the study, participants were asked to participate in four, 15-minute sessions of relaxation post procedure either through virtual reality imagery or personal reflection, relying on thoughts and memories. What Cimpean (2019) found was that, "when we conducted comparisons form pre-to post intervention, regardless of the group, we found significant differences on quality of life and pain intensity. It is well known that numerous investigations examining the utility of various psychological interventions (e.g., group support, individual psychotherapy, psychoeducation, relaxation training) were successful in treating psychological distress, manage pain, improve quality of life, and even extend survival in patients with cancer," (p. 122). The limitations noted by Cimpean (2019), including small sample sizes, degree of isolation, and doctor-patient relationships, were congruent to those found by Glennon et al., (2019). Cimpean (2019) concluded that virtual reality therapy "is considered a powerful distracter: it provides a high Six Source Essay 6 degree of immersion to the user and by directing the individual's attention away from the real world, and into the virtual environment, it may facilitate relaxation" (Cimpean, 2019, p. 117). This review has highlighted the advancement of virtual reality therapy on the treatment of symptom distress in oncological patients. All studies synthesized agreed that the implementation of virtual reality was beneficial in the treatment of alleviating symptom distress in oncological patients. When it comes to deciding if virtual reality therapy has the potential to combat symptom distress, all studies from the articles promote implementing some form of psychological therapy in addition to medication therapy to decrease the likelihood of symptom distress. Further research needs to be conducted to see how virtual reality can offer escapes from stress due to hospitalization and treatment, increase resilience, as well as curb onset of low mood, withdrawal, and depression (Tennent et al., 2020, p7). Virtual reality therapy will not replace conventional oncology treatment methods, but as an adjunctive therapy it offers increased beneficial outcomes over standard treatments alone. It is reasonable to conclude that virtual reality therapy can improve acute symptoms experienced by oncology patients during and after medical procedures.

Ten Source Essay:

Ten Source Essay 2 Does Virtual Reality Therapy Alleviate Symptom Distress in Oncology Patients? Given all the ways we have to treat cancer today, why is the global survival rate for individuals with cancer is only 67% after five years (Zeng et al., 2019, p1)? There are many pharmacological interventions being used today to help treat cancer, such as chemotherapy, radiation, surgery, and bone marrow transplants, yet the five-year survival rates are not higher. The use of medicine is the preferred choice of treatment thus far; however, there are new alternatives to medicinal treatment, one being virtual reality therapy. New studies have shown that the use of virtual reality therapy has proven successful in relieving pain and anxiety during and after cancer treatments. The purpose of this paper is to synthesize research on the use of virtual reality therapy in relieving pain and anxiety in physically and psychologically impaired oncological patients and to show what sources reveal about the topic. This paper will systematically consolidate the arguments from ten different journal articles that compare the effectiveness and limitations of implementation of virtual reality therapy in treating acute symptom distress in oncological patients. Virtual Reality Therapy Effects on Acute Symptom Distress Virtual reality therapy is a programmable, individual treatment, which allows the patient to control environmental stimuli to create an interactive distraction to their current environment. Banos et al., (2011) conducted a study of nineteen patients with metastatic cancer in measuring their mood, relaxation level, and distractedness during inpatient hospitalization while using virtual reality therapy. What the study found was significant increases in pleasantness, distraction from procedures, relaxation, and positive emotions. The study did conclude that while the outcomes were positive, therapy should be carried out in a timely manner, paying attention to stages of advanced disease. Zeng et al., (2019) conducted a meta-analysis study from multiple Ten Source Essay 3 scholarly articles found on Medline, PubMed, and CAJ Database using search terms such as virtual environment, head mounted display, oncology, and cancer. Zeng et al., (2020) did not conduct their own study, but they analyzed multiple studies and summarized their findings from previously conducted research studies. Zeng et al., (2019) state that "the long-term side effects of cancer and cancer treatment may include a number of physical and psychological consequences, such as pain, fatigue, anxiety, depression, and cognitive dysfunction" (p. 1). After conducting their research analyzation, it was theorized that the use of virtual reality therapy improved cancer patients' physical, emotional, and cognitive well-being. Like Banos et al., (2011), Zeng et al., (2019) concluded that the use of virtual reality therapy improved the acute effects of treatment on the individual patient. Both articles mention the importance of furthering research into therapeutic use of virtual reality on the long-term side effects experienced by cancer survivors. Glennon et al., (2018) conducted a randomized study of 100 adult cancer patients scheduled to receive bone marrow biopsies/aspirations on the effectiveness of implementing virtual reality goggles to reduce symptom distress. Participants were able to watch multiple distractive scenes during the bone marrow biopsy procedure, including, undersea life, a rushing brook, or a swaying palm tree background. In the study, "participants who wore virtual reality goggles during the bone marrow aspiration and biopsy procedure did not experience a statistically significant decrease in pain and anxiety. However, participants in the experimental and control groups did report a decrease in pain and anxiety levels overall pre to post procedure" (Glennon et al., 2018, p549). It was concluded that the measurement of pain and anxiety would have yielded more accurate results if the research patients had the procedure done by the same medical staff (Glennon et al., 2018). The research of Glennon et al., (2018), found similar outcomes to the previous two studies from Banos et al., (2011), and Zeng et al., (2019). All three Ten Source Essay 4 articles synthesized that patients can benefit from the use of virtual reality therapy during treatment. Virtual Reality Therapy and the Effects on Pediatric Patients with Symptom Distress Pediatric patients have also been studied in the experimental research of virtual reality therapy. A study compromised of 90 pediatric patients, ranging in age from 7-18, was performed to analyze if virtual reality could replace physical activity and play in patients who could no longer participate in group activities (Tennant et al., 2020, p1). Through their research, Tennent et al., (2020) state that the use of virtual reality goggles "found increases in overall child emotional wellbeing that was indicated by improvements in scores across all subjective wellbeing measures (i.e., enhanced positive mood state; reduction in anxiety and anger; and lowered nausea and pain perception)" (p7). A limitation found in this study noted that improvements in comfort, weight of devices, and device resolution could hinder long term use, especially in pediatrics (Tennent et al., 2020, p7). Similar findings of increased emotional wellbeing were found in this study as well as the other studies reviewed previously. As the study conducted by Tennent et al., (2020) is one of the first pediatric studies to involve virtual reality therapy, further research is needed to determine the overall effectiveness of virtual reality therapy in pediatrics. "Pain is one primary cancer symptom, being experienced by all cancer children, with more than 70% of them having severe pain," (Ferreira et al., 2015). Ferreira et al., (2015) conducted a meta-analysis of ten sources based on the claim that "Pain is one of the most persistent cancer symptoms. Non-pharmacological therapies are potential sources for cancer children care and should be considered alternatives for handling cancer signs and symptoms" (p.1). Ferreira et al., (2015) conducted a meta-analysis of ten articles, and synthesized research which addressed the Ten Source Essay 5 concept of distraction thru virtual reality therapy. Similar findings of increased emotional wellbeing were found in the studies conducted by Tennent et al., (2020) as well as Ferreira et al., (2015). Ferreira et al., (2015) and Tennant et al., (2020) both also note that pediatric age range is broad and that virtual reality therapy may not have the same effects on a child who is seven versus a child who is seventeen, as developmental competences of each age range are significantly different. As both studies synthesized above are pilot studies in the research of pediatric virtual reality therapy, Ferreira et al., (2015) and Tennant et al., (2020) alike agree that further research is needed to determine the overall effectiveness of virtual reality therapy in pediatrics, but they primary research claims that virtual reality therapy is beneficial in the treatment of symptom distress in pediatric oncology patients/ Virtual Reality Therapy and the Effects on Chronic Symptom Distress Garrett et al., (2020) introduce the issue of chronic pain management in oncology patients. In this study, twenty-three participants were sent home with virtual reality devices and asked to use them as a tool for self-management of chronic cancer pain. The most common effect reported was that virtual reality was beneficial in their pain management. Garrett et al., (2020) noted "Overall, the effectiveness of these interventions compared to other adjunctive chronic pain therapies such as massage, acupuncture, mindfulness relaxation, music therapy, or even placebo therapeutics remains to be established and well-controlled large randomized clinical trials are necessary to establish the size of any analgesic effect of VR as an adjunctive tool in chronic pain management". Unlike conventional oncology treatment programs, virtual reality therapy allows patients an at home option to pain and anxiety treatment control without the use of medications. This study agrees with the findings of Tennent et al., (2020) on the point of further research being needed, especially in age groups not considered young adult. Tennent et al., (2020) Ten Source Essay 6 researched pediatrics in a pilot study and it is found in Garrett et al., (2020) the same outcomes can be concluded in their research of long-term care across the age spectrum Cimpean (2019) conducted a research study in which a sampling of 20 adult patients diagnosed with cervical cancer were treated with virtual reality therapy. In the study, patients were separated into two equal groups, one participating in virtual reality therapy, the other participating in other forms of cognitive behavioral therapy conducted by psychotherapists. For the study, participants were asked to participate in four, 15-minute sessions of relaxation post procedure either through virtual reality imagery or personal reflection, relying on thoughts and memories. What Cimpean (2019) found was that, "when we conducted comparisons form pre-to post intervention, regardless of the group, we found significant differences on quality of life and pain intensity. It is well known that numerous investigations examining the utility of various psychological interventions (e.g., group support, individual psychotherapy, psychoeducation, relaxation training) were successful in treating psychological distress, manage pain, improve quality of life, and even extend survival in patients with cancer," (p. 122). The limitations noted by Cimpean (2019), including small sample sizes, degree of isolation, and doctor-patient relationships, were congruent to those found by Glennon et al., (2019). Cimpean (2019) concluded that virtual reality therapy "is considered a powerful distracter: it provides a high degree of immersion to the user and by directing the individual's attention away from the real world, and into the virtual environment, it may facilitate relaxation" (Cimpean, 2019, p. 117). Austin et al., (2019) note that "current treatments for cancer pain have major limitations, and inadequate pain relief occurs despite multiple guidelines" (p.2). One way in which Austin et al., (2019) measured the effectiveness of virtual reality therapy in the long-term effects of cancer treatments was by employing Google Earth in the setting of virtual reality therapy. Using Google Ten Source Essay 7 Earth VR, patients are able to travel to real-life memorable places such as, traveling back home, taking an overhead view of the Grand Canyon, or transporting patients to the shores of their favorite beach. Despite the benefits found, Austin et al., (2019) concluded that limitations such as affordability and accessibility may hinder therapy. Personal virtual reality headsets can be expensive, yet it is much more affordable to take advantage of these therapies in a hospital through a shared device. Austin et al., (2019) note further studies are needed to explore virtual reality therapy in oncology palliative care, virtual reality therapy in breakthrough pain, and virtual reality therapy in persistent severe pain, but that the preliminary research being done with Google Earth VR is producing therapeutic results. Virtual Reality vs. Sedation Therapy Cornelis et al., (2020) conducted a research study on the use of virtual reality therapy as virtual sedation on long term symptom distress in oncology patients. Cornelis et al., (2020) claim "to produce a dissociative state similar to clinical hypnosis without direct interaction with a professional, digital sedation captures all of the patient's attention by combining visual but also auditory sensations and verbal suggestions using a virtual reality mask and headphones" (passage 3.6). Sedation protocols during oncology procedures often involve sedative drugs which can be associated with side effects such as, respiratory depression, hypotension, bradycardia, and dependence. Cornelis et al., (2020) show that the effects of clinical hypnosis are similar to intravenous drug therapy without the need for pain medication during procedures. It was hypothesized that virtual reality sedation achieved greater patient satisfaction during procedures then not (Cornelis et al., 2020). A second study by Maindet et al., (2019) was conducted to study on the use of virtual reality therapy in conjunction with virtual sedation. Maindet et al., (2019) claim that through their research several trials have shown beneficial effects of hypnosis on Ten Source Essay 8 cancer-related pain relief as well as in activity against distress and anxiety. Virtual reality hypnosis was used in conjunction with chemotherapy administration, lumbar punctures and port access' with significant pain reduction. Cornelis et al., (2020) and Maindet et al., (2019) found similar outcomes in their research which showed participants whom were immersed in sedative virtual reality therapy reported, significantly less pain levels, less general distress, less unpleasantness and an actual want to use sedative virtual reality therapy in future procedures. Conclusion This review has highlighted the advancement of virtual reality therapy on the treatment of symptom distress in oncological patients. All studies synthesized agreed that the implementation of virtual reality was beneficial in the treatment of alleviating symptom distress in oncological patients. When it comes to deciding if virtual reality therapy has the potential to combat symptom distress, all studies from the articles promote implementing some form of psychological therapy in addition to medication therapy to decrease the likelihood of symptom distress. Further research needs to be conducted to see how virtual reality can offer escapes from stress due to hospitalization and treatment, increase resilience, as well as curb onset of low mood, withdrawal, and depression (Tennent et al., 2020, p7). Virtual reality therapy will not replace conventional oncology treatment methods, but as an adjunctive therapy it offers increased beneficial outcomes over standard treatments alone. It is reasonable to conclude that virtual reality therapy can improve acute symptoms experienced by oncology patients during and after medical procedures.