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Abstract
Background Aggression and negative activation in mental health inpatient units pose significant challenges for both patients and staff with severe physical and psychological ramifications. The Safewards model is an evidence-based conflict-containment framework including 10 strategies, such as ‘Calm Down Methods’. As virtual reality (VR) scenarios have successfully enhanced anxiolytic and deactivating effects of therapeutic interventions, they are increasingly considered a means to enhance current models, like Safewards.
Objectives The present participatory design investigates the feasibility and user experience of integrating VR therapy as an add-on strategy to the Safewards model, gathering preliminary data and qualitative feedback from bedside staff in an adult inpatient mental health unit.
Methods An exploratory within-subjects design combining qualitative observations, self-report questionnaires and semistructured interviews is employed with four nurse champions from the mental health unit at Michael Garron Hospital (Toronto, Canada).
Results A chronological overview of the design process, adaptations and description of the user experience is reported.
Conclusion ‘SafeVRwards’ introduces VR as a promising conflic-containment strategy complementary to the Safewards model, which can be optimised for deployment through user-oriented refinements and enhanced customisation capacity driven by clinical staff input.
- Mental health
- Healthcare quality improvement
- Community-Based Participatory Research
- Information technology
Data availability statement
All data relevant to the study are included in the article or uploaded as supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Mental health
- Healthcare quality improvement
- Community-Based Participatory Research
- Information technology
WHAT IS ALREADY KNOWN ON THIS TOPIC
Conflict from agitation and aggression in mental health inpatient wards can be distressing for patients and staff and lead to worse health outcomes.
The Safewards framework has been successfully implemented, managing conflict in mental health inpatient wards by employing strategies like ‘Calm Down Methods’.
Virtual reality (VR) has been used as a tool for relaxation in a growing number of healthcare settings and contexts.
Staff concerns and potential barriers to VR adoption in clinical settings, including limited awareness among clinicians, were acknowledged in the existing literature.
WHAT THIS STUDY ADDS
VR has not been previously evaluated as a tool in mental health inpatient wards. This study reveals positive potential outcomes, particularly when enhanced with scent, including relaxation, immersion and a sense of presence.
Insights into the high usability and applicability of VR for both staff and patients, along with some criticisms regarding experiences that may potentially break immersion or exacerbate symptoms, highlight the importance of continued participatory design.
VR is an appropriate complementary strategy to the Safewards framework that can augment the benefits and reach of existing training modules.
The importance of customisability in content and delivery, especially at the sensory level, to make VR suitable for various mental health profiles is highlighted.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Contributes to the body of knowledge demonstrating the value of participatory design and continued monitoring of staff and patient experience across implementation stages for successful integration of healthcare innovations.
Implies that VR can be introduced as a complementary strategy in the existing Safewards framework.
Suggests the need for specific clinical guidelines and treatment protocols for VR therapy, addressing concerns about symptom exacerbation and ensuring ethical application.
Future research may investigate optimal conditions for VR therapy administration, customisability in VR and benefits of VR therapy compared with other conflict-containment techniques, providing directions for further refinement and development.
Background
Conflicts in mental health wards pose serious concerns; aggressive behaviours maintain disorders, hinder treatment goals and cause discomfort for staff, exacerbating burnout symptoms and safety concerns that can negatively affect ward activities and consequently patient treatment outcomes.1 As ensuring a safe and secure environment in psychiatric wards is a priority for nursing staff,2 equipping them with non-harming strategies to regulate and manage aggressive behaviours is crucial. To address these needs, the widely implemented ‘Safewards model’ was developed: an evidence-based framework for training conflict management to health staff within psychiatric units.3 4 This model identifies a series of conflict-originating factors leading to specific flashpoints that can trigger incidents, indicating a dynamic relationship between conflict (patient behaviours threatening the safety of themselves or others, that is, violence, self-harm, absconding) and containment (methods to minimise harm, that is, medication, special observation, seclusion) where containment use can sometimes escalate conflict than prevent it.
As conflicts from psychiatric settings often stem from patient anxiety and agitation, they are manageable through relaxation techniques5 6 the Safewards model also incorporates, such as the ‘Calm Down Methods’. Common examples include exposure to hot or cold-scented towels and relaxing music.5 Exposure to nature is another calming activity affecting several neurophysiological signals7; in Japan, ‘forest bathing’ (shinrin-yoku), or multisensory immersion and engagement with nature is known to promote health.8 In line with psychoevolutionary theory, exposure to naturalistic environments enhances positive emotions9 and can reduce anxiety, rumination and depressive symptomatology.10–12 Virtual reality (VR) is an increasingly used care alternative enabling diverse populations to reap these benefits when physical presence in such spaces is not feasible.
VR can be defined as a sophisticated array of technologies designed to immerse users in computer-generated environments capable of emulating various aspects of the natural world.13 Through digital representation of natural stimuli, VR can induce psychological and physiological relaxation, and elicit a sense of presence with minimal confirmed difference between real and virtual natural environments.14–17 This substantiates the potential benefits of facilitating relaxation in virtual settings.
VR technologies typically engage only two senses—vision and audition—limiting the user’s virtual experience.18 Recent research explores the impact of stimulating additional senses on feelings of presence, immersion, user engagement and overall VR experience.19–24 Scents evoke experiences not solely influenced by cortical elaboration,7 25 26 activating emotion-related contents or experiences almost automatically. Their strong association with autobiographical memories allows personalisation of VR settings based on users’ past experiences and needs to enhance relaxation and positive emotional states.18 Despite extensive evidence on how smell influences mood, stress and anxiety,25–27 few VR applications and studies have explored olfactory stimulation to improve sensory experiences.19 28 Notably, one study demonstrated that aversive and unpleasant scents,19 or simultaneous stimulation of multiple senses (ie, hearing, touch, smell) in VR can heighten feelings of presence, improving outcomes in exposure therapy for specific phobias and post-traumatic stress disorder.29 30 Beyond presence, Pizzoli et al 18 suggest that involving smell may boost the effectiveness of relaxing interventions and enable more personalised VR scenarios.
VR is widely applied in clinical psychology and psychiatry, offering versatility across different settings for learning new adaptive skills (ie, improved coping strategies) and managing disorders (ie, anxiety disorders, pain management, eating and weight disorders, addiction, psychosis and autism).13 31 Clinical outcomes highlight VR’s efficacy in treating anxiety disorders, specific phobias, eating disorders and chronic pain, with promising results in managing psychosis and addictions.13 While VR shows potential as a therapeutic relaxation tool, research in psychiatry has mainly focused on applications in exposure therapy and less on other essential aspects of general mental health services.32 33
To our knowledge, Veling et al 34 were the first to explore the impact of a relaxing VR environment applied in an acute mental health setting. They studied the effects of VR exposure on 50 psychiatric outpatients and observed improved affective states. Both VR and standard relaxing interventions (audio tracks of guided meditation and progressive muscle relaxation exercises) contributed to this improvement, although VR exposure showed a greater impact on reducing negative affect (ie, state anxiety and sadness). In another study, VR was found to facilitate learning anxiety-management strategies and practising essential psychosocial skills, including emotion regulation through relaxation training, daily living and social skills, and pleasant activities to manage mood states.33
Past VR research seldom delved into the perspectives of service managers and clinicians (ie, psychologists, psychiatrists, mental health nurses, allied health), whose support ultimately determines the integration of VR into routine clinical practices.33 Limited evidence-based studies explore perspectives on implementing VR in general mental health services,33 35 such as potential barriers and advantages in enhancing treatment efficacy, patient engagement and therapeutic alliances with health staff.33 Chung et al 33 were the first to investigate clinicians’ and service managers’ perspectives on the cost-effectiveness of implementing therapeutic VR in mental health services. Through semistructured interviews, they identified three major schemas (clinical, organisational and professional) of enabling factors and possible barriers to successful VR implementation.33 The authors concluded that consulting clinical staff early in the implementation process was a vital source of feedback.33 A study by Ilioudi et al 36 also showed that a VR ‘calm room’ for psychiatric ward patients can transcend major logistical issues in accessibility, convenience and affordability that hinder the implementation of traditional, physically furbished relaxation spaces.
Although data indicate that VR-based relaxation therapy may enhance the quality of life on psychiatric wards,32 33 to our knowledge, no study has explored its potential to manage aggressive behaviours among acute mental health ward inpatients. Furthermore, the determining factors for VR implementation in real-world settings remain poorly understood, with no known effort to incorporate VR into a larger framework like Safewards.33
Objective
Our primary objective is to document the existing Safewards training process and use these sessions, together with stakeholder engagement, to test and refine any resources that might support VR’s incorporation into the broader Safewards framework. Additionally, we report on the impact of the VR intervention (both with and without smell) on nursing staff anxiety levels as a preliminary indication of its potential to support psychiatric patients.
Research methodology
Study design
This exploratory initiative comprised three study phases. In this manuscript, we focus on phase 1, ‘Observing and documenting the existing Safewards training at Michael Garron Hospital (MGH)’, along with recruiting and obtaining initial feedback from select staff who will assist with the study rollout. Phase 2 involves one-on-one VR experience sessions with a greater contingent of bedside staff to investigate whether (a) VR therapy helps relax healthcare staff (based on self-reported feedback and biomarkers); (b) the addition of smell to existing visual and auditory stimulation impacts relaxation; (c) staff believe this could be an effective tool to use with their patients to contain or manage conflict. Phase 3 will involve designing and delivering a ‘SafeVRwards’ training module based on insights from phases 1 and 2. The latter two phases will be described in subsequent publications.
Data collection for phase 1 occurred from July to August 2022 in a dedicated room provided by the H6 Adult Inpatient Mental Health Unit at MGH in Toronto, Canada. At the time of data collection, the primary researcher responsible for conducting observations and interviews was a clinical psychotherapist with training in clinical assessment, experimental procedure administration and administration of psychotherapy protocols.
Participants
Participants were included if they were health providers delivering bedside care to patients in the H6 Adult Inpatient Mental Health Unit at MGH and were excluded if they were temporary staff (eg, agency nurses, per diem nurses) or unable to comfortably communicate in English. There were no exclusion criteria for phase 1.
Procedure
The aim of the project’s first phase was to understand the rationale and activities of the standard Safewards training to determine when and how to model SafeVRwards. Phase 1 involved engaging stakeholders at four points in time, as summarised in figure 1.
SafeVRwards timeline. VR, virtual reality.
Team huddles
The research team first observed the H6 Psychiatric Unit staff during daily morning huddles—a dedicated time for clinical staff to address patient concerns or challenges, share resource needs and discuss new initiatives (such as Safewards) or studies (like this trial) involving the unit. The goal was to introduce the SafeVRwards initiative and its rationale, build rapport with staff and familiarise the research team with the ward’s day-to-day functioning.
Safewards full-day workshop
Next, the research team observed nurse champions37 as they participated in a full-day (6 hours) Safewards training workshop. The trainer explained the Safewards model’s origin, conflict dynamics in psychiatric units and containment methods, including Safewards strategies (eg, Talk Down, use of soft and positive words, mitigating bad news and the Calm Down Method). Each agenda module included a theoretical and practical component allowing participants to propose exercises where they could discuss daily challenges with patients. The session aimed to document the training format and identify effective learning strategies preferred by staff, informing the design of the VR intervention module for seamless integration into the overall training.
Informational meetings
Two 1-hour Zoom meetings were held with nurse champions to introduce the VR intervention and its potential application as a Calm Down Method. Participants were asked to reflect on the theoretical description of VR and identify potential challenges in teaching staff to use the technology to achieve widespread adoption within the unit. The goal was to validate the content and training methods for the SafeVRwards module, ensuring resonance with staff and minimal barriers to testing and adoption.
VR demo trial
Finally, 40-minute one-on-one demo trial sessions were conducted with nurse champions. During the session, participants wore the VR head-mounted display (HMD) for at least 6–8 min in two modalities (with and without smell). Participants could select from three scenes (beach, waterfall, lake) and were then randomised to view the experience first with or without the diffusion of scents. Before donning the VR headset, participants completed a pre-intervention questionnaire (see online supplemental material) capturing their previous experience working in mental health, awareness of VR and baseline relaxation levels. While in VR, the research team took detailed observational notes using a structured tool. After experiencing both modalities, participants filled out a post-questionnaire (see online supplemental material) on usability and participated in a semistructured interview asking for overall feedback on the experience and its impact on relaxation. This phase aimed to provide nurse champions firsthand experience with VR, helping them envision its potential use with patients and refining the ‘training and evaluation’ before introducing it to the broader unit staff as a complete ‘SafeVRwards module’.
Supplemental material
Materials and apparatus
VR hardware
The main hardware component was the Meta Quest 2 HMD,38 chosen based on affordability and user-friendliness compared with other devices, in line with our mission to facilitate VR adoption in more challenging clinical settings.
VR stimuli
In the HMD, participants viewed one of three immersive 360° videos of natural environments: a (A) tropical beach, (B) forest waterfall or (C) mountain lake (see figure 2), purchased from Atmosphaeres.39 These scenes included visuals and background audio designed to be calming (ie, waves, leaves blowing, waterfall sounds, etc), and each scene was matched to appropriate scents (eg, the forest waterfall had dirt-mud-earthy and wood smells) diffused using the OVR ION2 tool40 attached to the bottom of the HMD (see figure 3).
Screen captures of three virtual scene options and related scents. (A) Beach (scents: beach and breeze), (B) waterfall (scents: flowers, dirt, forest, wood and grass) and (C) lake (scents: flowers, dirt, forest and grass).
A participant during exposure to the virtual context. HMD, head-mounted display; PC, personal computer.
Data collection methods
The mixed-methods study included (1) observations, (2) self-report questionnaires and (3) semistructured interviews. Qualitative data (observations, interviews) were analysed by two independent coders, using the constant comparison method. Quantitative data (validated questionnaires (System Usability Scale (SUS)), scales about immersion, presence, etc) were reported using descriptive statistics.
Observations
Qualitative observations were conducted throughout the study, and notes were anonymised on paper without reference to specific participants. Team huddle observations documented standard activities in the unit, staff workflow and opinions about the resources available to manage conflict with patients.
During the full-day Safewards training session, the research team took observational notes on staff reactions to the training concepts and methods (eg, train the trainer), noting which learning strategies resonated best with staff. During the demo sessions, researchers adapted a structured guide, the Modified Observing Reactions in Virtual Reality Measure (ObsRVR),41 to observe staff reactions (eg, engagement, frustration) with VR in both smell and no smell mediums, to cross-reference with their self-reported feedback.
Self-report questionnaires
Before experiencing the VR intervention, participants completed a brief questionnaire with demographic information and scenery preference (lake, beach, forest). Relaxation levels were measured pre-demo and post-demo in both modalities, using a 0 (not at all relaxed) to 10 (totally relaxed) scale.
Post-demo participants also responded to the SUS, a 10-item instrument measuring user perceptions of product usability,42 and rated their degree of simulator sickness, feeling of presence, immersion and realism, as well as their overall impression of the VR experience in both modalities (with and without smell).
Interviews
Semistructured interviews were conducted immediately after the VR demo. Interview questions addressed four main themes: (1) the effectiveness of the training module in introducing VR as part of the Safewards framework, (2) VR’s ability to induce relaxation and the effects of added olfactory stimulus, (3) the feasibility of incorporating VR into the Safewards model, and (4) other potential uses of the technology for staff, patients and/or the hospital. Interviews were audio-recorded and anonymised during transcription. The original audio files were destroyed, and the digital transcriptions were stored on a password-protected computer.
Results
Four nurse champions (2=female; 2=male; average age 32 years (SD=5.44; min=26; max=39)) with 1–5 years of experience at the hospital were purposefully recruited from the H6 ward staff. These staff were among a select number of volunteers assisting hospital management in designing Safewards modules and organising staff training on the framework. As such, they were ideal participants to engage in designing complementary modules like SafeVRwards. They were first approached for participation via email invitation by the research team.
Observations
The complete observational notes taken by the research team are available upon request. Key findings indicated that staff valued role-playing activities in the training workshop, where they described and replicated challenging real-life situations and collectively brainstormed ways to implement new strategies and tools to ‘contain’ conflict situations. Regarding the VR technology, participants suggested avoiding human voices in the audio as patients may be unable to differentiate the source of sounds (virtual environment or psychotic experience). A common concern was potential damage to hardware components or injury to patients experiencing altered psychological states or unpredictable situations. Nurse champions criticised image quality and requested improvements to reduce blurriness. They also noted that adding smell enhanced immersion in VR. Observations from the ObsRVR supported all self-reported results, indicating that all participants experienced ‘some’ to ‘substantial’ engagement, enjoyment, relaxation and reminiscence during VR exposure, irrespective of modality.
Interestingly, participants reflected on the potential use of VR to relax staff in addition to patients.
Questionnaires
Table 1 details results from measures administered during the demo trial in the smell and no smell condition. In both modalities, participants reported a substantially higher level of subjective relaxation post-exposure compared with pre-VR. Although results should be interpreted with caution given the small sample size, it is worth noting that for every item except relaxation, the smell condition resulted in slightly higher ratings (more positive impact). Participants rated VR exposure as consistent with real-world experience, reporting feelings of presence and immersiveness, and a tendency to forget everyday concerns and lose track of time.
Feasibility, usability, and psychological data for both VR conditions
No participants reported symptoms of simulator sickness (ie, nausea and dizziness). However, the smell condition yielded slightly higher ratings of simulator sickness compared with the no smell condition.
All SUS scores exceeded the cut-off (>68), indicating a good-to-excellent usability rating for the VR system. Positive feedback on the hardware and software equipment indicated that the technology was ‘easy to use’, ‘comfortable’ and ‘smooth’. There was a slight increase in the rating of ‘wanting to use VR frequently’ in the smell condition.
Interviews
Feedback on the overall experience was relatively positive, with many seeing VR implementation as beneficial for patient care. In the smell condition, three of four participants felt it could enhance presence and reminiscence, although the fourth noted a negative impact due to a discrepancy between the expected and provided smell. The participant acknowledged this may not be a universal experience. See table 2 for a subselection of representative quotes.
Representative quotes from interviews on experiences in both VR conditions
Discussion
In this initial phase, preliminary data and qualitative feedback on the feasibility and user experience with VR therapy were collected from nurse champions at a mental health inpatient unit. Employing participatory design allowed end-users to collaborate with researchers in defining, creating and iterating on the potential VR intervention to ensure alignment with patient needs, unit workflow and ethical application principles.34–46 Addressing clinical staff’s concerns and perceived barriers to implementation is crucial to prevent biases against VR adoption.33 Continuous exposure to VR through research collaboration can improve staff comfort with the technology and align their perspectives to recent literature, demonstrating its promising clinical application. Results suggest that VR therapy, especially when enhanced with scent, offers benefits such as relaxation, immersion and sense of presence, and can be an effective complementary module to Safewards strategies with user-centric adjustments suggested by staff. This is in line with research that suggests broad clinical applicability of VR, such as Riches et al 47 who found VR to be an acceptable and effective intervention for patients exhibiting acute psychiatric conditions, with demonstrated potential for mitigating violent incidents and restrictive practices in psychiatric wards. This indicates that VR can find clinical application in stress management and relaxation for individuals with acute psychiatric conditions.
Given positive staff experience with the role-playing component in standard Safewards training, integrating simulation and post-simulation brainstorming into VR training could maximise learning benefits and facilitate seamless on-the-job application. Providing clarification on VR’s unique functions and benefits compared with other Safewards strategies may aid its integration to standard care practices, addressing potential staff resistance arising from perceived disruption to clinical workflow.33 Staff concerns regarding clinically appropriate VR application, especially for certain patient profiles (eg, impairment levels, symptoms, age), highlight the need for specific clinical guidelines and treatment protocols to ensure regulated, ethical VR application—a suggestion echoed by Chung et al.33
Nurse champions emphasised the importance of user-centric design for VR, especially the adaptability to varying symptoms and severity of impairment, to mitigate potential harm to patients. Similar to Chung et al,33 concerns were raised about possible adverse effects in unpredictable situations and the risk of amplifying certain psychotic states. Recommendations included modifying VR content and engagement to prevent exacerbating or triggering symptoms, such as using instrumental music instead of human voice, to prevent safety hazards to patients, staff and hardware. Echoing Chung et al,33 participants emphasised the need for ‘individual, tailored approaches’ in VR administration to ensure broad clinical utility (eg, group therapy, accommodating learning and cognitive disabilities), and the importance of broadening software constraints to offer clinicians greater flexibility in the virtual environment. Nurse champions further reported that customisation (ie, selecting from one of three natural environment videos) was the most engaging feature of the VR intervention, indicating its potential appeal to patients in acute mental healthcare where the need for a shifting balance of power, patient vocalisation and two-way process between patients and clinicians have been previously highlighted.48
Our study implies that enhanced customisation in content and delivery at the sensory level could make VR suitable for various mental health profiles, enabling greater personalised experiences for patients and improving the applicability of Safewards as well.33 49 Nurse champions reported that the addition of olfactory stimuli enhanced their experience across immersivity, engagement and want of use, although it did not translate to a higher degree of relaxation. This suggests that a multisensory VR experience may better distract from aggression-triggering emotions, with increased potential for continued use from staff and patients.
Participants highly rated the usability and applicability of VR for both themselves and patients, with no reported motion sickness symptoms. Motion sickness is a crucial feasibility information that contributes to reducing the likelihood of discomfort or other collateral manifestations.50 Nurse champions predominantly found VR to be comfortable, smooth and easy to use, expressing confidence that most individuals could quickly learn the technology. This aligns with insights from Chung et al,33 suggesting that VR is a relatively straightforward technology for a variety of patients, including older adults.
However, criticisms about image quality and blurriness indicate a need for continued monitoring of quality and patient experience, and engagement with clinical staff to ensure that the perceived usability of VR is true to the current state of technology. Chung et al 33 propose that as perceived barriers to implementation may stem from limited awareness among clinicians, which tends to have a stronger influence on staff intention to adopt technology than positive attitudes, ongoing efforts to dispel misconceptions and improve awareness are critical for VR’s successful integration. Continued collaboration with clinical staff in technical refinement and module design may support this need by offering consistent VR exposure, education and expert engagement for staff.
Participants unanimously viewed VR as a generally positive and beneficial experience, promoting engagement, enjoyment, relaxation and reminiscence for themselves and by extension, their patients. The ability to foster a sense of presence was considered valuable in redirecting attention from negative beliefs or conflicts, which may contribute to the distress-coping function of Calm Down strategies.7 Similar benefits were reported in Chung et al,33 with VR being viewed as a potential alternative to traditional therapies that might not engage appropriate senses or rely too heavily on specific methods (eg, patients ‘stuck in a rut’ with verbal therapies), or for younger patients who may have their ‘own world of interaction’. Participants in our study noted that VR could potentially increase patient engagement and attractiveness more than conventional activities, which are often less immersive (eg, two-dimensional VR, videos, music), consistent with reports of clinicians and managers in Chung et al 33 who believed that VR integration supports a culture of ‘trialling’ innovations that ensure long-term patient appeal and service competitiveness.
Strengths, limitations and future directions
This study’s strengths include using a mixed-methods participatory design approach and recruiting frontline staff directly involved in designing the Safewards modules and training. To enhance future research, we recommend increasing the number while also broadening the participant pool to encompass stakeholders across clinical disciplines (eg, managers, psychiatrists), given evidence that VR can impact clinical practices for various healthcare experts.51 Additionally, given the unit’s history of involvement in new initiatives and research studies, the openness to innovations may differ in other acute psychiatric wards, warranting further exploration into potential differences in innovation receptiveness based on unit or institution-specific cultural factors.
To enhance the customisability of VR therapy and the potential for improved realism, the next steps should involve exploring various smells, adjusting their intensity, and experimenting with sensory combinations for each VR scenario. To enhance the feasibility of integrating VR into Safewards training and optimise deployment strategies, essential steps involve conducting comparative research. This research should assess the distinctive benefits and risks of the VR intervention in comparison with alternative strategies within the framework. Additionally, investigating potential variations within the VR intervention, such as incorporating different smells, musical elements and narrative components, is crucial for a comprehensive understanding and effective implementation. Nurse champions’ concerns about potential symptom exacerbation also highlight the need to investigate optimal conditions for VR therapy administration, whether as a routine preventative activity or during acute phases of agitation. Drawing insights from implementation literature and clinical precedents is recommended for the development of treatment guidelines for VR therapy.
Conclusion
Within the expanding body of evidence supporting VR’s relaxation potential, a notable gap exists in exploring its use for anxiety and aggression management in mental health inpatients. Our multiphase study addressed this by assessing the feasibility and user experience of VR therapy as an adjunct to the Safewards model, designed to relax patients and contain conflicts in clinical mental health settings. In situ execution and participatory design led to instrument refinements showcasing VR’s potential (particularly with olfactory stimuli) to enhance immersion and thus induce relaxation. To ensure clinical appropriateness and applicability across diverse patient profiles, future iterations should continue to engage clinical staff, be user-oriented and enhance customisability. As we enter phase 2, qualitative data and feedback gathered in the study will shape the technological refinements and delivery of the VR intervention, positioning it for effective integration into the Safewards framework and clinical workflow.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and has been approved by the Michael Garron Hospital Research Ethics Board (REB reference number: 865-2204-Mis-379) on 28 July 2022. Participants gave informed consent to participate in the study before taking part.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Correction notice This article has been corrected since it was first published. Author name 'Tiago H Falk' has been updated.
Contributors LA (guarantor), SP, CS and THF contributed to the conception and design of the study. LA, SP, KL and CS organised the on-site data collection. SP, BJdJ and MKSL administered the experimental procedure, and SP and LA contributed to the methodology design and data analysis. BJdJ, MKSL and THF deployed the hardware and software apparatus. SP, LA and SK wrote the first draft of the manuscript. All authors read and approved the final manuscript.
Funding This work was supported by TD Community Health Solutions (2022-06-RIC003).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.