JA

Distraction using virtual reality for children during intravenous

injections in an emergency department: A randomised trial

Yen‐Ju Chen RN, MSN  Su‐Fen Cheng PhD, RN  Pi‐Chang Lee MD  Chi‐Hsiu Lai RN, MSN 
I‐Ching Hou PhD, RN  Chi‐Wen Chen PhD, RN

First published: 12 November 2019

https://doi-org.ezproxy.aut.ac.nz/10.1111/jocn.15088

Abstract

Aim and objectives

To determine whether the virtual reality as a distracting intervention could reduce pain and fear
in school‐age children receiving intravenous injections at an emergency department.

Background
An intravenous injection is the most common invasive procedure that paediatric patients
encounter in emergency department. School‐age children seldom show their fear or discomfort
during the procedure which may be ignored.

Design
A randomised controlled trial was conducted from December 2017–May 2018 and performed
according to the CONSORT guidelines.

Methods
One hundred and thirty‐six children aged 7–12 years were randomly allocated to receive either a
routine intravenous injection procedure or one with an immersive virtual reality experience.
Children were asked to rate their pain and fear along with their caregivers and nurses on the
Wong–Baker FACES Pain Rating Scale and Children's Fear Scale, respectively. The time
required for successful intravenous insertion was also assessed in the emergency department.
Clinical trial registration was done (ClinicalTrials.gov.: NCT04081935).

Results
Pain and fear scores were significantly lower in the virtual reality group, as were the children's
ratings as perceived by their caregivers and nurses. The children's ratings of pain and fear were
positively correlated with the caregivers’ ratings and the nurses' ratings as well. The time
required for successful intravenous insertion was significantly lower in the virtual reality group.
Conclusion
Visual reality intervention can effectively reduce the pain and fear during intravenous procedure
in school‐age children in emergency department.

Key words: distraction, emergency deparment, intravenous injection, school age children, virtual
reality.

1 INTRODUCTION
Most children experience pain and fear when receiving medical treatment; these feelings are
related and affect one another (Piskorz & Czub, 2018). Although intravenous injections are a
nonroutine type of invasive medical treatment, they are the most common type of invasive
medical treatment during emergencies. Children receiving intravenous injections may exhibit
behaviours such as crying, screaming, body twisting and muscular rigidity. To help administer
intravenous injections to children successfully, their primary caregivers or attending medical
staff members generally must spend additional time comforting or coercing the child; they may
even be required to restrain the child and administer intravenous injections by force. However,
restraining children and giving them intravenous injections by force can result in their discomfort
and violent attempts to break free, which increases the procedural duration and the number of
attempts required to successfully administer intravenous injections. This places extra burden on
human and medical resources and strains the patient–medical personnel relationships (Li, Yu,
Yang, & Chang, 2014).

School‐age children are already able to describe the locations and body parts where they
experience pain and the nature of said pain. In addition, they are able to adapt to pain and fear by
employing methods such as standing still, clenching their fists or teeth, or simply accepting these
emotions. Because some school‐age children may not show signs of fear such as crying, they
may be afraid to express their feelings of pain and fear to others (e.g., their primary caregivers
and medical personnel) and may feel obligated to behave in a brave manner (Chang &
Tsai, 2017), causing others to overestimate children's tolerance to pain and fear and
underestimate the level of pain and fear they experience. Thus, family members speaking about
the degree of pain and fear experienced by their children on their behalf are likely to
underestimate such experiences (Rajasagaram, Taylor, Braitberg, Pearsell, & Capp, 2009; Seers,
Derry, Seers, & Moore, 2018). Pain is a personal, subjective experience influenced by one's
emotions, body, mind, society and culture. Of all the types of pain reporting, self‐reporting is
 considered to be the most valuable because it directly reflects the degree and nature of an
individual's pain (Ming & Hong, 2011). By using effective, reliable pain assessment scales,
primary caregivers and medical personnel can accurately identify the true pain levels
experienced by school‐age children and apply appropriate methods to successfully relieve their
pain.

Relevance to clinical practice

The results of this study indicate the feasible clinical value of virtual reality interventions during
the administration of intravenous injections in school‐age children in emergency departments.

What does this paper contribute to the wider global clinical community?

 Visual reality could be a suitable nonpharmacological strategy to alleviate pain and fear
during an intravenous injection, which is one of the most common types of invasive medical
treatments at an emergency department. 
 Our randomised controlled trial indicated that the virtual reality as a distraction
intervention could reduce pain and fear during intravenous placement for school‐age children
in emergency departments.
 The results of this study can serve as feasible nursing practice for clinical intravenous
injections involving children.

2 BACKGROUND
In clinical settings, both pharmacological and nonpharmacological strategies can be used to
alleviate pain. Although drugs can relieve pain quickly, obtaining them is time‐consuming
because physicians must examine patients and write prescriptions, and nurses must prepare the
drugs. In addition, drugs may cause adverse reactions in patients. By contrast,
nonpharmacological strategies do not involve physician assessments, and nurses can care for
their patients by using their nursing knowledge and skills. Compared with pharmacological
strategies, nonpharmacological strategies are safer, relatively risk free and effective in alleviating
pain and fear self‐reported by children as well as the negative emotions experienced by their
observers (e.g., primary caregivers and medical personnel; El‐Gawad & Elsayed, 2015;
Wente, 2013). Nonpharmacological strategies can be divided into contextual, behavioural and
cognitive strategies, with cognitive strategies being the most widely used, which includes
techniques such as distraction, hypnosis, imagery, music therapy and thought stopping (Ali,
McGrath, & Drendel, 2016; Pillai Riddell et al., 2011). Of these techniques, distraction has a low
cost and is safe, easy to administer and the most effective option (Ali et al., 2016; Birnie, Noel,
Chambers, Uman, & Parker, 2018). Studies and analyses have shown that distraction does not
lead to complications or have any side effects. It is the most common coping strategy employed
for school‐age children and adolescents in the face of unpleasant situations (Koller &
Goldman, 2012).

Distraction can be divided into active and passive distraction. When receiving invasive medical
treatment, children who actively engage in activities or concentrate on performing tasks (i.e.,
active distraction) trigger their bodies’ pain suppression systems, causing them to forget about
their pain and fear, thus reducing the degree of pain and fear they experience. By contrast,
passive distraction entails stimulating children or asking them to observe activities (the children
are not directly involved in the activities) to distract them. Passive distraction is more effective in
quiet environments than in noisy environments (Birnie et al., 2018; Wohlheiter &
Dahlquist, 2013). Children's pain and fear of receiving intravenous injections can be alleviated
by any or a combination of the following: playing distraction cards; squeezing soft balls; blowing
balloons; blowing bubbles; playing with dough or Buzzy; and listening to music (Aydin &
Sahiner, 2017; Aydin, Şahiner, & Çiftçi, 2016; Maghsoudi et al., 2016; Moadad, Kozman,
Shahine, Ohanian, & Badr, 2016). Although most distraction measures are easy to adopt, they
produce varying results because users are in different environments, have different experiences,
and the human resources and time resources of medical teams vary. Virtual reality (VR) headsets
eliminate these variables because they are easy to install, do not require additional personnel, are
not affected by noisy external environments and require only a small amount of time
(approximately 5 min) to set up. Thus, VR is a suitable option for busy emergency departments
(Schneider & Workman, 2000).

VR presents virtual objects and environments using computer technology and generally does so
in three‐dimensional environments. By stimulating users’ auditory, visual and tactile senses and
using head‐mounted displays, VR can surround users with cool, fantasy‐like three‐dimensional
virtual environments in which they can interact with virtual objects (Mahrer & Gold, 2009;
Sanchez‐Vives & Slater, 2005). However, because the visual centre of children under 7 years of
age is not fully developed, head‐mounted displays are not recommended for those in this age
bracket. Virtual environments created in VR are more appealing than conventional cartoons and
video games (Wolitzky, Fivush, Zimand, Hodges, & Rothbaum, 2005). Although it is not clear
why VR relieves pain, most proposed mechanisms still attribute to distraction (Spiegel, 2018).

Studies have shown that VR can effectively alleviate the pain and fear experienced by patients
undergoing invasive treatment, such as those aged 6–47 years undergoing physical therapy and
receiving medication after sustaining burns and scalds (Hoffman, Patterson, & Carrougher, 2000;
Lien et al., 2007; Schmitt et al., 2011), children aged 4–10 years receiving general anaesthesia
and elective surgery (Ryu et al., 2019, 2017), patients aged 5–19 years receiving chemotherapy
after a diagnosis of cancer, patients receiving lumbar and port‐A punctures (Gershon, Zimand,
Pickering, Rothbaum, & Hodges, 2004; Nilsson, Finnström, Kokinsky, & Enskär, 2009; Sander,
Eshelman, Steele, & Guzzetta, 2002; Schneider & Workman, 2000; Wolitzky et al., 2005) and
children aged 7–17 years receiving intravenous injections (Gold, Kim, Kant, Joseph, &
Rizzo, 2006; Piskorz & Czub, 2018). VR did not cause major adverse events during the past
studies. There were only a small number of subjects felt temporary nausea and vomiting
(Spiegel, 2018). However, because the medical treatments performed in these studies were not
conducted in emergency departments, the feasibility and effectiveness of VR in emergency
departments remain unknown, as does the effectiveness of VR on mitigating the pain and fear of
children receiving intravenous injections.

2.1 Aim of the study and hypotheses

The aim of our study was to examine the effects of VR on the pain and fear ratings of school‐
age children during an intravenous injection in an emergency department. The study's
hypotheses were as follows:

 H0: There will be no significant difference in pain and fear ratings of school‐age children
who do and do not receive the VR intervention during an intravenous injection in an
emergency department.
 H1: There will be significant differences in pain and fear ratings of school‐age children
who do and do not receive the VR intervention during an intravenous injection in an
emergency department.

3 METHODS
3.1 Study design
This was a randomised controlled trial using a post‐only approach. The randomised trial met the
Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines (see File S1).

3.2 Study participants and settings

After signing a consent form, the participants and primary caregivers participated in an
experiment that was held from December 2017–May 2018 in the emergency department of a
regional teaching hospital in northern Taiwan.
3.2.1 Inclusion criteria and exclusion criteria

The inclusion criteria were as follows: children who were 7–12 years of age and who were
clearly conscious; children who agreed and were required to receive intravenous injections after
physicians’ diagnoses; children and their primary caregivers who could communicate in
Mandarin or Taiwanese; and children and their primary caregivers who could read Chinese that
agreed to participate in this study and sign written consent forms. The exclusion criteria were as
follows: children with developmental delay, epilepsy or heart diseases; children undergoing
chemotherapy; children who were visually or hearing impaired; children who were nearsighted
with more than 8.0 dioptres or farsighted with 5.0 dioptres; children who had sustained head
trauma in the past month; children who were confirmed to be obese according to the
recommended body mass index values for children and adolescents; children who required blood
transfusions and blood preparation to be performed according to physician diagnoses; and
children who received two or more intravenous injections and had their blood drawn only one
time.

3.3 Data collection

3.3.1 Enrolment

One trained research assistant who was a master's students enrolled the participants who met the
eligibility criteria and allocated them to either the experimental group or the control group.

3.3.2 Allocation

This study protected the right of its participants by adhering to the allocation concealment
principle, and the patients were divided into experimental and control groups by using the block
randomisation method. An experimental–control group with a post‐test only design was adopted.
This study used four groups and six combinations per group as the grouping criteria prior to
undertaking random grouping. Researchers who were not involved in this study were asked to
randomly divide the participants into the experimental and control groups (at a ratio of 1:1) and
assign six combinations (No. 1–6) per group using a random number generator. The researchers
placed the results in opaque, sealed envelopes and numbered the envelopes, which the
participants opened after they and their primary caregivers signed the consent forms. This was
the point at which the researchers, participants and primary caregivers learned which groups the
patients were assigned to.
3.3.3 Sample size

Power analysis to determine the best sample size was conducted using the G* power analysis
programme with an expected power of 0.8, a significance level (α) of 0.05, a medium effect size
(0.15) and 14 predictors with a multiple regression analysis. The total number of sample
participants required for this study was 135. Therefore, the number of participants in this study
was 68 in the experimental group and 68 in the control group.

3.4 Intervention
The experimental group participants underwent the experiment by using VR and iPhones, on
which they downloaded VR apps that were age‐appropriate, as recommended by the App Store.
The four virtual environments (i.e., roller coasters, space exploration, a wildlife park and travel
destinations) selected in this study were suitable for children aged 4 years and above and
featured clear video playback quality. A Xiaozhai V4 was used as the head‐mounted display,
which fully covered the users’ eyes and used one‐piece, soundproof, surround‐sound headphones
to provide immersive VR. The parts of the device that came into contact with the users’ faces
could be removed and cleaned to avoid hygiene concerns.

For the experimental group, the participants selected the virtual environments they desired and
wore the head‐mounted display; the nurses (one per participant) prepared the intravenous
injection equipment and calculated the intravenous injection time, which began the moment the
participants wore the tourniquets and the injection sites were determined, and ended when vein
catheters (No. 24) were inserted and blood returned to the return blood cavities. By contrast, the
VR usage time began when the injection sites were determined and ended 3 min after they were
determined.

After a further 5 min, the participants, primary caregivers and nurses used the Wong–Baker
Faces Pain Rating Scale (WBFPS) and Children's Fear Scale (CFS) to perform the post‐tests. For
the control group, regular intravenous injections were provided, and the participants were
promptly comforted verbally. The participants, primary caregivers and nurses used WBFPS and
CFS to perform the post‐tests 8 min after the tourniquets were worn. The researchers recorded
the intravenous injection sites and times. To properly compensate the time lost by the control
group, a 3‐min VR experiment was performed after the post‐tests.
3.5 Outcomes
In this study, the primary outcomes were pain and fear. The degrees of pain experienced by the
children were measured using the WBFPS. The scale contains six cartoon faces showing pain
ratings of 0–10, which are, from left to right, no pain (0), a little pain (2), mild pain (4), average
pain (6), severe pain (8) and excruciating pain (10). The children, primary caregivers and nurses
were asked to select the faces that best described the pain levels experienced by the children
receiving intravenous injections; the pain levels were subsequently converted into numerical
values (Tomlinson, von Baeyer, Stinson, & Sung, 2010). Similarly, the degrees of fear
experienced by the children were measured using the CFS. The scale consists of five cartoon
faces showing fear ratings of 0–4, which were no fear (0), a little fear (1), some fear (2), very
fear (3) and extreme fear (4). The children, primary caregivers and nurses were asked to select
the faces that best described the fear levels of the children receiving intravenous injections. The
fear levels were subsequently converted into numerical values (McMurtry, Noel, Chambers, &
McGrath, 2011).

3.6 Ethical considerations

This trial was conducted in this study that was approved by an institutional review board
(2017B002). All participants provided written informed consent before starting the study.
Participants were permitted to withdraw from the study whenever they desired without prejudice.
This study was registered with ClinicalTrials.gov.: NCT04081935.

3.7 Data analysis

Statistical analyses were performed using SPSS for Windows version 21.0 (IBM Corp).
A p value of <.05 was considered statistically significant. The sociodemographic data of the
children, caregivers and nurses were presented using frequency distributions for categorical
variables and means and standard deviations for continuous variables. A Pearson correlation test
was conducted to determine the correlations between the pain and fear experienced by the
children (receiving intravenous injections) and the perceived pain and fear in the children
according to their primary caregivers and nurses. Data related to pain, fear and time required for
successful intravenous injection insertions were compared between groups using an
independent t test.
4 RESULTS
4.1 Baseline characteristics
The total number of children and primary caregivers who met the study criteria and signed
written consent forms was 140. Because four participants decided to withdraw from the
experiment prior to division into the experimental and control groups, 136 participants remained,
who were randomly divided into the experimental and control groups (68 each). The flow from
enrolment to analysis is illustrated in Figure 1. The participants had an average age of 9.13 years
(±1.71) and an average body mass index of 17.18 (±2.79). Most were boys (77; 56.6%) and most
(107; 78.7%) did not have any previous VR experience. The primary caregivers had an average
age of 40.29 years (±7.60) and most were women (101; 74.3%) and mothers (87; 64.0%). The
nurses had an average age of 30.06 years (±6.97), mostly cared for girls (124; 91.2%), and had
an average of 6.53 (±6.72) years of emergency department experience. The times required for
intravenous injections in the experimental and control groups were significantly different
(p = .046), with the average time spent by the experimental group shorter than that for the control
group, confirming that the use of VR significantly reduced the time required to successfully
complete intravenous injections (Table 1).
Figure 1
Open in figure viewerPowerPoint
CONSORT diagram of the trial flow
Table 1. Participants’ characteristics (n=136)

Characteristics Virtual reality Control p value

(n = 68) (n = 68)

Child

Age, mean ± SD 9.3 ± 1.7 9.0 ± 1.7 .48

 Characteristics Virtual reality Control p value
(n = 68) (n = 68)

Male, number (%) 38 (55.9) 39 (57.4) .86

Body mass index, mean ± SD 17.4 ± 3.1 17.0 ± 2.5 .46

Have used virtual reality, number (%) 24 (35.3) 5 (7.4) <.001***

Primary caregiver

Age, mean ± SD 40.8 ± 8.2 39.8 ± 6.9 .45

Female, number (%) 50 (73.5) 51 (75.0) .84

Relationship, mother, number (%) 43 (63.2) 44 (64.7) .97

Nurse

Age, mean ± SD 31.3 ± 6.9 28.9 ± 6.9 .046*

Emergency work years, mean ± SD 7.4 ± 7.0 5.6 ± 6.4 .11

Time took for the IV insertion, Seconds, 53.5 ± 19.0 61.3 ± 25.8 .046*

mean ± SD

 *p < .05, ***p < .001.
 4.2 Pain and fear
The degrees of pain experienced by the children when receiving intravenous injections in
emergency departments were significantly and positively correlated with their degrees of fear
(r = .75–.80, p < .001). Additionally, the pain and fear experienced by the children as assessed by
them, their primary caregivers and their nurses were significantly and positively correlated (for
pain: p < .001, with correlation coefficients ranging from 0.48–0.68; for fear: p < .001, with
correlation coefficients ranging from 0.70–0.77) (Table 2).

Table 2. Correlations of pain and fear ratings for child, primary caregiver and nurse

1 2 3 4 5

1 Pain score by child

2 Pain score by primary caregiver .68***

3 Pain score by nurse .48*** .57***

4 Fear score by child .80*** .65*** .54***

5 Fear score by primary caregiver .65*** .76*** .65*** .77***

6 Fear score by nurse .61*** .60*** .75*** .70*** .75***

 ***p < .001.

In Table 3, pain and fear scores were significantly lower in the VR group for the children
(p = .031; .043), their caregivers (p = .020; .003) and nurses (p = .012; .006).

Table 3. Main study outcomes

Mean ± SD Virtual reality (n = 68) Control (n = 68) p value

Pain score by child 3.35 ± 2.38 4.35 ± 2.95 .031*

 Mean ± SD Virtual reality (n = 68) Control (n = 68) p value

Pain score by primary caregiver 3.26 ± 2.37 4.29 ± 2.70 .020*

Pain score by nurse 3.29 ± 2.01 4.29 ± 2.52 .012*

Fear score by child 1.32 ± 1.19 1.78 ± 1.40 .043*

Fear score by primary caregiver 1.35 ± 1.23 2.03 ± 1.36 .003**

Fear score by nurse 1.56 ± 1.20 2.15 ± 1.24 .006**

 *p < .05, **p < .01.

5 DISCUSSION
5.1 Summary of key findings
This study showed that the use of VR can effectively reduce the degrees of pain and fear
experienced by school‐age children receiving intravenous injections in emergency departments
as well as those observed by the children's primary caregivers and nurses. The pain and fear self‐
reported by the children as well as those reported by their primary caregivers and nurses were
highly correlated, and VR could significantly decrease the time required to successfully complete
intravenous injections. Studies have confirmed that the use of immersive VR can alleviate the
pain and fear of children aged 7–19 years receiving invasive, needle‐based medical treatment as
well as the pain and fear experienced by children, their parents and nurses, and researchers
(Gershon et al., 2004; Gold et al., 2006; Piskorz & Czub, 2018; Sander et al., 2002; Wolitzky et
al., 2005). Although children generally receive analgesic or sedative drugs before their injections
(Gershon et al., 2004; Gold et al., 2006; Sander et al., 2002), such drugs were not administered in
the present study in order to accurately reflect the degrees of pain and fear that they experienced.
In this study, a 9‐year‐old boy (Case 4 [i.e., N4]) continually stated “Wow! This is so beautiful!
The planet is colored” and “I feel very comfortable.” A 10‐year‐old boy (N27) exclaimed “Wait!
The car is going to fall!” An 8‐year‐old boy (N74) said “That scared me, it felt as if the car was
going to hit the bear.” The primary caregiver (mother) of a 7‐year‐old boy (N71) stated “Usually,
I need to hold my son when he receives intravenous injections, but I did not have to do that
today. All it took was one attempt, too. I think my son liked it.” The mother of a 7‐year‐old boy
(N81) remarked “I always have to hold my son when he receives intravenous injections, and was
pleasantly surprised that I did not have to do it this time!”

During the VR experience, a 7‐year‐old boy (N75) held his primary caregiver's (mother's) hand
tightly with his noninjection hand and described what he saw, such as a car crossing the bridge
and him hearing an elephant trumpeting, with the assistance of his fingers. The boy indicated that
the VR experience was fun and that he did not feel fear during the injection process. A 7‐year‐
old female participant (N94) repeatedly described what she saw, such as animals and rainbows;
she even imitated the sounds of the animals. An 11‐year‐old boy (N118) commented that “I felt
less afraid when I wore this.”

5.2 Effectiveness of visual reality

Studies have shown that the effectiveness of VR in alleviating children's pain and fear is not
diminished by them having previous experience with VR (Schmitt et al., 2011). Their fear of
intravenous injections is positively correlated with the pain they experience from receiving said
injections. Furthermore, the pain and fear that they exhibit have direct effects on how their
primary caregivers and nurses feel, and the pain and fear experienced by children receiving
intravenous injections as assessed by the children, their primary caregivers and their nurses are
significantly correlated (Wolitzky et al., 2005).

The advantages of this study were that it had an experimental design and employed random
assignments, easy‐to‐use pain and fear assessment tools and VR were used, children wore head‐
mounted displays that did not cause them to have headaches or feel dizzy or visual discomfort
(validating the safety of VR), and children could choose their VR experience and nurses could
interact with them while explaining the operation, strengthening the children's trust in the nurses
and the nurse–patient relationship.

6 STUDY LIMITATIONS AND RECOMMENDATIONS

FOR FUTURE RESEARCH
The participants of this study were school‐age children who visited the emergency department
for general medicine‐related problems. Thus, the results are only applicable to such children
receiving intravenous injections in emergency departments and not to children with physical
trauma or from other age groups. Future studies should examine other age groups, treatment
types and medical institutions (e.g., medical centres) as well as people who have difficulty
receiving intravenous injections (e.g., patients who are obese, with developmental delays, and
who have trouble communicating and expressing themselves). The inability of these patients to
verbally express themselves results in others neglecting their pain and fear when they receive
intravenous injections. The study results can be used to verify the effectiveness of VR in
mitigating their pain and fear when receiving said intravenous injections.

7 CONCLUSION
The use of VR for school‐age children receiving intravenous injections can effectively diminish
their pain and fear and the time it takes to complete such injections successfully. In addition, VR
does not require additional personnel resources, is not affected by noisy external environments
and requires only a minimal amount of time and effort to set up. Thus, VR is a suitable option for
assisting in such interventions in busy emergency departments with limited human resources.

8 RELEVANCE TO CLINICAL PRACTICE

When children face evasive behaviour in the face of intravenous injection, in addition to
increasing work manpower and treatment time, it is more likely to increase the number of
injections leading to child discomfort. It will also make children and the main caregivers feel
distrustful, which will cause the nurses to exert psychological pressure and affect the success rate
of intravenous injection. This study validates noninvasive VR as an intervention strategy that
allows children to quickly integrate into a virtual environment, in addition to significantly
reducing the pain and fear of children receiving intravenous injections, as well as reducing the
time to successful completion of intravenous injections. The results of this study can provide an
important reference for reducing the pain and fear in school‐age children receiving intravenous
injections at an emergency department.

ACKNOWLEDGEMENTS
This research was supported by the Higher Education Sprout Project by the Ministry of
Education (MOE) in Taiwan (108AC‐D112).

CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
 AUTHOR CONTRIBUTION
Study design: YJC, SFC, PCL, and CWC; data collection and analysis: YJC, SFC, PCL, CHL,
ICH, and CWC; manuscript writing: YJC and CWC; critical revisions for important intellectual
content: YJC, SFC, PCL, CHL, ICH, and CWC; study supervision: SFC, PCL, CHL, and CWC.

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