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Article

Staff Experiences with VR Simulation in Patients with Challenging Behavior

by
Øyvind Lockertsen
1,2,* and
Kjell Kjærvik
3
1
Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet—Oslo Metropolitan University, St. Olavs Plass, P.O. Box 4, N-0130 Oslo, Norway
2
Centre for Research and Education in Forensic Psychiatry South-Eastern Norway Regional Health Authority, Oslo University Hospital, Nydalen, P.O. Box 4950, N-0424 Oslo, Norway
3
Regional Department for Forensic and Security Psychiatry, Oslo University Hospital, Nydalen, P.O. Box 4950, N-0424 Oslo, Norway
*
Author to whom correspondence should be addressed.
Int. Med. Educ. 2025, 4(4), 44; https://doi.org/10.3390/ime4040044 (registering DOI)
Submission received: 20 June 2025 / Revised: 16 October 2025 / Accepted: 23 October 2025 / Published: 26 October 2025
Versions Notes

Abstract

Simulation is widely used in healthcare, with VR simulation replacing physical scenarios with virtual ones. Participants observe based on predefined learning objectives and reflect on them during debriefing sessions. De-escalation is recommended as the first-line response to potential aggression in mental healthcare. Staff in secure mental health units frequently face aggression, and training may enhance de-escalation skills. The study aimed to explore staff experiences with VR simulation as a supplement to physical simulation for de-escalation and examine differences between those with and without prior physical simulation experience. The study involved 58 frontline staff in a Norwegian high security secure mental health department. Twelve simulations were conducted, followed by a post-simulation questionnaire. Data was analyzed using thematic analysis and appropriate statistical analyses. Departmental and data protection approvals were obtained, and participation was based on informed consent. Two themes emerged: (1) enhances situational understanding, and (2) lack of training for action readiness. Participants rated the simulation highly on most questions and perceived VR simulation as a valuable supplement to physical simulation. Those without prior simulation experience were more satisfied with the VR scenario (mean difference = 0.421, 2-sided 95%CI = 0.036–0.807, t = 2.188, p = 0.033), learned more from the VR simulation (mean difference = 0.725, 2-sided 95%CI = 0.045–1.406, t = 2.136, p = 0.037), experienced VR scenario which was more applicable to clinical work (mean difference = 0.645, 2-sided 95% CI = 0.161–1.128, t = 2.674, p = 0.010), and reflected that the VR simulation increased their experienced safety (mean difference = 1.133. 95%CI = 0.478–1.788, t = 3.468, p = 0.001). Greater benefits were yielded from the VR simulation for those without prior simulation experience than those with previous experience. Further studies are recommended.

1. Introduction

Simulation is a pedagogical approach designed to upskill individuals in complex and challenging situations within safe environments, allowing healthcare professionals to practice without involving real patients [1,2]. Evidence supports the effectiveness of simulation training in mental health nursing throughout professional development grades [3] and simulation has been identified as an effective educational method and an essential component of quality and patient safety initiatives [4,5]. Simulation is facilitated by an accredited facilitator [1] and encompasses three phases: briefing, scenario, and debriefing [1]. The briefing aims to create a safe learning environment, clarify expectations and frameworks, and provide information about the scenario and learning objectives [1,2,6]. The physical scenario is executed with a standardized patient (typically trained healthcare personnel acting as a patient) and staff participants playing their roles (e.g., nurses as nurses) [1]. The facilitator manages the standardized patient, ensuring immediate feedback on staff approaches [7]. The facilitator notes topics, based on the learning objectives, which are explored during the debriefing [1,2]. Facilitated debriefing is a structured reflective process focusing on the learning objectives [1,8], and the debriefing process elements are an array of techniques to optimize reflective experience and maximize the impact of debriefing [8,9]. The facilitator guides the conversation through phases (description, analogy/analysis, and application), fostering reflection and learning [2,8]. The purpose of debriefing is to move toward assimilation and accommodation to transfer learning to future situations [2]
Virtual reality (VR) simulation refers to the application of immersive VR technology to create realistic, interactive simulations used for training, education [10], and assessment of healthcare professionals [11]. VR simulation distinguishes itself from physical simulation by replacing the physical scenario with a VR scenario, typically utilizing 360-degree film technology. Immersive 360° videos may have a positive effect on participants’ emotional response to the learning climate and motivation to learn [12]. VR may also improve participants’ knowledge and skill [13]. While VR simulation cannot replace physical simulations, it is considered a valuable supplement in simulation education [14] and enhances both the quality of learning and the overall competence [13]. A VR scenario aims to create an optimally realistic and credible environment tailored to learning objectives, providing participants with engaging experiences that enhance learning [11]. This immersive experience allows staff to feel fully present within the scenario [1,11].
A recent systematic review found that VR simulations can increase frontline staff’s knowledge and skills in the assessment and treatment of mental health disorders; however, the research base is characterized by study heterogeneity, small sample sizes, and studies with high risk of bias [15]. Physical simulation in de-escalation training might strengthen and improve students’ de-escalation skills and confidence level in coping with patient aggression [16]. A scoping review shows VR simulation can reduce stress in training while improving provider performance and affect [17].
Mental health frontline staff are exposed to inpatient aggression, and stressful situations affecting both quality of care and their health [18]. The recommended first-line response to potential violence and aggression in healthcare settings is de-escalation [19]. De-escalation encompasses communication, self-regulation, assessments, actions, and maintaining safety, with the intention of eliminating or reducing aggression and improving staff–patient relationships, while avoiding or minimizing coercive or restrictive measures. Communication should be empathetic, respectful, and patient-centered, aiding the patient in resolving issues non-confrontationally, while staff focus on managing their own emotions [20]. De-escalation is integrated into the Norwegian national staff training program called the Management of Aggression Program (MAP), which is implemented across mental healthcare in Norway [21,22,23], and recommended in national professional guidelines for preventing the use of coercive measures [24]. MAP emphasizes self-regulation in de-escalation and divides de-escalation into three phases: (1) Create secure environments: Focus on establishing a safe, welcoming atmosphere for dialog. Continue risk assessment and attempt to relocate to a more appropriate setting, while removing other patients; if possible, encourage the patient to sit, and prioritize personal safety at all times. (2) Acknowledge emotions and explore the patient’s perspective: Ask open-ended questions, listen actively, validate feelings, ensure the patient feels seen and heard, avoid solutions if they are highly distressed, and clarify misunderstandings. (3) Resolve the situation collaboratively with the patient: Explore previous experiences, joint strategies or goals. Explain and justify rules honestly, acknowledging if they seem unreasonable. Apologize if needed. Highlight consequences of actions, offer choices, and give the patient autonomy where possible. Stay flexible, seek collaborative solutions, and aim for compromises and support collaboration [21].
Secure mental health services in Norway consist of high security and medium security wards and units. All secure mental health units are responsible for the assessment and treatment of patients with severe mental disorders who also exhibit aggressive or violent behavior [25]. Staff in such units are frequently exposed to patient aggression [26,27], and it is hypothesized that training enhances the ability of employees to de-escalate situations, thereby contributing to increased safety within the units [28].
The aim of this study was to explore staff experiences with VR simulation as a supplement to physical simulation related to de-escalation. Additionally, the study aimed to examine whether there are differences between individuals with prior simulation experience and those without.

2. Materials and Methods

2.1. Design and Setting

The survey was part of a local professional development project utilizing a mixed method descriptive design to examine employees’ experiences with VR simulation as a supplement to physical simulation when caring for inpatients with challenging behavior in secure mental health units.

2.2. Recruitment, Inclusion Criteria, and Sample

Participants were recruited from the staff working across various high security secure mental health units within a Norwegian Regional Department for Forensic and Security Psychiatry, who engaged in VR simulation during their work hours. Inclusion criteria required participants to have completed a two-day MAP introductory course [21] and have no prior experience with VR simulation. The nurse on duty in each respective unit assigned participants for each VR simulation session, and participants were presented to the project on arrival. The sample consisted of 58 interdisciplinary frontline staff in rotating positions, including registered nurses, social educators, healthcare workers, and other health and social care professionals, both with and without postgraduate education in mental healthcare, and with and without previous experience with physical simulation. All invited frontline staff consented to participate.

2.3. Organization and Execution of the VR Simulation and Learning Objectives

A total of 12 VR simulations were conducted. Facilitated debriefing was chosen because it effectively manages conflict by promoting open communication and a safe learning environment, which is crucial to enhance teamwork and communication among professionals [29]. Each simulation was led by one accredited facilitator. Two experienced mental health nurses in the department (including the last author), who are both accredited facilitator trainers and experienced accredited facilitators, alternated in facilitating the simulations. To ensure simulation sessions were carried out as equal as possible, only two facilitators participated. A pilot session, where both facilitators participated, was conducted and afterwards evaluated. All 12 simulations followed the same script. Each simulation involved four to five participants from different units. Groups were formed naturalistically based on staff availability and each unit’s capacity to manage without them during the simulation.
Each simulation session lasted 45 min and followed the structure below:
Briefing: Participants received training on the use of VR glasses. They were introduced to the scenario and learning objectives (as detailed in the introduction) and informed that they would be observers in the scenario, focusing on the learning objectives.
Scenario: The group simultaneously started the film following instructions from the facilitator.
Facilitated debriefing: The facilitator first allowed space for immediate thoughts and reactions before proceeding to the description phase. Description phase: Participants established a shared understanding of what occurred in the scenario, providing a brief, objective description of the patient’s condition, behavior, and the chronological actions of the staff. Analysis phase: Participants reiterated the learning objectives and reflected on the scenario based on these. Participants considered what the staff succeeded in and why, what could have been performed differently, and how they would have addressed the challenge in their own practice. Application phase: Participants reflected on the learning objectives and what they could transfer from the simulation to their practice, as well as what is necessary to achieve success with these applications.
Learning objectives were the three phases in de-escalation according to MAP: (1) create a secure environment, (2) acknowledge emotions and explore the patient’s perspective, and (3) resolve the situation collaboratively with the patient.

2.4. Scenario Development

The scenario was developed by two experienced accredited facilitators, who were also accredited facilitator trainers, from the respective wards. The scenario was written by the facilitators, then revised based on feedback from fellow experienced accredited facilitators in the ward. The scenario was further validated by experienced mental health nurses and recorded as a 360° video in a simulation center at another Norwegian Health Trust. A group of facilitators with experience in acting in scenarios from the respective wards acted out the scenario, with one acting as a standardized patient. Afterwards, all participating in the scenario assessed and approved the final product.

2.5. Background Information Provided Before Viewing the VR Scenario

The patient, John, was involuntarily admitted to an acute psychiatric unit the previous shift. Recently, John has exhibited delusional beliefs about possessing special abilities, particularly combat skills, and prior to admission, he was planning to travel to Europe to train military personnel. According to the report from the previous shift, he is described as motorically restless, suspicious, and frequently looking around. He claims to be on a secret mission and was on his way to Europe when something occurred. He is unsure how he ended up in the unit and is questioning what has happened.

2.6. Scenario Description Provided via VR Glasses and Sequence of Events in the VR Scenario

The scenario was presented in VR glasses (model: PICO 3 headsets with headphones).
Description provided: “You will in this VR scenario be present in a patient situation where two frontline staff encounter the patient John in the common area. The situation unfolds in an acute psychiatric ward at the start of the evening shift.”
Sequence of events: John appears as described in the background information. He enters the common area wearing a hoodie with the hood up. In the common area, two frontline staff and the participant with VR glasses are present. John approaches one of the staff members (hereafter referred to as the leader of the situation) and inquiries about what has happened. Upon receiving a response, he quickly changes the subject and asks if the staff can provide him with cigarettes. When informed that he must wait until after the conversation, John becomes increasingly psychomotorically agitated and stands up. He then approaches the other staff member and the participant with VR glasses. John does not sit down when prompted and moves toward the staff, adopting a threatening stance while repeatedly stating his proficiency in martial arts. An additional staff member enters the room and joins the situation. Following instructions from the leader, the two other staff members take hold of John’s arms and guide him to sit down on a sofa as requested. They remain seated while continuing to hold his arms. John eventually becomes psychomotorically calmer, and the situation de-escalates shortly thereafter.

2.7. Data Collection and Description of Questionnaire

Data collection occurred between 1 January 2023 and 20 June 2023. All participants were asked to complete a questionnaire on their own following the simulation. The questionnaire was a brief evaluation form consisting of two questions with dichotomous response options, including twelve closed-ended questions for all participants using a seven-point Likert scale, and two concluding open-ended questions. The questionnaire also included an additional closed-ended question using a seven-point Likert scale for participants with previous experience with physical simulation (see Supplementary Figure S1). The questionnaire was developed by the authors and reviewed in advance by two experienced mental health nurses with facilitator training and accreditation, who provided input on its design.

2.8. Data Analysis

Qualitative and quantitative data were analyzed separately, and findings were subsequently discussed collectively. Open-ended questions were analyzed using thematic analysis, inspired by Braun and Clarke [30]. The first author, a researcher with mental health nursing background, and the last author, an experienced mental health nurse from the secure mental healthcare setting, coded the data from the open-ended questions separately. The authors then met five times in total to discuss the codes and emerging themes and to clarify and agree on the themes. In between meetings, the authors discussed the emerging themes externally for feedback, whereby the first author discussed the themes with an independent experienced qualitative researcher, and the last author discussed the themes with frontline staff at the ward. Statistical analyses were conducted using SPSS Version 29.0. Questions with a seven-point Likert scale were treated as continuous variables. A histogram and Q-Q plot were used to visually inspect the data distribution, and the Q-Q plot showed no major deviations from normality. Independent t-tests were used to investigate differences in mean scores between subgroups. Effect sizes were analyzed by Hedges’ g. Internal consistency was analyzed by Cronbach’s alpha, and each single item’s contribution was analyzed by removing each one from the scale. The significance level was set at p < 0.05 for all analysis.

2.9. Ethical Considerations

The present study was approved by the Data Protection Officer at Oslo University Hospital (ID: 25/20975) and conducted in accordance with the World Medical Association’s guidelines (Declaration of Helsinki) [31]. Participants received verbal information about the study, and participation was based on informed consent. Participants could withdraw before, during, and after the VR simulation. Questionnaires were completed anonymously, and no personally identifiable data was recorded. The authors adhered to EQUATOR guidelines [32], and the study is conducted and reported in accordance with SQUIRE-EDU (Standards for Quality Improvement Reporting Excellence in Education): Publication Guidelines for Educational Improvement [33]. When designing physical and VR scenarios involving aggression, facilitators should account for the potential emotional impact on participants both during the scenario and the debriefing reflection.

3. Results

3.1. Findings from Open-Ended Questions

Analysis of the open-ended responses revealed two main themes: (1) VR simulation enhances situational understanding, and (2) lack of training for action readiness. Table 1 illustrates the relationship between data, codes, subthemes, and themes.
Enhances situational understanding
Participants reported that engaging in VR simulation provided them with a meta-perspective and realistic experience. This is described by participants as allowing them to “see the situation from the outside,” while still experiencing it as “authentic” and “giving the feeling of being present in a realistic scenario.” Participants noted that it was “very nice to be able to observe and reflect from a distance,” providing a safe framework for reflection and a secure distance from the scenario. Overall, these findings suggest that tailored activation in VR simulation contributes to increased observational skills, thereby enhancing participants’ situational understanding.
Lack of training for action readiness
Participants described the simulation as passive, noting that it made them feel “less participatory” and that VR “withdraws some of the physical aspects of simulation.” The VR simulation was also perceived as static, lacking “options for choice.” One participant remarked that it becomes “more difficult to train stress management with VR,” while another noted that it “does not allow for experiencing the discomfort of being in a threatening confrontation.” Together, the static nature of the simulation and the absence of discomfort are interpreted as the simulation not providing participants with tailored stress activation. As observers, the participants perceived that VR simulation did not give them the same opportunity to train in action readiness as they were used to through physical simulation.

3.2. Findings from Closed-Ended Questions

Overall, participants rated the simulation highly on most questions. The relevance of the learning objectives to participants’ clinical work received the highest scores, and participants also considered that VR simulation provided a strong foundation for subsequent professional reflections. Those without previous simulation experience scored significantly higher than those with prior experience on four questions. Table 2 displays the participants’ scores for the entire sample, divided between those with previous simulation experience and those without.
The internal consistency (Cronbach’s alpha) for the summed score of all 12 questions in the questionnaire was 0.88 (95% CI 0.83–0.92, p  <  0.01). When one item of the scale was deleted and the other entered, the highest value, alpha  =  0.89, was obtained for Item 2 (Learning objectives are relevant to my clinical work). The lowest value, alpha  =  0.85, was obtained for Item 4 (Learned a lot).
When participants with previous simulation experience (n = 35) were asked to choose between VR simulation and physical simulation, sixteen (45.7%) preferred VR simulation, ten (28.6%) preferred physical, and eight (22.9%) chose both (despite instructions to select only one option), while one participant (2.9%) did not respond. Table 3 displays Participants with previous experience with physical simulation assessment of the VR simulation divided between those who prefer VR and those preferring physical.

4. Discussion

Participants reported that VR simulation enhances situational understanding but does not adequately train them for action readiness. Overall, participants rated the simulation highly on most closed-ended questions, with few differences between those with and without prior simulation experience. None of the participants expressed any negative emotional impact of the VR simulation.
Situational understanding among staff influences their decision-making and the facilitator may influence the development of situation awareness during the briefing [34]. The relatively high score on whether VR simulation enhances the participants’ understanding of patients combined with the high scores on VR simulation being a strong basis for professional reflections correspond with the theme of VR simulation enhancing situational understanding. If VR simulation enhances participants’ understanding of patients and provides strong basis for professional reflection, one might assume that reflections in facilitated debriefing contribute to participants’ situational understanding. Watching a scenario carefully and reflecting on it during debriefing may foster shared situational understanding and new strategies for action, as described in the foundational work resulting in the development of Kolb’s learning cycle [35]. Shared situational awareness is critical for effective teamwork and supports dynamic decision-making in unpredictable, time-pressured situations [36]. Enhanced situational understanding may thus contribute to the implementation of quicker and more appropriate interventions. During debriefing, participants are required to justify their own actions, necessitating critical thinking [37,38]. Such a process can enhance situational awareness and understanding, thereby improving the ability to adapt and prepare for how a situation might evolve [21]. Situational understanding is significant for anticipating any change to a situation [39]. Situational awareness is a dynamic process that involves perceiving clinical cues, assigning meaning to these, and using them to project interventions [40]. Thus, enhanced situational understanding and awareness improve clinical skills and is vital for vigilance, clinical decision-making, and patient safety at the frontline of care [41]. The learning objectives’ focus on exploring the patient’s perspective and resolving the situation collaboratively might have addressed the participants’ situational understanding.
Participants did not feel that VR simulation provided tailored stress activation, nor did it allow them to train for the stress experienced in clinical practice. Nevertheless, participants scored high on the closed-ended question regarding the scenario’s applicability to clinical work; particularly, those without previous simulation experience scored high on the theme of VR simulation helping to increase their experienced safety. Facilitated debriefing is found to provide participants deeper insights [42] with a broader understanding of the simulation experience [29]. Reviews found that VR interventions effectively train frontline staff in assessment and treatment within mental healthcare [15], and that integrating VR simulation into violence prevention training may improve safety [43]. However, the link to action readiness is scarcely examined. Although simulation is widely used in healthcare education, excessive stressful simulations may not enhance performance [44,45]. On the other hand, simulation programs in mental health nursing have shown potential in enhancing the educational experience, and utilizing standardized patients can increase confidence and improve therapeutic communication skills [46]. VR simulation can have a positive effect on mitigating the negative aspects of stress during simulation as well as improving provider performance [17]. Increased participant experience may be a contributing factor to performance under stress [44]. Simulation may also help reduce stress in subsequent clinical situations [47]. The participants noted that VR simulation helped them become more familiar with their own reactions, improved their understanding of patients, and provided substantial learning. VR simulation is found to enhance the ability to assess body language, manage personal emotions, and gain a better overview [14]. Being a present observer facilitates the ability to observe “from the outside,” reducing activation and enabling comprehensive engagement with the scenario.
The learning objectives were related to de-escalation according to the MAP. De-escalation is part of secondary prevention strategies covering actions and measures used to reduce or stop aggression from occurring [23]. Action readiness might be related to tertiary prevention strategies in MAP, covering actions and attitudes used to reduce the consequences of and limit the impact of violence [22,23]. Comprehensive and longer-lasting scenarios could complicate the focus on specific learning objectives. Thus, branching the scenario is a possibility. A short VR scenario focusing on risk management strategies, with corresponding learning objectives tailored to address risk management strategies in critical situations or physical intervention, might facilitate action readiness reflection in the debriefing. The facilitator could address the issue in the analysis phase and the application phase of the debriefing. Nevertheless, hands-on learners are found to be more emotionally activated than observers in simulation [48]. In nursing education, VR simulation may require integration with more interactive methods for optimal impact [49]. Action readiness may require interactions and might be a limitation to VR simulation. Participants’ high scores on most closed-ended questions suggest an overall positive impact from the VR simulation, which might partially contribute to action readiness. With more resources and a combination of VR simulation followed by physical simulation, with the testing of potential effective interventions in scenarios, it might improve outcomes related to action readiness for participants.
The findings must be understood in light of the scenario in question and other scenarios may influence situational understanding and action readiness differently.
Participants rated the VR scenario as providing a strong foundation for impactful professional reflections. Learning occurs during debriefing sessions [37,38], and participants reported gaining insights from these reflections that were beneficial in their clinical practice. Kolb’s experiential learning model, introduced in 1984, formalized the cycle of learning (experience, reflection, analysis, and experimentation) [35], and continues to influence education, training, and organizational development practices worldwide [50]. The foundational nursing model “From Novice to Expert” by Benner, introduced in 1982 [51], describes five levels of nursing expertise, and remains central to nursing education internationally [52]. Both Kolb’s cycle of learning [35] and Benner’s nursing model emphasize how experience (VR scenario) and reflective observation (debriefing) contribute to new learning [14]. Facilitated debriefing allows for the integration of multiple perspectives, encourages active engagement among participants, and supports the exploration of deeper insights [29]. Shared reflection and systematic and thorough analysis of the VR scenario in the debriefing, based on learning objectives, can lead to perceived insight and learning, enhancing participants’ ability to think critically in challenging situations [8,10]. Critical thinking involves analyzing, examining, assessing, and making decisions. The results suggest that VR scenarios, like physical scenarios, can facilitate effective professional reflections during debriefing.
Participants considered both the learning objectives and the scenario useful and relevant. These are essential prerequisites in simulation [3,44,53], and VR-based simulation can contribute to creating safer healthcare professionals by exposing them to relevant and realistic situations [11,17]. In VR simulation, the scenario can be perceived as experience, the learning objectives as theory, and debriefing as reflection on theory and practice within Kolb’s learning cycle [14]. When both scenario and learning objectives are perceived as relevant, VR simulation might be regarded beneficial and aligns with Knowles’s principles of adult learning [14].
The results suggest VR simulation can serve as a valuable supplement to physical simulation. Participants without prior simulation experience scored higher on four questions (see Table 2). Large effect size was found on one question, namely whether VR simulation increases their experienced safety (Hedges’ g = 0.866, 95% CI [0.319–1.405]). This may be attributed to the department’s regular simulation practices over the past decade, which have provided employees with simulation experience, longer clinical experience, and greater practical competence in the area. Nonetheless, remaining differences between the groups are moderate, and all scores are generally high. VR simulation was a new experience for the participants. Hence, the positive results might be partly due to a novelty effect. For those without prior simulation training, the entire simulation setting will be new and might strengthen the novelty effect. These results from a Forensic Psychiatry Department, where frontline staff are frequently exposed to aggression [27], are in line with previous findings describing simulation training as effective in psychiatry, in terms of improving nurses’ skills, attitudes and behaviors, and knowledge at all stages of their training and careers [3]. When asked to choose between VR simulation and physical simulation, most participants found VR simulation useful, despite missing physical interaction and the ability to influence the situation directly. Many participants with simulation experience expressed a preference for both types, suggesting that they do not view VR simulation as a replacement for physical simulation, but rather, as a supplement. Several also noted that VR simulation should not replace future physical simulations, as they missed the opportunity to impact and physically interact with the situation, which they felt was necessary for practice. The preference for VR simulation could be due to the perception that exposure is less daunting and that it provides a safer training environment. Additionally, some participants reported gaining more insights as observers in VR simulation compared to physical simulation, reasoning that in physical simulations, they were uncertain about how standardized patients and colleagues would act.
The investigation into VR simulation related to de-escalation within a psychiatric secure context is novel. The study’s clinical proximity and naturalistic implementation further enhance its robustness. The involvement of two facilitators ensured consistent execution, and feedback on the questionnaire design, which strengthened its reliability. However, the study also presents several limitations. Conducting the research in a single department with relatively few participants and only one VR scenario limits generalizability and transferability. A comparison between multiple scenarios, including diverse situations, would have enabled a more in-depth analysis, allowing for more robust conclusions. Another significant limitation is the lack of control over participants’ work experience and educational level. Additionally, findings must be interpreted in light of the context of the study. Norway is a high-income country with relatively high staff-to-bed ratio, and the respective ward organizes systematic violence risk management training to all frontline staff members. The naturalistic recruitment process may have introduced bias. The familiarity of participants with the facilitators may well have biased responses, and facilitators’ knowledge of participants might have influenced the debriefing process. Results represent participants’ self-reported perceptions immediately post-debrief, and not behavioral performance nor incident rates. Those with previous physical simulation experience were familiar with facilitated debriefing. Nevertheless, even though participants completed the questionnaire anonymously, this may well have contributed to higher scores on closed-ended questions and made it more difficult to express negative feedback.
Even though closed-ended questions in the questionnaire showed good internal consistency (Cronbach’s alpha 0.8–0.9), the questionnaire is not validated in previous studies and was completed immediately after the debriefing. Hence, results are to be considered exploratory. Expert reviews by two experienced facilitators enhanced the content validity of the questionnaire by ensuring that the items accurately measured the intended construct and domain. This process involves evaluating whether the questions are directly aligned with the construct, consistent with the theoretical framework, and adhering to established definitions within the simulation. While expert review is valuable, it has limitations for content validity. Experts may introduce biases, fail to represent diverse perspectives, or overlook relevant practical considerations. Input from both experienced and inexperienced frontline staff and pilot testing of the questionnaire would have strengthened content validity by ensuring clarity, relevance, and inclusivity.

5. Conclusions

Participants perceived VR simulation as a valuable supplement to physical simulation. Frontline staff without previous simulation experience reported greater benefits from VR simulation compared to those with prior experience, which is expected as the latter group likely comprised more experienced personnel. The finding that VR simulation did not provide tailored stress activation, nor allowed them to train for the stress in clinical practice, suggests VR simulation cannot replace physical simulation in de-escalation training. Neither physical simulation nor VR simulation is suitable for all types of simulations, and the choice of simulation method should be guided by the learning objectives. Based on the limitations, results should be interpreted cautiously. Future studies should include larger sample sizes from multiple departments and diverse scenarios. Randomized cross-over designs comparing VR-first and physical-first simulations, focusing on behavioral outcomes and stress measures, are also recommended.

Supplementary Materials

The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/ime4040044/s1, Figure S1: questionnaire.

Author Contributions

Conceptualization, Ø.L. and K.K.; methodology, Ø.L. and K.K.; data collection, K.K.; formal analysis, Ø.L.; original draft preparation, Ø.L.; writing—review and editing, Ø.L. and K.K.; supervision, Ø.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Prior to commencement, the professional development project was approved by the head of the Department for Forensic and Security Psychiatry. The hospital’s Data Protection Officer was contacted by phone, informed about the project, and provided approval. The study was conducted in accordance with the Declaration of Helsinki, and approved in writing by the Data Protection Officer at Oslo University Hospital (ID: 25/20975) on 29 September 2025.

Informed Consent Statement

Informed consent was obtained from all participants involved in the study.

Data Availability Statement

The dataset used is available from the corresponding author upon reasonable request.

Acknowledgments

The authors express gratitude to the management and the frontline staff who participated in this study and shared their experiences.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Illustration of the analysis process.
Table 1. Illustration of the analysis process.
ThemesSubthemesCodesQuotes
Enhances situational understandingEnhanced observational skillsMeta-perspective“You see the situation from an external perspective.”
“A good opportunity to solely assess and observe.”
“It is nice to be a ‘fly on the wall’ and observe body language.”
Safe distanceRealistic“Engaged much more deeply in the situation, leading to valuable reflections afterward.”
“Provides a sense of being present in a realistic situation.”
Safe framework for reflection“Very beneficial to observe and reflect from a distance.”
“Skilled at creating a safe environment.”
Lack of training for action readinessObserverPassivating“Unable to contribute.”
“Removes some of the physical aspects of simulation.”
“Unusual not to intervene when it feels real.”
“A bit frustrating to be a passive observer.”
Does not provide tailored stress activationStatic“Compare scenarios with different outcomes.”
“Multiple videos of the same events, good performance vs. poor performance, allowing participants to make their own choices with different consequences.”
“Options for decision-making.”
Discomfort“More challenging to practice stress management with VR.”
“A disadvantage is that one cannot experience their actual reactions in the situation or feel the stress and practical application of knowledge, communication, and techniques.”
“Does not allow for experiencing the discomfort of being in a threatening confrontation.”
Table 2. Assessment of the VR simulation divided between those with previous experience with physical simulation and those without.
Table 2. Assessment of the VR simulation divided between those with previous experience with physical simulation and those without.
All (N = 58)Previous
Physical SIM (n = 35)		No Previous Physical SIM (n = 23)TpMean
Difference		Hedges’ g (95% CI)
VR sim is relevant to my clinical work6.09 (SD = 0.84)6.03 (SD = 0.86)6.17 (SD = 0.84)0.6420.5240.1450.169
(−0.352–0.688)
Learning objectives are relevant to my clinical work6.24 (SD = 0.63)6.29 (SD = 0.62)6.17 (SD = 0.65)−0.6520.518−0.112−0.174
(−0.693–0.347)
I am satisfied with the VR scenario6.22 (SD = 0.80)6.06 (SD = 0.87)6.48 (SD = 0.59)2.1880.033 *0.4210.536
(0.005–1.062)
I learned a lot5.35 (SD = 1.39)5.06 (SD = 1.50)5.78 (SD = 1.09)2.1360.037 *0.7250.530
(−0.001–1.055)
The VR scenario is applicable to my clinical work5.74 (SD = 1.03)5.49 (SD = 1.14)6.13 (SD = 0.69)2.6740.010 *0.6450.643
(0.108–1.172)
VR sim increases my experienced safety4.62 (SD = 1.40)4.17 (SD = 1.42)5.30 (SD = 1.06)3.4680.001 **1.1330.866
(0.319–1.405)
VR sim makes me more aware of own reactions4.69 (SD = 1.62)4.46 (SD = 1.70)5.04 (SD = 1.46)1.3990.1680.5860.359
(−0.166–0.880)
VR sim enhances my understanding of patients?4.84 (SD = 1.29)4.73 (SD = 1.33)5.00 (SD = 1.24)0.7920.4320.2710.207
(−0.314–0.727)
Provides strong basis for professional reflections6.20 (SD = 0.85)6.21 (SD = 0.90)6.17 (SD = 0.78)−0.1810.857−0.040−0.047
(−0.565–0.473)
Debriefing reflections are useful to my clinical work5.54 (SD = 1.19)5.39 (SD = 1.31)5.78 (SD = 0.95)1.3370.1870.3970.332
(−0.192–0.853)
VR sim contributes to aggression reduction5.10 (SD = 1.50)5.13 (SD = 1.44)5.04 (SD = 1.61)−0.2050.838−0.085−0.056
(−0.574–0.464)
VR sim contributes to coercion reduction4.68 (SD = 1.44)4.49 (SD = 1.49)5.00 (SD = 1.35)1.3480.1840.5140.353
(−0.178–0.882)
Note: Mean scores on a seven-point Likert scale (1 = to a very small extent, 7 = to a very large extent). Likert scale treated as a continuous variable. Independent t-test; equal variances not assumed. Two-tailed p-values are reported. * = p < 0.05; ** = p < 0.01.
Table 3. Participants with previous experience with physical simulation assessment of the VR simulation divided between those who prefer VR and those preferring physical.
Table 3. Participants with previous experience with physical simulation assessment of the VR simulation divided between those who prefer VR and those preferring physical.
Prefers VR SIM (n = 16)Prefers Physical SIM (n = 10)TpMean DifferenceHedges’ g (95% CI)
VR sim is relevant to my clinical work6.38 (SD = 0.81)5.70 (SD = 0.82)2.0500.0540.6750.804 (−0.001–1.595)
Learning objectives are relevant to my clinical work6.38 (SD = 0.50)6.40 (SD = 0.52)−0.1220.905−0.025−0.048 (−0.813–0.718)
I am satisfied with the VR scenario6.31 (SD = 0.87)5.60 (SD = 0.84)2.0670.0520.7130.800 (−0.005–1.590)
I learned a lot5.63 (SD = 1.36)4.05 (SD = 1.38)2.8430.010 *1.5751.114 (0.277–1.931)
The VR scenario is applicable to my clinical work5.69 (SD = 1.25)5.15 (SD = 1.11)1.1460.2650.5380.434 (−0.345–1.205)
VR sim increases my experienced safety4.56 (SD = 1.71)3.65 (SD = 0.67)1.9120.0700.9130.625 (−0.166–1.404)
VR sim makes me more aware of own reactions4.81 (SD = 1.76)3.60 (SD = 1.58)1.8230.0831.2130.693 (−0.103–1.476)
VR sim enhances my understanding of patients?4.88 (SD = 1.41)4.15 (SD = 1.06)1.4940.1490.7250.545 (−0.240–1.320)
Provides strong basis for professional reflections6.38 (SD = 0.96)5.90 (SD = 0.88)1.2980.2090.4750.496 (−0.287–1.269)
Debriefing reflections are useful to my clinical work5.75 (SD = 1.39)4.95 (SD = 1.30)1.4860.1530.8000.571 (−0.217–1.347)
VR sim contributes to aggression reduction5.63 (SD = 1.36)4.20 (SD = 1.48)2.4680.024 *1.4250.982 (0.160–1.787)
VR sim contributes to coercion reduction4.75 (SD = 1.65)3.65 (SD = 1.16)1.9940.0581.1000.717 (−0.082–1.501)
Usefulness of VR sim compared with physical sim5.13 (SD = 1.00)3.33 (SD = 1.00)3.4060.002 **1.7921.202 (0.329–2.053)
Note: Mean scores on a seven-point Likert scale (1 = to a very small extent, 7 = to a very large extent). Likert scale treated as a continuous variable. Independent t-test, equal variances not assumed. Two-tailed p-values are reported. * = p < 0.05; ** = p < 0.01.
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Lockertsen, Ø.; Kjærvik, K. Staff Experiences with VR Simulation in Patients with Challenging Behavior. Int. Med. Educ. 2025, 4, 44. https://doi.org/10.3390/ime4040044

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Lockertsen Ø, Kjærvik K. Staff Experiences with VR Simulation in Patients with Challenging Behavior. International Medical Education. 2025; 4(4):44. https://doi.org/10.3390/ime4040044

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Lockertsen, Øyvind, and Kjell Kjærvik. 2025. "Staff Experiences with VR Simulation in Patients with Challenging Behavior" International Medical Education 4, no. 4: 44. https://doi.org/10.3390/ime4040044

APA Style

Lockertsen, Ø., & Kjærvik, K. (2025). Staff Experiences with VR Simulation in Patients with Challenging Behavior. International Medical Education, 4(4), 44. https://doi.org/10.3390/ime4040044

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