XR2ESILIENCE - XR-Based Resilience Training for Stress and Mental Health in Healthcare Workers

This study is part of the XR2ESILIENCE project, a European multicenter research initiative aimed at promoting resilience and mental health among healthcare professionals through innovative extended reality (XR) technologies. The present randomized controlled trial evaluates the effectiveness of a newly developed XR-based resilience training program for nurses working in hospital settings.

Nurses are frequently exposed to high workload, emotional labor, time pressure, and organizational stressors, which are associated with increased stress levels, burnout symptoms, and mental health impairments. Despite the high relevance of resilience promotion in this occupational group, accessible and scalable preventive interventions remain limited. XR technology offers the opportunity to deliver immersive, engaging, and standardized resilience training that can be flexibly integrated into clinical and non-clinical settings.

The study uses a pragmatic, parallel-group, waitlist-controlled randomized design. A total of approximately 232 nurses aged 18 to 65 years will be recruited across multiple hospital sites in Europe. After completion of baseline assessments and provision of informed consent, participants are randomly allocated in a 1:1 ratio either to the XR-based intervention group or to a waitlist control group. The control group continues with care as usual and receives access to the intervention after the waiting period.

The XR-based resilience training consists of eight sessions delivered over approximately ten weeks using a standalone head-mounted display. Each session lasts around 20 to 30 minutes. The training is structured into modules addressing behavioral coping (e.g., problem-solving and proactive coping), cognitive coping (e.g., appraisal and reappraisal of stressors), and emotional coping (e.g., emotion regulation, acceptance, and fostering positive emotions). The intervention is theoretically grounded in contemporary resilience frameworks and the concept of regulatory flexibility. Participants complete the sessions individually, with technical support available if needed.

The primary outcome is perceived stress measured by the 10-item Perceived Stress Scale at post-intervention. Secondary outcomes include resilience, occupational self-efficacy, psychological distress, burnout symptoms, coping strategies, work-related rumination, quality of life, and career-related variables such as turnover intentions. Data are collected at baseline, immediately after the intervention period, and at a 20-week follow-up.

In addition to questionnaire-based outcomes, optional digital biomarker data are collected during selected XR sessions to explore physiological indicators of stress and recovery, such as heart rate variability and other sensor-based measures, depending on study site capabilities. User experience, technology acceptance, satisfaction, and potential side effects of XR use are assessed descriptively after completion of the intervention.

The study follows an intention-to-treat approach for primary analyses. Results are expected to provide robust evidence on whether XR-based resilience training can reduce perceived stress and improve mental health outcomes among nurses. The findings will also inform the feasibility, acceptability, and potential health-economic value of implementing XR-supported resilience interventions in hospital workplaces.

• XR-based Resilience Training (Behavioral): The XR-based resilience training is delivered via a standalone extended reality head-mounted display and consists of eight immersive sessions over approximately ten weeks. The training addresses behavioral coping strategies such as problem solving, cognitive coping strategies such as appraisal and reappraisal of stressors, and emotional coping strategies including emotion regulation and positive self-care. Sessions last approximately 20 to 30 minutes and are completed individually with technical support available if needed.
• Waitlist Control (Other): Participants assigned to the waitlist control condition receive no active intervention during the initial study period and continue with care as usual. After completion of the post-intervention assessment, participants are offered access to the XR-based resilience training.

Primary outcomes

• Perceived Stress Assessed by PSS-10 [Baseline, 10 weeks post-randomization & 20 weeks post-randomization]: Perceived stress measured using the 10-item Perceived Stress Scale (PSS-10). The PSS-10 assesses the degree to which situations in one's life are appraised as stressful during the past month. Scores range from 0 to 40, with higher scores indicating higher perceived stress.

Secondary outcomes

• Resilience Assessed by BRS [Baseline, 10 weeks post-randomization & 20 weeks post-randomization]: Self-perceived resilience will be assessed using the Brief Resilience Scale (BRS), a self-report measure consisting of six items rated on a 5-point Likert scale. Total scores are calculated by summing item responses (range: 6 to 30) and dividing by the number of items answered, resulting in a mean score ranging from 1 to 5. Higher scores indicate greater resilience.
• Occupational Self-Efficacy Assessed by OSE-SF [Baseline and 10 weeks post-randomization]: Occupational self-efficacy will be assessed using the Occupational Self-Efficacy Scale - Short Form (OSE-SF), a self-report measure consisting of items rated on a 6-point Likert scale ranging from 1 (not at all true) to 6 (completely true). Total scores are calculated by summing item responses, with higher scores indicating greater occupational self-efficacy.
• Psychological Distress Assessed by GHQ-12 [Baseline and 10 weeks post-randomization]: Psychological distress will be assessed using the General Health Questionnaire-12 (GHQ-12), a 12-item self-report measure with items rated on a 4-point Likert scale (0 to 3). Total scores range from 0 to 36, with higher scores indicating greater psychological distress.
• Burnout symptoms Assessed by BAT-12 [Baseline and 10 weeks post-randomization]: Burnout symptoms will be assessed using the Burnout Assessment Tool - Short Version (BAT-12), a 12-item self-report measure with items rated on a 5-point Likert scale ranging from 1 (never) to 5 (always). Total scores range from 12 to 60, with higher scores indicating higher levels of burnout-related symptoms.
• Coping Strategies Assessed by CSI-SF [Baseline, 10 weeks post-randomization & 20 weeks post-randomization]: Coping strategies will be assessed using the Coping Strategies Inventory - Short Form (CSI-SF). The CSI-SF is a 16-item measure rated on a 5-point Likert scale ranging from 1 to 5. Subscale scores range from 4 to 20, with higher scores indicating greater use of coping strategies.
• Coping Flexibility Assessed by CFS-R [Baseline, 10 weeks post-randomization & 20 weeks post-randomization]: Coping flexibility will be assessed using the Coping Flexibility Scale - Revised (CFS-R). The CFS-R is a 10-item measure rated on a 4-point Likert scale ranging from 0 to 3. Total scores range from 0 to 30, with higher scores indicating greater coping flexibility.
• Health-Related Quality of Life Assessed by EQ-5D-5L [Baseline and 10 weeks post-randomization]: Health-related quality of life will be assessed using the EuroQol 5-Dimension 5-Level questionnaire (EQ-5D-5L), a standardized instrument comprising five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), each rated on a 5-level scale (1 to 5). Health states are converted into a single index value using a country-specific value set, typically ranging from less than 0 (worse than death) to 1 (full health), with higher values indicating better perceived health status.
• Turnover intentions [Baseline and 10 weeks post-randomization]: Turnover intentions assessed using self-developed items measuring intention to leave the profession or current workplace.
• User Experience Assessed With the AttrakDiff Mini [10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]: User experience will be assessed using the AttrakDiff Mini. The AttrakDiff Mini is a 10-item measure rated on a 7-point bipolar scale ranging from -3 to +3. Higher scores indicate a more positive user experience.
• User Satisfaction Assessed With the Client Satisfaction Questionnaire for Internet-Based Interventions [10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]: User satisfaction will be assessed using the Client Satisfaction Questionnaire adapted for Internet-based interventions (CSQ-I). The CSQ-I is an 8-item measure rated on a 4-point Likert scale. Total scores range from 8 to 32, with higher scores indicating greater satisfaction.
• VR-Related Side Effects Assessed With the Virtual Reality Neuroscience Questionnaire [10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]: VR-related side effects will be assessed using the Virtual Reality Neuroscience Questionnaire (VRNQ), specifically the Virtual Reality-Induced Symptoms and Effects (VRISE) subscale. Items are rated on a 7-point Likert scale, with higher scores indicating lower intensity of side effects.
• Positive Effects Assessed With Adapted Items From the Oxford VR Side Effects Checklist [10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]: Positive effects will be assessed using three adapted items from the Oxford VR Side Effects Checklist (O-VRES). Items are rated on a 5-point Likert scale. Total scores range from 3 to 15, with higher scores indicating greater endorsement of positive effects.

Sex: All, ages: 18 Years to 65 Years, accepts healthy volunteers

Inclusion Criteria:

1. working as a nurse in direct patient care within a clinical setting;
2. working at least 10h/week in their profession;
3. speaking the language in which the RCT is conducted sufficiently well;
4. able and willing to participate in all aspects of the study;
5. understanding and signing the appropriate informed consent form.

Exclusion Criteria:

1. a diagnosed severe mental disorder associated with alterations in reality perception (e.g., delusions, hallucinations, derealization, depersonalization, or dementia), including in particular schizophrenia, bipolar disorder, severe major depressive disorder, or other psychotic disorders (lifetime);
2. a current major depressive episode or a current post-traumatic stress disorder (PTSD);
3. an acute or clinically significant medical condition that may interfere with the safe use of an XR headset or study participation, including but not limited to epilepsy, pronounced dizziness, balance disorders, or acute cardiovascular conditions;
4. an acute eye infection (e.g., conjunctivitis);
5. unstable medication related to a mental health condition, defined as recent changes in dosage or class of psychotropic medication;
6. initiation of psychotherapy or any structured stress-management training within the past three months.

• Study Protocol, Statistical Analysis Plan, and Informed Consent Form (PDF, 2026-03-26)