Tree: Reducing the use of restrictive practices on psychiatric wards through virtual reality immersive technology training

Table 1 Brief summaries of virtual reality simulations used in the study

Simulation	Scenario	Scene purpose	Scene written description
1	A patient with a weapon approaching a ward staff on the corridor/room - “Chelsea Cosh”/Millwall Brick	To demonstrate de-escalation of situation without the need to use restrictive practices	Staff member encounters patient with a weapon in day room
2	A patient confronting, shouting and screaming at a ward staff	To introduce learner to a spontaneous situation that may occur on a ward	Conversation between colleagues about an escalated patient who is angry that another patient has taken their cigarettes and isn’t giving them any back
			They are distressed that their needs are not being seen to and the ward staff are gesturing that they will be with them soon
3	Experience of being a patient under observation - filmed from a patient’s perspective	To give user/learner the experience of being under supervision or observation	Filmed from perspective of patient (1st person). Clinical worker talking to camera explaining that they are being placed under observation
4	Conflict over restricted area. Dealing with conflict over access to a locked fridge/restricted area	For learners to understand/empathise with frustrations around patients trying to do day to day tasks	Set in ward communal area/kitchen. Patient enters and is attempting to make a cup of tea

Table 2 Demographic characteristics of the sample

Characteristic	VR (n = 34)	TAU (n = 22)
Age (year), mean (SD)	40.8 (13.2)	40.7 (11.9)
Sex, n (%)
Male	9 (26.5)	10 (45.5)
Female	25 (73.5)	12 (54.5)
Ethnicity, n (%)
White	23 (67.6)	11 (50)
Other white background	2 (5.9)	1 (4.5)
White and Asian	1 (2.9)	1 (4.5)
Indian	1 (2.9)	0 (0)
Pakistani	0 (0)	1 (4.5)
Other Asian background	1 (2.9)	0 (0)
African	4 (11.8)	8 (36.4)
Other Black background	1 (2.9)	0 (0)
Other	1 (2.9)	0 (0)
Education level, n (%)
No formal qualifications	1 (2.9)	0 (0)
GCSE or equivalent	9 (26.5)	4 (18.2)
A-level or equivalent	7 (20.5)	4 (18.2)
Undergraduate	15 (44.1)	9 (40.9)
Postgraduate or above	2 (5.9)	5 (22.7)
Disorder, n (%)
Anxiety	1 (2.9)	2 (9.1)
Depression	8 (23.5)	4 (18.2)
Post-traumatic stress disorder	1 (2.9)	0 (0)
None	21 (61.8)	13 (59.1)
Other	3 (8.8)	3 (13.6)
Role, n (%)
Mental health nurse	9 (26.5)	9 (40.9)
Healthcare support worker	22 (64.7)	12 (54.5)
Occupational therapist	0 (0)	1 (4.5)
Other	3 (8.8)	0 (0)
Work time in NHS, n (%)
> 8 months	0 (0)	1 (4.5)
8 months to 1 years	3 (8.8)	1 (4.5)
1-5 years	19 (55.9)	6 (27.3)
6-10 years	2 (5.9)	2 (9.1)
< 10 years	10 (29.4)	12 (54.5)
Experience in inpatient psychiatric wards, n (%)
> 1 year	3 (8.8)	2 (9.1)
1-2 years	5 (14.7)	2 (9.1)
3-4 years	7 (20.6)	1 (4.5)
4-5 years	7 (20.6)	3 (13.6)
≤ 5 or more year	12 (35.3)	14 (63.6)
Experience in restrictive training, n (%)		n = 21
None	2 (5.9)	1 (4.5)
> 1 year	3 (8.8)	6 (27.3)
1-2 years	6 (17.6)	1 (4.5)
3-4 years	4 (11.8)	0 (0)
4-5 years	6 (17.6)	3 (13.6)
≤ 5 or more years	13 (38.2)	10 (45.5)

VR: Virtual reality; TAU: Treatment as usual; GCSE: General Certificate of Secondary Education; NHS: National Health Service.

Table 3 Baseline comparison

Characteristic	VR (n = 34)	TAU (n = 21)	P value	Effective size	Power
Total GAD7 score, mean (SD)	2.88 (4.13)	4.32 (5.71)	0.663	0.0597	0.9998
Total GSE score, mean (SD)	32.71 (4.36)	31.14 (3.73)	0.295	0.142	0.9939
EDS measure
Item 1	4.29 (1.27)	3.71 (1.52)	0.166	0.194	0.9685
Item 2	4.50 (1.13)	3.90 (1.37)	0.93	0.205	0.9575
Item 3	5.53 (0.71)	5.43 (1.03)	0.986	0.0028	1
Item 4	4.79 (1.07)	5.14 (1.11)	0.209	0.179	0.9796
Item 5	5.35 (0.88)	4.71 (1.74)	0.363	0.136	0.9951
Item 6	5.62 (0.70)	5.71 (0.56)	0.722	0.0616	0.9998
Item 7	4.88 (0.98)	4.29 (0.90)	0.035a	0.296	0.7211
Item 8	5.06 (1.37)	4.29 (1.79)	0.096	0.239	0.9028
Item 9	5.09 (1.22)	3.71 (1.79)	0.005b	0.395	0.258
Total BAT12 score	27.24 (6.99)	25.67 (7.00)	0.423	0.2211	0.1225
Compassionate
To others	78.03 (11.65)	82.86 (8.36)	0.109	0.4458	0.3511
From others	68.56 (18.65)	67.62 (24.65)	0.874	0.0435	0.0527
Compassion engagement
To others	42.97 (8.65)	46.67 (6.97)	0.101	0.4564	0.3651
From others	37.94 (11.92)	39.14 (14.79)	0.742	0.0907	0.0619
Compassionate action
To others	35.06 (5.07)	36.19 (4.34)	0.377	0.121	0.9972
From others	30.62 (7.82)	28.48 (10.30)	0.55	0.0808	0.9995

^aP < 0.05.

^bP < 0.01.

VR: Virtual reality; TAU: Treatment as usual; GAD7: Generalised anxiety disorder assessment 7; GSE: General self-efficacy; EDS: Everyday Discrimination Scale; BAT12: Burnout Assessment Tool 12.

Table 4 Levels of confidence and anxiety

Outcome measures	Sample groups	Baseline	One-month	P value	Effectiveness size	Power
GAD	VR (n = 23), mean (SD)	2.88 (4.13)	3.39 (3.60)	0.341	0.128	0.9577
	TAU (n = 17), mean (SD)	4.32 (51.7)	5.24 (5.56)	0.64	0.0768	0.9951
	VR vs TAU1	-	-	0.702	0.0613	0.9974
GSE	VR (n = 23), mean (SD)	32.17 (4.13)	31.78 (4.31)	0.531	0.0833	0.9996
	TAU (n = 17), mean (SD)	31.14 (3.73)	32.83 (4.75)	0.147	0.237	0.7974
	VR vs TAU1	-	-	0.367	0.143	0.9717

¹Virtual reality vs treatment as usual comparison at one-month.

VR: Virtual reality; TAU: Treatment as usual; GAD: Generalised anxiety disorder assessment; GSE: General self-efficacy.

Table 5 Levels of discrimination - Everyday Discrimination Scale

Outcome measures	Sample groups	Baseline	One-month	P value	Effectiveness size	Power
Item 1	VR (n = 23), mean (SD)	4.29 (1.27)	4.13 (1.29)	0.62	0.0677	0.9998
	TAU (n = 17), mean (SD)	3.71 (1.52)	4.12 (1.54)	0.454	0.125	0.9784
	VR vs TAU1	-	-	0.924	0.0155	0.9995
Item 2	VR (n = 23), mean (SD)	32.17 (4.13)	31.78 (4.31)	0.531	0.0833	0.9996
	TAU (n = 17), mean (SD)	31.14 (3.73)	32.83 (4.75)	0.147	0.237	0.7974
	VR vs TAU1	-	-	0.367	0.143	0.9717
Item 3	VR (n = 23), mean (SD)	5.53 (0.71)	5.08 (10.4)	0.152	0.213	0.9575
	TAU (n = 17), mean (SD)	5.43 (10.3)	5.47 (0.80)	0.918	0.0198	0.9992
	VR vs TAU1	-	-	0.286	0.187	0.9236
Item 4	VR (n = 23), mean (SD)	4.79 (1.07)	4.78 (1.24)	0.909	0.0157	1
	TAU (n = 17), mean (SD)	5.14 (1.03)	5.06 (1.03)	0.725	0.0619	0.9964
	VR vs TAU1	-	-	0.547	0.1	0.9912
Item 5	VR (n = 23), mean (SD)	5.35 (0.88)	5.09 (1.08)	0.375	0.129	0.9974
	TAU (n = 17), mean (SD)	4.71 (1.74)	5.06 (1.43)	0.628	0.0864	0.9925
	VR vs TAU1	-	-	0.692	0.0678	0.9967
Item 6	VR (n = 23), mean (SD)	5.62 (0.70)	5.30 (0.97)	0.216	0.192	0.9768
	TAU (n = 17), mean (SD)	5.71 (0.56)	5.59 (0.71)	0.714	0.0773	0.9943
	VR vs TAU1	-	-	0.359	0.166	0.9513
Item 7	VR (n = 23), mean (SD)	4.88 (0.98)	4.43 (1.34)	0.251	0.157	0.9927
	TAU (n = 17), mean (SD)	4.29 (0.90)	4.35 (0.86)	0.86	0.0306	0.9988
	VR vs TAU1	-	-	0.753	0.0517	0.9981
Item 8	VR (n = 23), mean (SD)	5.06 (1.37)	5.17 (1.11)	0.981	0.0036	1
	TAU (n = 17), mean (SD)	4.29 (1.79)	4.06 (1.60)	0.567	0.095	0.9904
	VR vs TAU1	-	-	0.023	0.375	0.2722
Item 9	VR (n = 23), mean (SD)	5.09 (1.22)	5.13 (1.14)	0.987	0.0024	1
	TAU (n = 17), mean (SD)	3.71 (1.79)	4.18 (1.51)	0.445	0.126	0.9778
	VR vs TAU1	-	-	0.04	0.339	0.4144

¹Virtual reality vs treatment as usual comparison at one-month.

VR: Virtual reality; TAU: Treatment as usual.

Table 6 Levels of burnout - Burnout Assessment Tool 12 Scale

Outcome measures	Sample groups	Baseline	One-month	P value	Effectiveness size	Power
Total BAT12 score	VR (n = 23), mean (SD)	27.24 (6.99)	29.13 (7.25)	0.625	0.2634	0.1601
	TAU (n = 17), mean (SD)	25.67 (7.00)	26.94 (7.64)	0.602	0.1708	0.0792
	VR vs TAU1	-	-	0.369	0.2899	0.1397
Item 1	VR (n = 23), mean (SD)	3.41 (1.79)	2.78 (1.54)	0.157	0.195	0.9746
	TAU (n = 17), mean (SD)	2.19 (1.54)	3.19 (1.76)	0.075	0.307	0.5218
	VR vs TAU1	-	-	0.408	0.136	0.9721
Item 2	VR (n = 23), mean (SD)	3.91 (1.11)	3.52 (1.31)	0.302	0.145	0.9953
	TAU (n = 17), mean (SD)	3.67 (1.32)	3.81 (1.28)	0.794	0.0453	0.9973
	VR vs TAU1	-	-	0.432	0.132	0.9748
Item 3	VR (n = 23), mean (SD)	1.18 (0.39)	1.22 (0.42)	0.795	0.0504	0.9999
	TAU (n = 17), mean (SD)	1.10 (0.30)	1.00 (0)	0.624	0.206	0.8663
	VR vs TAU1	-	-	0.253	0.316	0.4992
Item 4	VR (n = 23), mean (SD)	1.85 (0.93)	1.74 (0.62)	0.916	0.0151	1
	TAU (n = 17), mean (SD)	2.29 (0.90)	2.00 (0.73)	0.391	0.151	0.9538
	VR vs TAU1	-	-	0.304	0.183	0.9212
Item 5	VR (n = 23), mean (SD)	2.03 (1.06)	2.04 (0.88)	0.801	0.0351	1
	TAU (n = 17), mean (SD)	1.81 (1.17)	1.94 (1.18)	0.646	0.0824	0.9918
	VR vs TAU1	-	-	0.458	0.126	0.9783
Item 6	VR (n = 23), mean (SD)	2.06 (0.95)	2.09 (1.12)	0.961	0.0069	1
	TAU (n = 17), mean (SD)	1.81 (1.08)	2.06 (1.29)	0.581	0.098	0.9873
	VR vs TAU1	-	-	0.797	0.0433	0.9981

¹Virtual reality vs treatment as usual comparison at one-month.

VR: Virtual reality; TAU: Treatment as usual; BAT: Burnout Assessment Tool.

Table 7 Levels of compassion - the Compassionate Engagement and Action Scales

Outcome measures	Sample groups	Baseline	One-month	P value	Effectiveness size	Power
Total compassionate score
To others	VR (n = 23), mean (SD)	78.03 (11.65)	76.26 (9.64)	0.548	0.1611	0.0902
	TAU (n = 17), mean (SD)	82.86 (8.36)	80.69 (6.81)	0.424	0.2624	0.1201
	VR vs TAU1	-	-	0.122	0.5041	0.326
From others	VR (n = 23), mean (SD)	68.56 (18.65)	62.36 (15.30)	0.205	0.3464	0.2375
	TAU (n = 17), mean (SD)	67.62 (24.65)	73.13 (22.81)	0.492	0.2256	0.1014
	VR vs TAU1	-	-	0.051	0.5605	0.3824
Compassionate engagement
To others	VR (n = 23), mean (SD)	42.97 (8.65)	42.21 (6.89)	0.728	0.093	0.0632
	TAU (n = 17), mean (SD)	46.67 (6.07)	44.13 (4.21)	0.177	0.4472	0.2586
	VR vs TAU1	-	-	0.331	0.3141	0.1557
From others	VR (n = 23), mean (SD)	37.94 (11.92)	34.65 (9.32)	0.270	0.2965	0.1904
	TAU (n = 17), mean (SD)	39.14 (14.79)	42.38 (13.21)	0.495	0.2237	0.1005
	VR vs TAU1	-	-	0.039a	0.6839	0.5344
To others	VR (n = 23), mean (SD)	35.06 (5.07)	34.04 (5.05)	0.375	0.1180	0.9984
	TAU (n = 17), mean (SD)	36.19 (4.34)	36.56 (4.94)	0.679	0.0694	0.9944
	VR vs TAU1	-	-	0.058	0.307	0.5373
From others	VR (n = 23), mean (SD)	30.62 (7.82)	27.64 (7.31)	0.138	0.199	0.9629
	TAU (n = 17), mean (SD)	28.48 (10.30)	30.75 (10.36)	0.540	0.101	0.9863
	VR vs TAU1	-	-	0.156	0.232	0.8066

^aP < 0.05.

¹Virtual reality vs treatment as usual comparison at one-month.

VR: Virtual reality; TAU: Treatment as usual.