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.

• Resilience Assessed by BRS [Time frame: Baseline, 10 weeks post-randomization & 20 weeks post-randomization]
• Occupational Self-Efficacy Assessed by OSE-SF [Time frame: Baseline and 10 weeks post-randomization]
• Psychological Distress Assessed by GHQ-12 [Time frame: Baseline and 10 weeks post-randomization]
• Burnout symptoms Assessed by BAT-12 [Time frame: Baseline and 10 weeks post-randomization]
• Coping Strategies Assessed by CSI-SF [Time frame: Baseline, 10 weeks post-randomization & 20 weeks post-randomization]
• Coping Flexibility Assessed by CFS-R [Time frame: Baseline, 10 weeks post-randomization & 20 weeks post-randomization]
• Health-Related Quality of Life Assessed by EQ-5D-5L [Time frame: Baseline and 10 weeks post-randomization]
• Turnover intentions [Time frame: Baseline and 10 weeks post-randomization]
• User Experience Assessed With the AttrakDiff Mini [Time frame: 10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]
• User Satisfaction Assessed With the Client Satisfaction Questionnaire for Internet-Based Interventions [Time frame: 10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]
• VR-Related Side Effects Assessed With the Virtual Reality Neuroscience Questionnaire [Time frame: 10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]
• Positive Effects Assessed With Adapted Items From the Oxford VR Side Effects Checklist [Time frame: 10 weeks post-randomization (Training Group) or 20 weeks post-randomization (Control Group)]