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Virtual Reality–Based Resilience Programs: Feasibility and Implementation for Inpatient Oncology Nurses

Sarah H. Michael
Pamela Martinez Villarreal
Michelle Frances Ferguson
Jennifer L. Wiler
Richard D. Zane
Kathleen Flarity
CJON 2019, 23(6), 664-667 DOI: 10.1188/19.CJON.664-667

The high prevalence of compassion fatigue contributes to burnout among oncology nurses. Interventions are needed to support individuals across diverse roles and practice settings in oncology. Virtual reality (VR) is an emerging technology that has been applied in healthcare education and training and is being explored as an intervention to reduce stress and support wellness for healthcare providers. This article reviews recommendations from an implementation project about a VR intervention for oncology nurses.


  • Interventions that reduce compassion fatigue and burnout among high-risk healthcare providers can improve job satisfaction and patient safety while reducing turnover-related expenses. 
  • VR programs are one tool that may help to improve resilience and well-being among nurses and other healthcare providers. 
  • Successful VR implementation requires prospective attention to a variety of organizational cultural and technical considerations. 

Oncology nurses, like their colleagues in emergency medicine, intensive care, and behavioral health, are at risk for elevated levels of stress, burnout, and compassion fatigue (CF) (Cañadas-De la Fuente et al., 2018; Epp, 2012; Rushton, Batcheller, Schroeder, & Donohue, 2015). The experience of challenging patient cases, suffering, and death affects nurses and other healthcare providers emotionally, physically, and spiritually (Flarity, Moorer, & Jones-Rhodes, 2018; Gentry, 2016; Neumann et al., 2018). Many studies have documented a high prevalence of CF and its two components, burnout and secondary traumatic stress, in nurses, including those specializing in oncology (Flarity, Gentry, & Mesnikoff, 2013, Flarity, Nash, Jones, & Steinbruner, 2016; Gómez-Urquiza et al., 2016; Perry, Toffner, Merrick, & Dalton, 2011). Secondary traumatic stress is defined as trauma experienced by witnessing the pain and suffering of others (Beck, 2011). Burnout includes emotional exhaustion, depersonalization, and reduced personal accomplishment and is greatly affected by the work environment (Mashlash & Mayer, in press; Rushton et al., 2015). CF is associated with adverse health outcomes, absenteeism, increased turnover, and decreased satisfaction for nurses and decreased safety and satisfaction for patients (Cañadas-De la Fuente et al., 2018; Hall, Johnson, Tsipa, & O’Connor, 2016; Perry et al., 2011). The cost of burnout-related attrition is high. Replacing one nurse is estimated to cost six to nine months’ salary (NSI Nursing Solutions, Inc., 2019). Organizations that implement burnout interventions may experience reduced turnover, increased retention, and increased patient satisfaction (Henry, 2014).

Resilience measures, such as self-care activities, may mitigate the negative effects of occupational-related burnout (Flarity et al., 2018; Henry, 2014; Rushton et al., 2015). In healthcare institutions, such interventions have included training programs to improve individual staff members’ abilities to practice mindfulness, mental rehearsal, positive self-talk, communication skills, and tactical breathing exercises, all of which are associated with decreased acute stress and improved technical and nontechnical performance (Anton, Bean, Hammonds, & Stefanidis, 2017; Lauria, Rush, Weingart, Brooks, & Gallo, 2016; van Agteren, Iasiello, & Lo, 2018).

The Role of VR Interventions in Mitigating Burnout

Virtual reality (VR) is a head-mounted technology that creates an interactive and engaging simulation for the user so that he or she believes the experience is taking place in reality. VR is being explored to address healthcare provider burnout. VR first entered the healthcare space as distraction therapy for painful procedures or stressful clinical experiences (Glennon et al., 2018) and has since demonstrated improved physical rehabilitation outcomes among patients with neurologic injuries, such as stroke (Ahn & Hwang, 2019; Lee, Park, & Park, 2019). VR has also been used as supportive therapy for individuals with anxiety (Geraets et al., 2019), depression (Zeng, Pope, Lee, & Gao, 2018), and post-traumatic stress disorder (Maples-Keller, Yasinski, Manjin, & Rothbaum, 2017).

VR has been increasingly adopted in educational settings to enhance complex visualizations, decision making, and technical skills. Healthcare training programs and hospitals have begun to adopt this educational technology to train healthcare providers and workers in critical event response (Bracq et al., 2019) and procedural skills (Fealy et al., 2019). Since healthcare training programs have invested in VR, there is interest in expanding VR use to healthcare providers’ development and well-being.

Implementing VR Interventions

An interprofessional team at a large urban hospital evaluated the feasibility of implementing a VR-based stress-reduction intervention during a clinical shift. The program was implemented on two inpatient units at high risk for CF, including an oncology unit, from which 24 nurses participated, in addition to 8 nurses from a substance abuse treatment unit. Two dedicated rooms were made available to staff across all shifts for a period of six weeks. Participants chose the duration of their VR sessions and selected from a list of eight possible virtual experiences using third-party software (Rendever). During the final three minutes of the session, participants were asked to perform guided breathing exercises aimed at improving relaxation. At the conclusion of each session, participants evaluated whether they felt better, worse, or the same overall compared to just prior to starting the session.

During the course of the six-week trial period, 27 participants completed 56 VR-based relaxation sessions. Half of the sessions were completed during the first week of the VR-based stress-reduction intervention. According to data obtained from participants at the time each session was completed, the majority of participants reported improvement in mood after sessions (n = 30, 53%). According to a post-intervention survey, which 11 participants (41%) completed, a similar majority of respondents believed the VR sessions were beneficial (n = 6, 55%). However, most of these respondents (n = 10, 91%) also reported struggling to integrate VR sessions into their breaks, often citing having too much to accomplish with break time or experiencing guilt about time away from patients, despite perceived benefit and support from colleagues and leaders. These challenges speak to important factors that must be taken into account when considering the implementation of VR-based strategies to combat CF and burnout.

Challenges and Opportunities

Encouraging participation: Although 100% of participants in the VR intervention trial period reported leadership support to engage in VR, many reported difficulty finding time or expressed guilt associated with a variety of self-care activities that were not limited to VR, including using the restroom or hydrating. This emphasizes the challenges faced in implementing any self-care activities in the context of clinical care and suggests that self-care is set up as an expectation rather than just encouraged.

Ensuring access across shifts: When offering resilience programs, staff working all shifts benefit from those programs. Unlike many interventions that are implemented during day shifts because of the availability of facilitators, VR-based initiatives are attractive because they are self-guided and not limited to traditional dayshift periods. During the VR intervention trial period, VR implementation peaked from 4 am to 6 am, indicating accessibility and usability during off-peak hours.

Technical considerations: VR hardware and software can vary significantly in terms of technical, storage, and maintenance requirements, and any hardware chosen should be selected for its ability to meet desired utilization scenarios. Complex, interactive simulations and the VR headsets able to generate them require high-level computing power, usually from a desktop-type device with specialized graphics capabilities. When implementing this technology, adequate storage and maintenance, as well as the cleaning of headsets between uses, should be factored into the decision of which technology to purchase and the logistic preparation. When Internet access is required, wired Internet or ethernet connections are preferred over wireless Internet whenever possible. If advanced computing power is not required to meet the goals of a VR project, teams can also consider consumer-based technology, such as inexpensive headsets that incorporate a smartphone or similar device as a screen, simultaneously lowering financial barriers to entry and maintenance cost.

Space and logistics: The physical location selected for the VR experience is important to the usability of the equipment. When users are expected to interact physically with virtual environments, a sufficiently large (2 m x 1.5 m) space clear of furniture and trip hazards is needed (HTC Corporation, 2019). Much smaller spaces can be used when participants are expected to remain seated, in which case, comfortable furniture is recommended. Privacy considerations are also important; spaces that are large enough for several people, such as conference rooms, can create a sense of being watched when participants are no longer able to perceive their physical surroundings. This can lead to poor engagement with virtual environments. Rooms intended for VR use should have adequate cooling and ventilation to ensure comfort, safety, and hardware performance. The benefit of VR interventions is that they can be implemented in inpatient and ambulatory settings, ranging from major academic medical centers to community-based oncology settings, given the appropriate technologic and logistic resources.

The role of choice in VR experiences: Many virtual environments are available for relaxation exercises; however, that amount of choice can prove overwhelming or use extra time the individual may not have while on break. A prospective needs assessment can determine what kinds of experiences are most likely to be popular with users. This feedback can be used to offer a selection of offerings, possibly in rotation, to provide choices to the end user without requiring significant time to make a decision.


As VR technology continues to mature and healthcare organizations further embrace its potential to benefit patient care and educational programming, nursing leaders should also consider making this technology available for resilience initiatives. Although a long-term approach to burnout mitigation in high-risk nursing fields likely requires a combination of individual and institutional optimization, and no single solution will address the needs of an entire team, VR is one modality that has potential for application in the workplace to reduce stress and improve nursing performance. The authors’ experience suggests that VR is a feasible and well-accepted intervention with the potential to reduce stress and, ultimately, burnout among oncology nurses. Further research is needed to evaluate the effect of VR on burnout and its feasibility and sustainability in diverse oncology settings.

About the Author(s)

Sarah H. Michael, DO, MS, is an assistant professor of emergency medicine at the University of Colorado Anschutz in Aurora; Pamela Martinez Villarreal, MSE, is an operations engineer and systems innovation analyst in the Department of Emergency Medicine at the University of Colorado Denver; Michelle Frances Ferguson, BSN, RN, OCN®, is an oncology associate nurse manager at Memorial Hospital at the University of Colorado Health in Colorado Springs; Jennifer L. Wiler, MD, MBA, is the executive vice chair of the School of Medicine and executive medical director of the University of Colorado Health, both at the University of Colorado; Richard D. Zane, MD, is the George B. Boedecker Jr. and Boedecker Foundation Endowed Chair of Emergency Medicine and a professor in the Department of Emergency Medicine in the School of Medicine, both at the University of Colorado Anschutz; and Kathleen Flarity, DNP, PhD, CEN, CFRN, FAEN, is the deputy director of the Center for COMBAT Research in the Department of Medicine at the University of Colorado Anschutz and a research nurse scientist at the University of Colorado Health. The authors take full responsibility for this content and did not receive honoraria or disclose relevant financial relationships. Michael can be reached at sarah.michael@cuanschutz.edu, with copy to CJONEditor@ons.org.



Ahn, S., & Hwang, S. (2019). Virtual rehabilitation of upper extremity function and independence for stroke. Journal of Exercise Rehabilitation, 15, 358–369.

Anton, N.E., Bean, E.A., Hammonds, S.C., & Stefanidis, D. (2017). Application of mental skills training in surgery: A review. Journal of Laparoendoscopic and Advanced Surgical Techniques, 27, 459–469.

Beck, C.T. (2011). Secondary traumatic stress in nurses: A systematic review. Archives of Psychiatric Nursing, 25, 1–10.

Bracq, M.S., Michinov, E., Arnaldi, B., Caillaud, B., Gibaud, B., Gouranton, V., & Jannin, P. (2019). Learning procedural skills with a virtual reality simulator: An acceptability study. Nurse Education Today, 79, 153–160.

Cañadas-De la Fuente, G.A., Gomez-Urquiza, J.L., Ortega-Campos, E.M., Cañadas, G.R., Albendín-García, L., & De la Fuenta-Solana, E.I. (2018). Prevalence of burnout syndrome in oncology nursing: A meta-analytic study. Psycho-Oncology, 27, 1426–1433.

Epp, K. (2012). Burnout in critical care nurses: A literature review. Dynamics, 23(4), 25–31.

Fealy, S., Jones, D., Hutton, A., Graham, K., McNeill, L., Sweet, L., & Hazelton, M. (2019). The integration of immersive virtual reality in tertiary nursing and midwifery education: A scoping review. Nurse Education Today, 79, 14–19.

Flarity, K., Gentry, J.E., & Mesnikoff, N. (2013). The effectiveness of an educational program on preventing and treating compassion fatigue in emergency nurses. Advanced Emergency Nursing Journal, 35, 247–258.

Flarity, K., Moorer, A., & Jones-Rhodes, W. (2018). Longitudinal study of a compassion fatigue resiliency intervention in nurse residents. Journal of Nursing Education and Practice, 8(9), 61–67.

Flarity, K., Nash, K., Jones, J., & Steinbruner, D. (2016). Intervening to improve compassion fatigue resiliency in forensic nurses. Advanced Emergency Nursing Journal, 38, 147–156.

Gentry, J.E. (2016). Forward-facing trauma therapy: Healing the moral wound. Sarasota, FL: Compassion Unlimited.

Geraets, C.N.W., Veling, W., Witlox, M., Staring, A.B.P., Matthijssen, S.J.M.A., & Cath, D. (2019). Virtual reality-based cognitive behavioural therapy for patients with generalized social anxiety disorder: A pilot study. Behavioural and Cognitive Psychotherapy, 47, 745–750.

Glennon, C., McElroy, S.F., Connelly, L.M., Mische Lawson, L., Bretches, A.M., Gard, A.R., & Newcomer, L.R. (2018). Use of virtual reality to distract from pain and anxiety. Oncology Nursing Forum, 45, 545–552.

Gómez-Urquiza, J.L., Aneas-López, A.B., Fuenta-Solana, E.I., Albendín-García, L., Díaz-Rodríguez, L., & Fuente, G.A. (2016). Prevalence, risk factors, and levels of burnout among oncology nurses: A systematic review [Online exclusive]. Oncology Nursing Forum, 43, E104–E120.

Hall, L.H., Johnson, J., Tsipa, A., & O’Connor, D.B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLOS ONE, 11(7), e0159015.

Henry, B.J. (2014). Nursing burnout interventions: What is being done? Clinical Journal of Oncology Nursing, 18, 211–214. https://doi.org/10.1188/14.CJON.211-214

HTC Corporation. (2019). Planning your play area. Retrieved from http://bit.ly/2NSPids

Lauria, M.J., Rush, S., Weingart, S.D., Brooks, J., & Gallo, I.A. (2016). Potential role for psychological skills training in emergency medicine: Part 1—Introduction and background. Emergency Medicine Australasia, 28, 607–610.

Lee, H.S., Park, Y.J., & Park, S.W. (2019). The effects of virtual reality training on function in chronic stroke patients: A systematic review and meta-analysis. BioMed Research International, 2019, 7595639.

Maples-Keller, J.L., Yasinski, C., Manjin, N., & Rothbaum, B.O. (2017). Virtual reality-enhanced extinction of phobias and post-traumatic stress, Neurotherapeutics, 14, 554–563.

Mashlash, C., & Mayer, T. (In press). Burnout. In Strauss and Mayer’s emergency department management (2nd ed.). Irving, TX: American College of Emergency Physicians.

Neumann, J.L., Maue, L.-W., Virani, S., Denzen, E.M., Boyle, D.A., Boyle, N.J. . . . Burns, L.J. (2018). Burnout, moral distress, work–life balance, and career satisfaction among hematopoietic cell transplantation professionals. Biology of Blood and Marrow Transplantation, 24, 849–860.

NSI Nursing Solutions, Inc. (2019). 2019 national health care retention and RN staffing report. Retrieved from http://bit.ly/2Npkm5O

Perry, B., Toffner, G., Merrick, T., & Dalton, J. (2011). An exploration of the experience of compassion fatigue in clinical oncology nurses. Canadian Oncology Nursing Journal, 21, 91–105.

Rushton, C.H, Batcheller, J., Schroeder, K., & Donohue, P. (2015). Burnout and resilience among nurses practicing in high-intensity settings. American Journal of Critical Care, 24, 412–422. https://doi.org/10.4037/ajcc2015291

van Agteren, J., Iasiello, M., & Lo, L. (2018). Improving the wellbeing and resilience of health services staff via psychological skills training. BMC Research Notes, 11, 924.

Zeng, N., Pope, Z., Lee, J.E., & Gao, Z. (2018). Virtual reality exercise for anxiety and depression: A preliminary review of current research in an emerging field. Journal of Clinical Medicine, 7(3), E42.