Implementing a virtual reality-based intervention to support the wellbeing of mental health staff in the workplace: A mixed-methods pilot study

Abstract

Mental health staff experience high stress levels. Novel workplace stress-management interventions are needed. This study aimed to evaluate a virtual reality (VR)-based staff support intervention. Participants (N = 43) were a wide range of multidisciplinary mental health staff from outpatient and inpatient services at the South London & Maudsley NHS Foundation Trust. Participants received a single VR session, including virtual art, nature walks, and meditations. Pre- and post-VR visual analogue scales and qualitative feedback were collected. Post-VR, there were significant increases in positive wellbeing and happiness, and decreases in stress and anxiety (all large effects). Mean scores for helpfulness, ease of use, and immersion were high. Almost all participants reported the VR was a positive, enjoyable, and immersive experience that made them feel more relaxed and provided escapism from work-related stress. Participants were enthusiastic about increasing access to the intervention. A small minority highlighted implementation issues, including headset comfort and difficulty adjusting psychologically to VR. Findings indicate that the VR intervention was feasible and acceptable to support the wellbeing of mental health staff in the workplace. Future studies could employ more robust methodologies to investigate facilitator roles, user experience, greater user input in intervention development, and adapted methods of delivery.

Keywords:

• Digital mental health
• healthtech
• extended reality
• virtual reality relaxation
• stress
• workforce
• staff support [7]

Introduction

Healthcare workers experience high stress levels, given that they work under significant pressures, with limited resources, and balance patient care with their own wellbeing (Greenberg et al., 2020; Hood & Patton, 2022). The welfare of mental health professionals is of particular concern because they report poorer wellbeing than staff from other healthcare sectors (Johnson et al., 2018; Kramarz et al., 2023). As a result, stress management interventions are increasingly offered to healthcare professionals in the workplace, e.g., wellbeing workshops, yoga, and mindfulness; and these can be effective breaktime activities during the working day (Riley et al., 2017). However, many of these interventions can be challenging to implement within fast-paced working environments, due to lack of time and the cognitively taxing nature of some traditional relaxation methods, so there is a need for novel and accessible workplace stress management interventions (Armstrong & Tume, 2022; Lamb & Cogan, 2016).

The immersive, engaging, and accessible nature of virtual reality (VR) relaxation may overcome some of the limitations of other relaxation and stress management interventions and it is emerging as a useful and effective tool for reducing stress, promoting relaxation, and increasing wellbeing (Riches et al., 2021; Riches, Jeyarajaguru, et al., 2023). VR relaxation promotes psychological and physiological relaxation, reducing arousal and anxiety using exposure to pleasant, soothing virtual environments (Riches et al., 2021). Research indicates that VR-based relaxing natural environments gain positive user feedback (Fagernäs et al., 2021) and have clear applications for workplaces, including in healthcare settings (Naylor et al., 2020; Riches, Taylor, et al., 2023; Riches & Smith, 2022), although many studies are lab-based and not implemented directly in workplace settings. Studies from the Netherlands and United States of America found that VR relaxation can reduce stress among healthcare workers (Beverly et al., 2022; Nijland et al., 2021), while a pilot study of VR relaxation for clinicians in the United Kingdom’s National Health Service (NHS) reported increased relaxation and decreased anxiety (Adhyaru & Kemp, 2022). However, there are very few studies with mental health staff, especially multidisciplinary samples; VR interventions have generally focused primarily on relaxation rather than wellbeing more broadly; and there is limited reporting of qualitative data from staff who have experienced the VR (Riches et al., 2021; Riches, Jeyarajaguru, et al., 2023; Riches, Taylor, et al., 2023). Therefore, the aim of this mixed methods pilot study was to implement and evaluate a VR-based wellbeing intervention for mental health staff in the workplace. Hypotheses were that the intervention would be feasible and acceptable to staff.

Materials and methods

Participants

This observational, cohort pilot study with a mixed-methods design was approved as a quality improvement project by the South London and Maudsley NHS Foundation Trust (SLaM). The project team who led on both implementation and evaluation were clinicians and clinical academics who worked for Staff Support Services, SLaM. SLaM is a multisite mental health NHS Trust that provides over 240 community-based and inpatient services for both children and adults to the local South London population, as well as specialist UK and internationally-based services. Its workforce includes a wide range of mental health professionals.

Participant recruitment comprised email and online communications to SLaM staff, including to the professional contacts of the VR project team, drop-in visits to SLaM services and staff training events from the VR project team with verbal invitations for staff to participate, and by incorporating the VR intervention within “The Winter of Wellbeing” events at various SLaM sites. This was a Trust-wide initiative from the Staff Support Team to promote the mental wellbeing of staff. Therefore, this study recruited a convenience sample and researchers aimed to recruit as many people as they could on the allotted days that this was offered to staff. All participants gave verbal consent to participate in the study. People with a history of epilepsy or seizures were excluded due to known risks with VR (Riches et al., 2019).

Virtual reality session

The VR intervention was offered to participants as a single session. An in-session evaluation component aimed to collect staff feedback. Feedback was prioritized given that such a Trust-wide VR-based staff support initiative had not previously been offered to SLaM staff. All sessions were facilitated in hospital meeting rooms or clinical rooms by assistant psychologists, who briefed, debriefed, and supported participants throughout the session. Sessions and data collection occurred during February and March 2023.

During the session, participants wore a VR head-mounted display while seated. The VR provided a fully immersive, audio-visual experience of virtual environments that aimed to improve wellbeing, promote relaxation, and provide respite from the workplace. To carry out sessions, the project team used three Meta Quest 2 head-mounted displays, a lightweight wireless device worn over the head with two controllers, that enable users to navigate virtual environments and menu screens. The three headsets meant that the intervention could be offered to three staff members concurrently if needed. This meant that participants typically experienced the VR alongside other people in the room, including the facilitators, participants, and staff. Three VR apps, which collectively included numerous VR environments, were purchased and downloaded to the head-mounted displays by the project team. These apps were available for participants to freely select from menus accessed within the headset. They were chosen to provide several different virtual experiences that relate to wellbeing. In sessions, participants were told that they could experience as many environments as they wished, in any order, and with no limit on their duration of time in VR, with the aim of ensuring that this was a staff support intervention that maximized choice and accessibility. The Tilt Brush app (Google; https://www.tiltbrush.com/) enabled users to paint in three-dimensional space with a virtual palette and a range of dynamic brushes; the Nature Treks VR app (Greener Games; https://www.greenergames.net/nature-treks) provided fifteen interactive natural environments that aimed to elicit different emotional states; and the Maloka app (PlayMaloka; https://playmaloka.com) offered guided mindfulness experiences in colorful environments. Table 1 lists all the VR apps and their environments that were used in the study by participants. The YouTube VR app was initially trialed, but its ultra-high-definition resolution appeared unsupported by local Wi-Fi, so it was not possible to use in the study.

Table 1. Demographic characteristics of participants (N = 43).

Demographics	N (%)
Gender
Female	33 (76.7)
Male	9 (20.9)
Non-binary	1 (2.3)
Ethnicity
Asian	5 (11.6)
Black	11 (25.6)
White	22 (51.2)
Mixed/multiple ethnic groups	5 (11.6)
Occupation
Administrator	1 (2.3)
Assistant psychologist	9 (20.9)
Clinical practitioner and trained psychotherapist	1 (2.3)
Clinical psychologist	4 (9.3)
Employment coach	1 (2.3)
Medical student	2 (4.7)
Nurse	9 (20.9)
Occupational therapist	2 (4.7)
Occupational therapy assistant	1 (2.3)
Psychiatrist	3 (7.0)
Psychology wellbeing practitioner	1 (2.3)
Psychotherapist	2 (4.7)
Service user research ambassador	1 (2.3)
Smoking cessation specialist	1 (2.3)
Social worker	2 (4.7)
Student nurse	1 (2.3)
Therapy enabler	1 (2.3)
Tobacco dependence advisor	1 (2.3)
Main work setting
Inpatient services	13 (30.2)
Outpatient services	15 (34.9)
Other	14 (32.6)
Prefer not to say	1 (2.3)
Virtual reality apps (and their environments) used by sample
Tilt Brush	18 (41.9)
Nature Treks	26 (60.5)
Black Beginning (outer space scene with stars, planets, and galaxies)	5 (11.6)
Blue Deep (underwater landscape with marine life)	17 (39.5)
Blue Moon (moonlit landscape)	2 (4.7)
Blue Ocean (crystal water and white sandy beach with palm trees)	14 (32.6)
Green Bamboo (bamboo trees and cherry blossom trees at dusk)	6 (14.0)
Green Meadow (grassy meadow clearing from dense forest with rainbow and woodland animals)	5 (11.6)
Grey Storm (sea front landscape with thunderstorm)	5 (11.6)
Jade Jurassic (pre-historic land with dinosaurs)	8 (18.6)
Orange Sunset (forest clearing with setting sun)	8 (18.6)
Pine Vista (mountain valley with woodland animals)	1 (2.3)
Red Earth (Australian Outback with kangaroos)	1 (2.3)
Red Fall (woodland mountain range)	3 (7.0)
Red Savana (African plane with mountains and safari animals)	7 (16.3)
Turquoise Cove (hidden beach cove)	4 (9.3)
White Winter (a snowy mountain valley with roaming woodland animals)	7 (16.3)
Maloka	10 (23.3)
Evening wind down	2 (4.7)
Good morning	1 (2.3)
Healing relationships	2 (4.7)
Larimer focused meditation experience (for cleansing negative thoughts)	2 (4.7)
Power and peace	3 (7.0)

Measures

Participants self-reported their age, gender, ethnicity, occupation, and main work setting. Table 1 lists all demographic variables. Session facilitators recorded which apps and environments participants accessed, and their total length of time in VR to the nearest minute. Pre-VR, visual analogue scales (VAS) of self-reported wellbeing, stress, anxiety, and happiness, on an 11-point Likert scale from 0 (“Not at all”) to 10 (“Very”), were administered. Immediately post-VR, all pre-VR VAS were repeated, and additional VAS, using the same scale, were administered to measure how helpful, easy to use, and immersive participants found the VR. Table 2 lists full VAS items.

Table 2. Pre- and post-virtual reality visual analogue scales (N = 43).

Visual analogue scale (“Please mark on the line…”)	Pre-VR Mean (SD)	Post-VR Mean (SD)	Test	p	Effect (r)
…how POSITIVE you feel about your WELLBEING right now	6.57 (1.81)	7.67 (1.71)	−3.907	<.001	−0.596
…how STRESSED you feel right now	3.85 (2.39)	2.20 (2.34)	−3.997	<.001	−0.610
…how ANXIOUS you feel right now	2.72 (2.30)	1.71 (2.12)	−3.739	<.001	−0.570
…how HAPPY you feel right now	6.32 (1.46)	7.70 (2.00)	−4.075	<.001	−0.621
…how HELPFUL you found the virtual reality experience	–	7.64 (2.61)	–	–	–
…how EASY TO USE you found the virtual reality equipment	–	7.35 (2.21)	–	–	–
…to what extent you FELT YOU WERE ACTUALLY IN THE ENVIRONMENTS THAT YOU EXPERIENCED	–	7.21 (2.34)	–	–	–

Key: VR: virtual reality; SD: standard deviation.

Note. Visual analogue scales were scored from 0 (“Not at all”) to 10 (“Very”). Test = Wilcoxon signed ranks test (rank sum Z).

Participants provided written qualitative feedback in response to the following questions: “How did the virtual reality experience make you feel? Do you have any other feedback? What did you like? What did you dislike? Was there anything that you would have liked to be different? Was there anything about the virtual reality experience that might help your wellbeing in future?” Text boxes allowed unlimited space for participants to write as much as they wished but, in general, participants wrote one or two sentences. Tablets with links to Qualtrics online surveys that included demographic items, VAS, and free text boxes for qualitative feedback were used to collect all data.

Analysis

SPSSv27 was used to analyze quantitative data. Means or frequencies were reported for demographic characteristics, minutes in VR, and VR programs used. Demographic items comprised predetermined categories, including “Other” and “Prefer not to say” options to cater for staff confidentiality, and which were reported if populated. VAS and qualitative feedback aimed to evaluate the impact of the VR on participants. There was a within-subjects design for the study, with two levels: VAS ratings immediately pre- and post-VR. Given normality violations, Wilcoxon matched-pairs signed-rank tests compared pre- and post-VR VAS for all participants by pooling all session data. Post-VR means for helpfulness, ease of use, and immersion were reported. Qualitative data from all feedback questions were pooled and a thematic analysis was carried out in NVivo, aiming to represent participant views. All analyses were carried out by two independent researchers.

Results

Sample

Participants (N = 43) were mental health staff from both outpatient and inpatient services, and represented a wide range of professions, with nurses and assistant psychologists the most frequent occupations (each approximately 20% of the sample). There was also participation from psychiatrists, social workers, smoking support clinicians, other psychology and psychotherapy professionals, medical and nursing students, and a service user ambassador. A third of participants reported that their main work setting was “Other,” i.e., they did not select “Outpatient” or “Inpatient,” likely indicating that their roles encompassed both outpatient and inpatient services, although this data was not recorded. More than three-quarters of participants were female. On average, participants were in their late thirties (mean = 39.23 years, standard deviation = 13.26), although ages ranged from staff in their early twenties to those in their mid-sixties (range = 21–64 years). Half the participants were of White ethnicity and a quarter were of Black ethnicity. On average, participants spent just under twenty minutes in VR (mean = 18.47 min, standard deviation = 11.84), although there was considerable variation in durations, from a few minutes to nearly an hour (range = 3–55 min). Most participants accessed several VR environments, with Nature Treks VR environments widely used. Under water or ocean-based environments, such as Nature Treks’ Blue Deep and Blue Ocean environments, had the highest number of uses. Table 1 provides full details of demographics characteristics and VR use.

Quantitative findings

Post-VR, there were significant increases in positive wellbeing and happiness, and significant decreases in stress and anxiety (all large effects). Mean scores for helpfulness, ease of use, and immersion were all >7. Table 2 provides all VAS analyses.

Qualitative findings

Seven themes were identified. Participants reported that they found the VR to be a positive and relaxing experience, which was immersive and realistic. Many participants found the VR intervention to be helpful escapism from work-related stress, had enthusiasm for future VR engagement, and made recommendations for future implementation, including greater interactivity, and increasing access to staff. A small minority of participants experienced difficulties adjusting psychologically to VR and reported practical and technical issues, such as with headset comfort, using controllers, and general distraction. Table 3 reports in full all themes, explanations, and supporting quotes.

Table 3. Themes from post-virtual reality qualitative feedback (N = 43).

Theme	Explanation and supporting quotes
Positive and relaxing experience	Almost all participants reported that the VR was a positive and relaxing experience. Participants reported that they felt “calm” (P17), “peaceful” (P19), “grounded” (P40), “more at ease” (P26), and “really felt relaxed – absolutely loved it!” (P14). They said it was a “great way to relax and go somewhere else!” (P14) and “it was very relaxing to see the images whilst meditating [and they] found it very soothing and calming” (P36). For many, this meant it was “good to reduce stress and anxiety” (P7). Others reported that they felt “content” (P25) and the VR “helped to relax my mind and calm my nerves. It was very refreshing” (P22). They reported the VR was “absolutely wonderful – [I felt] relaxed and at one with the environment” (P15) and “it’s a really good tool for meditation and relaxation as it blocks out everything around you” (P35). One participant reported that they felt it was “beautiful” (P19) and experienced the benefit of VR by “just taking 10 or 15 mins out of your day to be in a bit of a dream or relaxed state” (P19). Participants liked specific features of the VR experience. They said, “the visual and auditory combination was great” (P8), the VR had “relaxing music” (P8) and they were “relaxed and astounded by the technology…Very impressed” (P16). These features were linked to how absorbing they found the experience.
Immersive, realistic experience	Participants found the VR experience to be immersive, realistic, and believable. Participants reported they felt “it takes you out of reality” (P39) and “immersed into a different world” (P11). They described it as “an immersive relaxation experience” (P43), “an escape from the world where I could just chill and forget things for a while” (P31), and “you can escape for a little bit which makes it easier to focus on the meditation” (P35). Participants found the VR realistic, and it reminded them of relaxing environments that they were familiar with in the real world, reporting “everything was realistic - as if I am home in the Caribbean” (P27), “it was so nice to escape to a beach and other beautiful locations so quick and easily!” (P18) and the VR “was like being on holiday without leaving the office” (P17). Participants found the immersive element pleasurable, in that it felt “incredible - it made me go to a world that was so beautiful and away from reality and it immersed me into that world” (P3) and “you only need a few moments in the environments to put you in a different state” (P8).
Helpful escapism from work-related stress	Participants reported that the VR experience was a helpful source of escapism from the workplace. They reported it was “a useful distraction from work” (P11), “it helped [them] completely switch off from [their] day-to-day work to such a deep level” (P3), and it could function as “a micro break during a stressful day” (P38) or “a break from workplace stress” (P34), which felt “mindful and it took [their] mind away from work” (P32). Many participants found the VR improved their breaktime, reporting “a bit of escapism is enjoyable at lunch time” (P30) and “the sense of escape in the office was helpful as it made me feel like I'd actually had a real break today” (P31).
Enthusiasm for future VR engagement	Participants reported that they would like more VR sessions, stating that “regular sessions can be invaluable to my mental health” (P3), “we need more of these sessions regularly” (P25), “I'd like to do this regularly” (P5), “I think if I tried it multiple times it would be more relaxing now that I know what to expect” (P35), and “I wish I had this at home as it would support my wellbeing” (P24). Participants said they would like “to have more days and more opportunities to experience the additional landscapes” (P26) and “just sitting in the environment and taking a few minutes to be present is reminding me that I need to do this more” (P17).
Recommendations for future implementation	Participants felt that many of their colleagues could benefit from the VR intervention and reported “I think if this was offered in teams it would be a good experience to escape from work stresses for a short period of time” (P4) and “I would like all staff to have the opportunity to experience this” (P15). Participants recommended particular times and occasions when the VR could be helpful, stating that “it would be great when you’re quite stressed at the beginning of the day” (P13), “it will be good if I can access this when I am low or stressed” (P9), and recommended “increased accessibility of this kind of thing in the future for a change of environment whilst you’re on the ward” (P8). One participant reported “I would highly recommend and encourage more people to experience this as it will truly transform your day” (P26). Others made suggestions for improvements to the VR, such as, they would like to have multiple people in the VR with them and “have a shared experience with a peer, a sort of co-op experience” (P26). Participants said that “I would have liked if it was even more interactive because at times, I felt limited” (P18), “I would have liked the imagery to relate more directly to the meditation” (P37) and “the audio guide was nice and the female voice was calming but you could add a few more lines in between the meditation…otherwise after a while, you forget to keep doing those things” (P34).
Difficulties adjusting psychologically to VR	A very small minority of participants experienced some difficulties in adjusting psychologically to immersion in a virtual environment. These participants reported they felt “really stressed” (P41), they were “a bit stressed as it was hard to use and felt that I wasn’t in real-life” (P1), and “I just didn’t find it relaxing as it’s scary to be in a different reality” (P1). Another participant reported “I found some environments easier to connect with than others, sometimes with the night setting it was unnerving” (P19). One participant reported they “felt like I was in the scenery displaced. I frightened myself several times by objects being near to me. It was so surreal” (P22). Another participant described a negative experience with how realistic they found the VR: “it was quite realistic; at one point I was underwater and felt like I could drown” (P8). These participants generally reported feeling relaxed after settling into the session. One participant reported they were “very overwhelmed and a little claustrophobic at first but then I relaxed a bit more into it and I felt a sense of happiness afterwards” (P35). Three participants reported minor negative sensations, such as “a headache by the end because it strained my eyes” (P18), “sensory overload” (P19), and one felt “dizzy but relaxed” (P28).
Practical and technical issues	Some participants reported technical issues when using the VR, but these were typically minor and did not disrupt the sessions. Participants reported that “getting used to the controls is a bit fiddly” (P5), “sometimes it was difficult to navigate the environments” (P13), and they “found it hard to navigate the controls as I have stiff arthritic fingers” (P30). Participants reported some difficulties in wearing the head-mounted display comfortably, highlighting that it was “difficult to use with glasses” (P11), “tricky to get the headset to stay on” (P21), and the “headset didn’t fit my head-to-nose ratio well” (P24). One participant reported “the VR headset was a bit heavy, there was a gap between my nose and the headset, so I could see a bit of light from the room” (P34). Further implementation issues were reported such as some participants finding the hospital environment of the session too noisy, such as “I felt a bit distracted as there was noise from the room during the session, but overall, it was relaxing” (P38) and “it would be better in a quiet room” (P38).

Discussion

The aim of this pilot study was to implement and evaluate a VR intervention to support the wellbeing of multidisciplinary mental health staff in the workplace. Quantitative and qualitative findings indicate that the VR session was feasible and immersive, despite often being delivered in the busy hospital and clinic settings. Almost all participants found it to be a positive and helpful experience, and participants were enthusiastic about its continued use and increased application, indicating the acceptability of the intervention to staff. Staff reported numerous benefits of the intervention, such as the VR being enjoyable, relaxing, stress-reducing, helpful for their wellbeing, and an effective respite from work-related stress.

These positive findings are consistent with evidence that VR is a feasible and helpful tool to promote staff wellbeing in the workplace for a range of healthcare professionals (Adhyaru & Kemp, 2022; Riches, Taylor, et al., 2023; Riches & Smith, 2022). They also support the case for VR as a staff support intervention for mental health staff. Participant feedback about frequency of sessions highlights potential to offer VR as a multi-session staff support intervention. With greater regularity of sessions, staff could have the opportunity to explore more VR environments. This may allow more time for individuals who found it difficult to adjust psychologically during a single session to identify their preferences and experience benefits to their wellbeing, as well as providing potential for longer-term benefits. The minority of participants who had mixed or negative experiences highlights both the importance of offering alternative choices in the package of staff support interventions, i.e., it is unlikely that any interventions will be universally liked, but also the need for in-session briefing, debriefing, and support, especially on both head mounted display comfort and on psychologically adjusting from being present in the real world to immersion in a virtual environment. These in-session issues emphasize the important role of session facilitators, and the need for optimal training and supervision for the facilitator role. Supporting users to navigate the transition back and forth from the real world to the virtual world appears likely to be a key supervision and training need for those facilitating VR-based interventions.

This project aimed to build on previous research findings that virtual natural environments are effective for increasing a sense of relaxation (Li et al., 2021), but it also targeted a broader concept of wellbeing by introducing interactive elements of creativity and meditation exercises in non-natural virtual environments. Project team capacity meant that app choice was limited, especially due to the time-consuming need for session facilitators to have a working understanding of app functionality in VR to support participants to navigate the environments. However, there is huge potential for future projects to increase app choice to users. App stores include numerous wellbeing and relaxation apps that could support workforce wellbeing, e.g., jigsaws, fishing, art, sailing, and space walking (many free or costing less than £10) and new software is being developed all the time. User choice will be vital to the development and the success of these interventions. This choice needs to be a feature at the stage of both intervention delivery and of app development. Greater user research at app development stages will ensure app content is tailored to the specific needs of target user groups, in this case mental health professionals (Pizzoli et al., 2019).

Participant feedback in this study highlights potential for VR developers to design more interactive “co-op” or shared experiences of wellbeing in VR, such as implementing team wellbeing exercises using staff avatars. Studies have investigated VR-based staff training for teams in this sector, but less is known about the potential of VR for group wellbeing exercises (Mantovani et al., 2003; Riches et al., 2022). Greater choice would enable VR sessions to be more person-centred. It also allows potential to make such VR interventions more psychologically informed. VR-based wellbeing interventions could be designed according to a cognitive behavioral framework, encouraging participants to put what they learn about stress-reduction or wellbeing in VR into practice in the real world, which has potential to lead to more sustained, longer-term benefits (Riches, Jeyarajaguru, et al., 2023). Integrating VR interventions like the one used in this study within low-intensity cognitive behavioral approaches further emphasizes the importance of the session facilitator role and on requisite training and supervision requirements.

Strengths and limitations

Strengths of the current study include the sample size, the novel intervention tested in multiple naturalistic hospital and clinic settings, implementation nested in an established NHS staff support service, and the direct, subjective experience of staff participants who trialed the VR from the qualitative feedback. As such, the study presents the potential of new practices for stress-reduction for mental health staff. The project was relatively low cost as a staff support intervention, although costs for VR head mounted displays and software are likely to remain prohibitive for many NHS services, and there would be significant additional costs for a larger scale implementation.

Limitations include use of convenience sampling and lack of a control group, standardized measures, longitudinal data, and of a power calculation to determine an appropriate sample size. This methodology, although appropriate for a pilot study, does not enable this study to address more significant questions such as adequately testing the effectiveness of the intervention. Given the different apps and environments used by participants in the study, there was no standardization of the intervention, which hinders comparison from an evaluation perspective. However, from an implementation perspective, this had the advantage of allowing participants to tailor the intervention to their own preferences, which several participants reported as a merit of the approach and is an important aspect of the choice required to make these staff support interventions feel engaging to participants and, ultimately, a success. Nevertheless, these limitations mean that it is unclear whether there is any benefit of the VR relaxation to staff wellbeing, which future research could explore with a more robust methodology.

The convenience sampling employed in the recruitment strategy for this study meant that it was not possible to know if some staff were unable to access the intervention or whether the intervention reached those staff in greatest need of support, particularly those who may be excluded or experience barriers to accessing support (Riches, Fallah, et al., 2023). It is a notable aspect of the present study that many professional groups were not well represented by the sampling. It was also notable that the baseline mean score for positive wellbeing was moderately high and the baseline mean score for stress was moderate-to-low, indicating that the sample was not highly stressed or experiencing poor wellbeing.

Future implementation and research

Future implementation projects and evaluations could aim to test VR-based staff support using larger and more representative samples, power calculations, validated measures, and control groups, e.g., a non-VR wellbeing group. These projects may wish to identify samples who are experiencing higher stress levels than the sample in this study, or proactively target staff members who are help seeking or at high susceptibility to stress, such as staff who work on wards or with high-risk service users (Williams et al., 2024; Williams & Riches, 2023). Such projects could also be more broadly applied in these inpatient or high-risk settings to also include patients (Riches, Nicholson, et al., 2023). Equally, it is important that staff support is available to the whole workforce, given that interventions such as this can protect staff stress from escalating into more serious mental health difficulties. Given the findings from this study, such future VR projects could potentially use dedicated quiet spaces or wellbeing hubs that are separate from the busiest parts of the hospital to deliver the VR, although it would be important to be mindful of the needs of specialist staff, e.g., staff on forensic wards may not easily be able to leave the ward.

Future implementation projects may wish to consider the practicalities of offering longer-term VR interventions to staff, such as time constraints, when and how to offer the VR, and who might benefit most. More in-depth qualitative data could provide a richer account of staff experience of the VR. It was not in the remit of the present study to compare differences in VR experience between demographic characteristics, different apps, or length of time in VR, but future, appropriately powered research may wish to investigate those factors. Following feedback in this study, future research might explore developing and evaluating more immersive, interactive, and multi-sensory VR experiences (Kaleva & Riches, 2023). It could also be helpful for future research to investigate the role of the facilitator, from what training and supervision is required for human facilitators, to delivery of the intervention with greater in-app avatar support instead of human facilitators, which may enable greater scalability of VR-based staff support interventions for the workplace and allow for the development of VR as a self-help intervention accessible for home-use, especially given increases in hybrid working amongst sections of healthcare professionals.

Authors contributions

Simon Riches, Isobel Arday, and Uma Bartlett conceived the concept and the design of the study. Uma Bartlett and Zoe Bird conducted the data collection under the supervision of Simon Riches and Isobel Arday. Simon Riches, Grace Williams, and Sarah L. Nicholson conducted the analysis. Simon Riches led on writing the manuscript. All authors contributed to and approved the final manuscript.

Ethical approval

This study was approved as a quality improvement project by the South London and Maudsley NHS Foundation Trust. Reference numbers are not provided for this approval. All participants provided verbal consent to participate.

Acknowledgements

The authors would like to thank the Maudsley Charity and all the participants in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The quality improvement project approval did not permit sharing of participants’ data.

Additional information

Funding

This project was funded by a grant from Maudsley Charity [www.maudsleycharity.org, registered charity no. 1175877], with thanks to a donation from NHS Charities Together (www.nhscharitiestogether.co.uk, registered charity no. 1186569 (England & Wales)). Maudsley Charity is a mental health charity based in South-East London, committed to funding the solutions that make a real difference in the lives of people living with mental illness.