A Scoping Review Identifying the Need for Quality Research on the Use of Virtual Reality in Workplace Settings for Stress Management

Abstract

Workplace stress management is a growing problem that can have significant mental health and financial impact for workers and their employers. There is a growing body of evidence supporting the efficacy of Virtual Reality (VR) treatments for stress and anxiety, however no reviews of VR to date have looked specifically into the use of VR for this purpose in the workplace. This scoping review aimed to identify available evidence in this environment (i.e., workplace) and investigate whether using VR might reduce workplace stress levels. The academic databases, CINAHL, Medline, Proquest, PsychINFO, PubMed, Scopus, and Web of Science, were searched using terms focused on VR, stress or relaxation, and workplaces. Results from the articles reviewed demonstrate a wide variety of study designs and techniques, with a general indication that the interventions reduce stress. Commonalities, differences, and levels of workplace focus are examined. Areas for future studies are highlighted, and the importance of the unique contribution VR can make to stress management in the workplace is identified as a gap in the research to be filled.

Introduction

Virtual Reality (VR) is continuing to rise in the consumer market as its benefits as a useful tool for research, work, and recreation are better understood. A recent article in Forbes titled “2019: The Year Virtual Reality Gets Real”¹ puts this rise into perspective—“Worldwide, VR market volume is expected to reach 98.4 million sales by 2023, generating an installed base of 168 million units with a worldwide population penetration of 2%.” These numbers suggest that we are not seeing a repeat of the VR-as-fad of the 80’s, but instead that VR is here to stay.

As distinct from Augmented Reality, VR can be thought of as a primarily visual experience (normally paired with appropriate audio) created and displayed entirely through a computer program and specialized screens. VR experiences can be interactive (e.g., the user can influence the world they are viewing using devices like controllers) or passive (e.g., like watching a movie). Definitions can vary as to what counts as VR, but authors such as Wiederhold and Bouchard,² and Howard,³ stress “immersion” and “presence” as key features. This review will be using a definition of presence based on the article of Slater and Usoh,⁴ that is, presence is “the extent to which a subject allows themself to be convinced that they are somewhere other than where they physically are, determined by the images, sounds, and physical sensations provided by the virtual environment.”

Medicine and health are one of the driving areas for VR advancement. Just a sample of areas to utilize VR include body image,⁵ distraction from chronic pain,⁶ the treatment of gambling addiction,⁷ improving the clinical skills of military battlefield personnel,⁸ and the treatment of sexual assault survivors.⁹ Such is the interest in VR research that a growing number of systematic reviews and meta-analyses have been published, with examples from recent years, including Dascal et al.¹⁰ who evaluated VR interventions in acute inpatient settings; Freeman et al.¹¹ who investigated the potential for VR in mental health care; and Howard,³ who conducted a meta-analysis of different hardware and software aspects of VR interventions.

One of the key health approaches adopting VR research is the focus of preventative health. Preventative health interventions such as meditation, relaxation, and breathing techniques are recognized by the Australian Psychological Society as beneficial for psychological stress and anxiety conditions.^12,13 Relaxation and meditation techniques are increasingly being found to be beneficial interventions for both clinical and subclinical psychological health and wellbeing.^14,15 There is also growing evidence to suggest that VR can be a very effective medium that can produce feelings of relaxation in users^3,16 without outside distraction, and that in general, VR is efficacious and well tolerated by patients across a wide range of clinical settings.¹⁰

This review aims to examine VR as a tool in the workplace to manage stress. Workplace stress is a growing issue, with the Australian Psychological Society's 2014 edition of the “Stress and wellbeing in Australia survey” identified that one-in-four Australians reported moderate-to-severe levels of stress, with 44 percent of the 1,020 respondents rating issues in the workplace as a source of stress.¹⁷ These authors also report finding a decline in factors such as job satisfaction and overall workplace wellbeing compared with the 2011 results. Workplace stress at numbers like this can have major financial implications, even at a national economy level. Fotinatos-Ventouratos and Cooper¹⁸ report that workplace stress cost the UK £3.7 billion in 2005 alone, whereas Kalia¹⁹ argues that per annum costs of stress in the United States range from $42 billion, up to $150 billion if factors such as absenteeism and lost productivity are included. Another factor is employee turnover, with one conservative estimate by the U.S. Bureau of Labor Statistics placing the average cost of replacing an employee at $13,996 USD,²⁰ with this number, including costs that arise from job vacancy and new training. Turnover has been linked in multiple studies to job dissatisfaction and work-life balance (WLB) concerns,²¹ and while in many instances people leave their job for reasons such as retirement, O'Connell and Kung²⁰ suggest that ∼89 percent of turnover is to find another job. One damaging outcome that may begin with poor WLB and ends in turnover is burnout.

Mamidenna and Viswanatham²² use Pines and Aronson's^{23(p 55)} definition of burnout as “a state of physical, emotional, and mental exhaustion caused by emotionally demanding situations.” Burnout has been linked not only to turnover but also nonparticipation, absenteeism, counterproductive work, and even aggressive retaliation.²² Several studies have connected burnout to acts like workplace sabotage, theft, interpersonal aggression, and hostility,^22,24,25 which can result in not only financial loss to the employee's company, but may also risk harm to customers or clients. Employees' abilities to cope can be worn down by high job demands, low job control, and prolonged periods of reactivity, brought on by intensification and extensification factors resulting in poor WLB. Burnout can further negatively interact with WLB leading to a negative spiral.²⁶

Improving things at this stage is not an easy task; while a person in this position can seek professional treatment, there is no quick fix for the effects of workplace stress and resultant declining mental health. Indeed, for some, the road is even more difficult, with Bystritsky²⁷ reporting that, of those that seek treatment for anxiety, 40 percent do not respond to standard treatments such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Cognitive Behavioral Therapy (CBT). Even when effective, SSRIs and other drugs like sedatives can have major negative side effects.²⁸ Strains on finances, time, and energy can further hamper this process, especially without a clinical diagnosis. To minimize both the personal cost to employees and the financial costs to businesses, researchers and policy makers must turn to organizational level interventions for instigating new options for workplace stress management.

VR and other tech-based interventions are already being considered by businesses for stress and wellbeing within the workplace, with Howard³ reporting that the application of the computer-assisted simulation market (which includes VR) to workplace training and wellbeing (i.e., apps and online modules) generated US$2.4 billion in revenue in 2012, with projections of US$6.7 billion for 2017. However, as this review will outline, there have been very few empirical studies that provide a clear explanation of the application of VR technology in the workplace setting and/or the rigor of methodology to provide a strong evidence base for their efficacy in managing stress. Furthermore, none of the systematic reviews of VR research to date has looked specifically into the use of VR to manage workplace stress. Given this, a review of the evidence base regarding the possible benefits of VR in this area is needed to guide and support spending of this magnitude, as well as identify research gaps that need to be addressed to provide a greater scientific evidence base for the uptake of VR for stress management interventions in the workplace.

For the purpose of this review, VR devices and studies will be restricted to devices that prioritize “immersion” and “presence” as features (based on the findings of studies such as Howard³), meaning that Head-Mounted Displays (HMDs; such as the Oculus Rift) and CAVE Automatic Virtual Environment (CAVE) systems would qualify (as they offer near-complete control over visual and auditory stimuli, promoting a strong sense of presence and immersion in the virtual world²⁹), while studies that rely solely on standard computer screens or projections would not.

Methods

Given that VR in aid of stress management is a developing area, and that nonclinical applications are a subset of that number, a scoping review was carried out to examine the limited body of research currently available. Arksey and O'Malley³⁰ provide a framework to conduct such a review when a full systematic review would be untenable, and this method has been used to great effect by several authors (e.g., Dodemaide et al.³¹). We follow the same five-step framework^30,31 in this review.

Stage 1: identifying the research question

Based on an initial unsuccessful attempt at a systematic review, it was determined that the broader approach of a scoping review would be the better tool to examine this developing topic. Our research questions were therefore as follows:

(a) What peer-reviewed experimental research studies exist that examine stress management (and/or relaxation promotion) in nonclinical populations through immersive VR?

(b) What (if any) commonalities can be drawn from these studies?

(d) What are the implications for the development of the field?

Stage 2: identifying relevant studies

The following databases were systematically searched for this review: CINAHL, Medline, Proquest, PsychINFO, PubMed, Scopus, Web of Science. These were chosen to ensure perspectives and research beyond traditional cyberpsychology. Given the rapidly changing and evolving technology at the focus of this topic, a limiting start date was set at 2016 to ensure useful comparisons across recent generations of VR technology. As can be seen in Figure 1, 2,139 articles were returned.

FIG. 1.

Study identification flowchart.

Stage 3: study selection

All studies were required to be available in English and be published in peer-reviewed journals. Protocols without data were excluded, as were opinion pieces and editorials. Included articles were required to contain “Virtual Reality” as well as either “stress” or “relax” in their title, abstract, or keywords. Articles that used incompatible definitions (e.g., calling video content projected onto a two-dimensional [2D] monitor “immersive VR”) or unrelated homonyms (e.g., mechanical stress) were removed. Due to the rapid and substantial changes in VR technology over the last decade, a cutoff date of 2016 was selected to only capture studies utilizing modern technology. A final total of 22 articles were selected for examination and analysis (Fig. 1). The primary author was supervised by the other members of the team during this stage.

Stage 4: charting the data

The synthesizing of common themes from the chosen articles was undertaken by M.N. under the guidance of B.R. (Table 1).

Table 1.

Summary of Scoping Review articles

References	Year	Country	Publication type	Population	Rough aims	Measures	Example findings	Workplace
Ahmaniemi et al.³⁹	2017	Finland	Conference	Undefined adults (4; office workers)	Compare VR nature scenes to audio only for stress reduction	Objective + subjective	Questionnaire responses revealed that participants got significantly better distracted from work related thoughts and duties in the full VR condition.	Y
Anderson et al.³⁸	2017	United States	Journal	Healthy population (18; students)	Evaluate immersive natural settings using VR to reduce stress + improve mood. Neutral indoor control versus two natural settings.	Objective + subjective	Reductions in electrodermal activity from baseline were greater at the end of the natural scenes compared with the control. The natural scenes reduced negative affect from baseline but control did not. MRJPQ scores for the control scene were lower than both natural scenes. Preferred scene reduced negative affect greater than second choice, and first choice had greater than MRJPQ than second.	N
Blum et al.⁴⁴	2019	Germany	Journal	Healthy population (60)	HR biofeedback traditional versus with VR, as well as effects of relaxation self-efficacy, focus on presence, attentional resources, cardiac results, and reduction in “mind wandering.”	Objective + subjective	While both conditions were comparable for cardiac performance, with VR condition buffered perceived stress in subsequent stressor task, increased relaxation self-efficacy more, reduced mind wandering, helped participants focus on the present moment, and helped preserve attentional resources.	N
Cikajlo et al.³²	2017	Slovenia	Journal	Healthy population (4) + clinical (4)	Test VR mindfulness with cloud technology	Objective + subjective	Employees showed high Mindful Attention Awareness Scale scores, considerable reduction in high-frequency movements <0.34 Hz, particularly with the 360° video.	N
Gao et al.⁴¹	2019	China	Journal	Healthy population (120; students)	Examine VR on stress and preference through different urban environments.	Objective + subjective	The results showed that the six environments had positive restorative effects on attentional fatigue and negative mood; however, all the participants obtained the highest levels of physiological stress restoration when asked to close their eyes for relaxation. EEG showed no difference between groups. Negative mood was the only variable with significant differences: “partly open green space” had the most positive effect on negative mood and “closed green space” the worst. Strong correlation between preference and improvement to mood.	N
Hedblom et al.⁴²	2019	Sweden	Journal	Healthy population (117)	Test effect of VR + soundscapes on arousal/stress.	Objective only	No significant difference in stress recovery was found between the soundscapes. All three soundscapes, however, significantly reduced stress.	N
Huang et al.⁵²	2020	China	Journal	Healthy population (89; students)	Examine effects of different types of VR environments on stress.	Objective + subjective	The grassy environment had the greatest effect on positive affect. Skin conductance levels during the second half of VR immersion were significantly lower in both the grass and tree environments than in the concrete-only environment.	N
Kanehira et al.⁴⁰	2018	Japan	Conference	Undefined adults (8; students)	Examine combination of music therapy and VR on relaxation.	Objective + subjective	No p values given. Alleged reduction in “uneasiness state,” largest value was VR + favorite music. Face scale suggests improvement in mood in all but “no stimulus”. Questionnaire suggests positive results.	N
Kiefl et al.⁴⁵	2018	Germany	Conference	Healthy population (74; students)	Compare effects of graphical styles on emotional states.	Subjective only	Both styles can have a relaxing effect, neither rendering style is superior, and prior experience with VR may influence relaxation.	N
Koinuma and Ohkura⁴⁶	2019	Japan	Conference	Healthy population (6; students)	Compare relaxation effects of watching nature scene using HMD versus 2D monitor.	Objective + subjective	Bio-signals (electrocardiogram) and saliva α-amylase values lower (i.e., more relaxed) after watching scene on HMD compared with 2D monitor (p < 0.01). Saliva α-amylase values after stress task significantly reduced after watching HMD (p < 0.05), but not 2D monitor.	N
Kosunen et al.⁴⁷	2016	Finland	Conference	Undefined adults (43; students)	Test RelaWorld system, VR versus not, neurofeedback or not, two meditation types.	Subjective only	VR + neurofeedback = best performance on meditation depth and presence. No significant difference between meditation types.	N
Liszio et al.⁴⁸	2018	Germany	Journal	Healthy population (62; “mostly” students)	Examine if VR + natural environments provide relaxation during acute stress.	Objective + subjective	The VR group experienced significantly lower stress and higher positive affect than the desktop group and a control group. Claim that high immersion results in less anxiety.	N
Maarsingh et al.³³	2019	Netherlands	Journal	Healthy population (111) + clinical (64)	Examine if VR + real-time biofeedback could aid training stress-is-enhancing mindset.	Subjective only	Both groups had more positive stress mindset posttest.	N
Perhakaran et al.⁴⁹	2016	Malaysia	Journal	Undefined (30)	Examine meditation effectiveness for VR (with audio elements) stress therapy with EEG (vs. non-VR).	Objective only	Both conditions lowered stress but the VR participants were observed to be in a better meditation state compared with the imaginary participants at the end of the study.	N
Rockstroh et al.³⁶	2019	Germany	Journal	Healthy population (68)	Test feasibility and advantages of VR HR variability biofeedback VR HRV-BF vs. 2D HRV-BF vs. Control (10 minutes nature vid).	Objective + subjective	Both the VR and 2D version of HRV-BF were equally effective in increasing short-term HRV. However, the VR-based implementation was associated with higher motivation and helped users better maintain attentional focus.	N
Soyka et al.⁵⁰	2016	Germany	Conference	Undefined adults (21)	Test VR + breathing-based relaxation, underwater scenes versus jellyfish only.	Objective + subjective	Overall participants were relatively relaxed already before VR exposure. Participants in underwater scene condition were more relaxed before and after than control. Both groups had improved relaxation after VR. HR suggests both conditions equally effective.	N
Straßmann et al.³⁷	2019	Germany	Conference	Undefined adults (41; students)	Evaluate their design, tested VR versus not, “Napshell” versus normal deck chair.	Subjective only	In progress results. Participants overall had a positive attitude toward VR technologies, no feelings of simulator sickness. Mental state less negative after relaxation phases. Participants in VR reported “escape from reality” (enhanced relaxation), more common from those in Napshell. Authors indicate “people want to adapt the method to their own needs and preferences.”	Y
Thoondee and Oikonomou⁵¹	2017	England	Conference	Undefined adults (32; office workers)	Compare effectiveness of two VR modes for break time stress management.	Subjective only	Participants enjoyed the relaxation experience, felt more relaxed after using the application and responded favorably to the idea of using VR for relaxation at work as well as combining relaxing virtual environments with work-related activities.	Y
Tinga et al.⁵⁴	2019	Netherlands	Journal	Healthy population (60; students)	Test effectiveness of respiratory biofeedback (w/meditation) in lowering arousal after stress in VR.	Objective + subjective	Reduction in arousal (on all outcome measures combined and HR specifically) was largest in the control feedback placebo condition, in which no biofeedback was used, indicating that respiratory biofeedback had no additional value in reducing arousal.	N
Wang et al.⁴³	2019	China	Journal	Healthy population (96; students)	Explore effects of different VR forest environments on stress.	Objective + subjective	All conditions provided some level of relaxation. Most natural environment did not have the most significant effect on stress relief.	N
Yin et al.⁵³	2019	United States	Journal	Healthy population (30; students)	Compare three levels of biophilic design versus open/closed workspaces on stress/creativity.	Objective + subjective	Biophilic elements linked to lower stress and higher creativity.	Y
Zhu et al.⁵⁹	2019	China	Conference	Healthy population (13; students)	Compare impact of VR scenes with music, identify stress-relevant features, and establish EEG model for stress evaluation.	Objective + subjective	Self-rating scale suggests participants felt relaxed, EEG suggests positive effects of VR scenes with music.	N

2D, two-dimensional; HMD, head-mounted display; HR, heart rate; HR V-BF, HR variability biofeedback; MRJPQ, Modified Reality Judgment and Presence Questionnaire; VR, virtual reality.

Stage 5: collating, summarizing, and reporting the results

Publications were collated and mapped to include outcomes related to stress management or problems of achieving significant findings. This was undertaken by MN under the guidance of A.C. and B.R.

Results

Twenty-two studies met the criteria for the search. From those, supporting evidence for the research questions have been provided in sections below.

General features

Of the 22 studies, half (11) were published in 2019, with 2018 being the next most populous year with 5. Distribution of studies was more even geographically, with 13 (59.09 percent) studies conducted in Europe, 7 (31.82 percent) in Asia, with only 2 (9.09 percent) in North America. Nine articles (40.91 percent) came from conferences with the rest from traditional journals. In terms of sample population, 13 (59.09 percent) reported used university students in at least part of their sample, whereas only 2 (9.09 percent) specifically used workers. Seven (31.82 percent) of the studies did not appear to use any screening apart from selecting for adults, and an equal number had a total sample population of <30. While two studies (Cikajlo et al.³² and Maarsingh et al.³³) did include clinical populations, they also contained experimental data and results derived from healthy adults, and so were included in this study with examination looking just at the nonclinical results. Finally, 17 (77.27 percent) experiments were conducted in a single session (including some within-subject designs where participants took part in multiple conditions), whereas the remaining 5 (22.73 percent) had participants return for at least 1 additional session.

Commonalities from aims

The selected studies all in some way explored the use of VR (often in tandem with some other technology) to reduce stress/arousal. The most prominent similarity was found to be the use of natural environments and landscapes (both real world and artificial) to investigate any aid to relaxation, which were used in 18 (81.82 percent) studies. VR environment factors (e.g., amount, concentration, and type of plant life, or office structure) were explicitly explored in the aims of six (27.27 percent) studies. Biofeedback featured frequently (40.91 percent) as a major component of the interventions. Other components of intervention delivery included heart rate (HR), breathing, and electroencephalogram (EEG)-based neurofeedback.

Commonalities from measures, instruments, and results

Nearly all the included studies used a common, commercially available HMD such an Oculus Rift, HTC Vive, or Playstation VR. Most other studies used a mobile phone-based system like the Samsung Gear VR. No CAVE VR setups were reported. A sizable majority (81.82 percent) of studies employed at least one objective measure (e.g., HR), and one subjective measure (published or bespoke) to analyze any change in stress, or other factors such as immersion. While some published measures (e.g., The Positive and Negative Affect Schedule [PANAS]³⁴ and the State-Trait Anxiety Inventory [STAI]³⁵) were used in a few of the selected studies (4 and 5 studies, respectively), 18 different questionnaires and measures were only used in a single study. In terms of objective and biological measures, 12 (54.55 percent) examined HR (or variations) or blood pressure, 4 (18.18 percent) used EEG data, 5 (22.72 percent) looked at skin conductance, and 3 (13.63 percent) processed samples of salivary α-amylase. The common finding that can be drawn from the results in these selected articles appears to be that relaxation tends to be reported after a stress reduction activity, and this frequently occurs in both experimental and control groups.

Workplace focus

While many of the experimental interventions could potentially find use in a workplace setting, only four (18.18 percent) of the selected articles had a dedicated focus on workplace stress.

Discussion

This scoping review identified 22 articles that examined nonclinical stress and/or relaxation VR interventions. While this modest number is indicative of the developing area, the skew toward more recent publications suggests that there is a definite, growing interest in nonclinical, evidence-based VR stress management applications.

Commonalities between studies

Relaxation effects over time and user preference

One of the major findings from this review was that participants tended to show some level of relaxation posttest, regardless of intervention type. This factor, combined with the number of studies taking place entirely within one session, raises the issue of potential novelty and or placebo effects. This concern is noted by some of the authors^33,36,37 of the included articles. Of the studies that sought participant feedback, there appears to be a possible trend reported among participants that the use of VR technology for stress reduction shows promise and would be something they are interested in seeing more of (if not outright declaring interest in using it for themselves). Authors such as Anderson et al.³⁸ and Straßmann et al.³⁷ flagged how important it was to participants for interventions to be adaptable to user choice. While not surprising, this user feedback can greatly help inform future intervention designs.

Environment

One of the biggest points of commonality was the use of environmental scenes (both natural or artificial). While it was expected that studies would largely utilize commercially available relaxing nature-themed 360° videos,^38–40 researchers in the studies identified chose to either make their own footage^41–43 or use computer-generated environments.^{33,36,37,44–51} These studies can be divided into two groups: (a) impacts of urban green spaces (UGS); and (b) impact of immersive natural scenes.

Impacts of urbanization

Gao et al.,⁴¹ Hedblom et al.,⁴² Huang et al.,⁵² and Yin et al.,⁵³ were all concerned with the impacts of the built environment. Gao et al.⁴¹ and Hedblom et al.⁴² were interested in the impacts of urbanization (characterized as something that separates people from nature⁴¹) and availability of UGS on wellbeing. Both studies linked decreased availability of UGS to mental and physical ailments and aimed to explore the restorative effects of VR UGS. Both found a reduction in stress regardless of condition, however neither bird song, nor any specific tested environment, was vastly more restorative than controls.

Huang et al.⁵² and Yin et al.⁵³ both discussed the importance of biophilia in design, with the latter defining biophilia as “an innate connection to nature which may affect our health and productivity.” Huang et al.⁵² focused on the effects of trees, grass, or concrete on a user's experience, and found a preference for nonconcrete environments and support for the importance of UGS. Yin et al.⁵³ focused entirely on the workplace environment and endeavored to see how varying amounts of plant life (alongside open vs. more closed office designs) in a virtual office could impact stress reduction and creativity.

Immersive natural scenes

Anderson et al.,³⁸ Blum et al.,⁴⁴ and Liszio et al.⁴⁸ all have the words “immersive” and “nature” or “natural” in their titles and as part of the focus of the studies. Wang et al.⁴³ took a slightly different focus and discussed the emergence of “forest therapy” as an intervention, which they defined as “a health promotion method that is based on the forest environment and activities such as walking and rest” and claim that is growing in popularity in China. These studies collectively cited a wealth of evidence to suggest that natural scenes and environments (or specifically forests⁴³) provide relaxation and other wellbeing benefits.

These two groups highlight one of the current key foci in current nonclinical relaxation interventions: the duality between the benefits of natural VR settings on stress and wellbeing, paired with the detrimental effects raised by urban environments, and in the case of Yin et al.,⁵³ workplaces specifically. While an immersive natural environment or UGS alone does not appear to be enough for an effective intervention, it does signal to future researchers that this area may be a valuable starting point. Finally, it should be stressed that the research influence from disciplines such as urban planning, architecture, and design provide a valuable multidisciplinary perspective to help give breadth to cyberpsychology research, especially given the current focus on clinical research.

Biofeedback

As reported previously, biofeedback was used in concert with VR in nine articles. While Tinga et al.⁵⁴ reported partial-null results, other authors reported that there were some additional benefits that come from VR and biofeedback. Given the importance and commonality of devices like EEGs and HR monitors as objective measures in this field, it is likely that studies combining biofeedback and VR will increase in number.

Exploratory research

One of the strongest commonalities within the selected articles was revealed by their design: the predominantly exploratory, feasibility, or pilot level of the current body of research. All the selected articles fit into this category, and beyond any quality or “risk of bias” (RoB) assessment, it is clear that current research is in a very mixed place. This will be discussed further in the differences section below.

Differences

While examining study quality and RoB is the domain of a Systematic Review,⁵⁵ it would be remiss to not discuss the disparate nature of the selected study designs. Study designs ranged from being described as “a double-blind, randomized, controlled, between-subjects, laboratory experiment”⁴⁴ to a feasibility study with no control or comparison.⁵¹ The variety of different measures (especially subjective questionnaires) used demonstrate that no standardized or dominant testing regime for nonclinical stress management in VR has yet been established. This variety also means that synthesizing common outcomes (e.g., stress ratings, qualitative feedback) for interstudy comparisons is very difficult, if possible at all. In a related vein, not all designs utilized specific stressors, which led to authors such as Ahmaniemi et al.^39(p209) saying of their study, “the results reported in this paper are based on a study that consisted of only 4 participants that were not particularly stressed in the first place.” The implications of testing stress reduction interventions solely on nonstressed participants, as part of a design aimed at nonclinically stressed users, are concerning. Of those designs that did involve a stressor, the variation was quite large. Stressors included “mild electric shocks,” variations based on the Stroop test⁵⁶ and the Trier social stress test (TSST⁵⁷; including a virtual version of the TSST⁴⁸).

There were also differences in sample populations across the studies with seven (31.82 percent) having a total sample population of n < 30, while only three (13.64 percent) had n > 100. Several of the studies made no mention of any participant screening process. Many studies looked at prior experience with VR, with most participants reporting being largely unfamiliar with VR, although Kiefl et al.⁴⁵ was an exception. This is important because if there is a powerful novelty factor associated with the positive effects of VR, future studies must investigate it specifically, with (at minimum) a second/repeat session. Given that many of these articles involved only a single session, this could be (and has been acknowledged by some authors to be) a possible confound.

One positive for this area of study is that some studies^42,54 are being published with partial-null results, which is important given that publication bias is a well-known issue.⁵⁵ Less promisingly, some of these published articles present their conclusions based on incomplete or otherwise in-progress research. While this is far from ideal, it must be stressed that early research designs like these are not without value. Indeed, even the Cochrane Handbook^{55(ch21, p594)} makes the case for the situational importance of exploratory designs, saying that “reviewing nonrandomized evidence can give an estimate of the nature, direction, and size of effects.” The claims being made by these articles provide future directions of study for this intervention type, rather than definitive treatment outcomes. Given this, the area of research must eventually move toward repeatable, full-scale, robust experiments, even if high complexity designs such as double-blind randomized controlled trials (RCTs) are unfeasible for the short term.

Applicability to workplace settings and general implications

Of the 22 included studies, only 4 (18.18 percent) of the selected articles had a dedicated focus on stress in the workplace. Considering this review, it is reasonable to conclude that there is a gap in the literature on this topic that should be filled as a matter of some importance. As discussed previously, stress in the workplace has a growing cost, for individuals and their WLB, health, and general wellbeing, as well as for businesses who want to increase productivity while avoiding factors like burnout, turnover, and a bad public image. Given the success in providing meaningful distraction from clinical pain,⁶ it seems reasonable to believe that there may be similar or transferable benefits when giving users a chance to mentally “step away” from their stressful work, but more research is needed.

Limitations

This scoping review was limited by several factors. First, this area of study could be considered quite niche, necessitating the use of reasonably strict search and sorting protocols. As is often the case, it is possible that articles were missed, despite the number of databases searched. This is further compounded by the search-only examining articles available in English, and the ongoing issue of publication bias surrounding null or negative findings. Second, this area of study is a relatively new one. As this review found, there are limited prior articles to draw upon.

Areas for future study and implications for the field

With only four of the 22 selected studies having a dedicated focus on workplace stress, it follows that the field of workplace VR interventions for stress and relaxation warrants further exploration. Ideally, future studies would employ a RCT (or robust non-RCT that includes a separate control condition) design with the specific aim of examining stress reduction in the workplace through VR interventions that have been designed to fit in with work life (e.g., for use during breaks). Future studies should seek to employ objective measures such as HR to complement subjective qualitative and quantitative metrics, with full statistical reporting included wherever possible, ideally with a mind to the establishment of robust standardized techniques. The results of this review suggest that future studies should have the identification of any placebo and or novelty effects as a cornerstone of their design. One such step should be aiming to repeat sessions over time if possible. Factors such as intervention length, device differences (e.g., dedicated HMD vs. phone-based), age, and gender effects are all important areas to expand upon. Additionally, the importance of participant choice and requirement for interventions to be adaptable to user choice cannot be overstated.

Given the current bias toward nature-based interventions, a broader array of stimuli will need to be investigated to identify what unique contributions VR can make to relaxation (e.g., how much influence immersion has vs. a passive experience), with an ideal endpoint being an experience that is engaging enough to stave off boredom, but not be so engaging as to thwart the effect of relaxation. It is important that this topic continues to see more exploratory investigations that take these factors into consideration, from which a sizeable knowledge base can develop to support to use of VR in workplaces to provide affordable and accessible interventions to improve work force wellbeing.

Conclusion

Expanding the parameters of this article into a scoping review has allowed us to capture the broader snapshot of not just why this area is important, but also that the case is ready to be made that VR is here to stay, and research must be undertaken to explore what is effective (or even detrimental) to improving workers' abilities to cope with workplace stress using VR. The Cyberpsychology Research Group at The University of Sydney will now be leading the exploration of this area over the years 2019–2021, with the aim of expanding on pilot investigations⁵⁸ to establish an evidence base regarding what factors can help or hinder the use of VR as a break-time stress management intervention.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was solicited or received for this study.

References

Rogers

(2019) 2019: The year virtual reality gets real. Forbes Media. www.forbes.com/sites/solrogers/2019/06/21/2019-the-year-virtual-reality-gets-real (accessed Aug. 1, 2019).

Wiederhold

, Bouchard

. (2014) Advances in virtual reality and anxiety disorders. Boston, MA: Springer US.

Howard

MC.

Virtual reality interventions for personal development: a meta-analysis of hardware and software. Human-Computer Interaction, 2019; 34:205–239.

Slater

, Usoh

. (1993) Presence in immersive virtual environments. In Proceedings of IEEE Virtual Reality Annual International Symposium. Washington, DC: IEEE Computer Society, pp. 90–96.

Tremblay

, Roy-Vaillancourt

, Chebbi

, et al. Body image and anti-fat attitudes: an experimental study using a haptic virtual reality environment to replicate human touch. Cyberpsychology, Behavior, and Social Networking, 2016; 19:1–106.

Wiederhold

, Gao

, Sulea

, et al. Virtual reality as a distraction technique in chronic pain patients. Cyberpsychology, Behavior, and Social Networking, 2014; 17:346–352.

Giroux

, Faucher-Gravel

, St-Hilaire

, et al. Gambling exposure in virtual reality and modification of urge to gamble. Cyberpsychology, Behavior, and Social Networking, 2013; 16:224–231.

Stetz

, Kaloi-Chen

, Turner

, et al. The effectiveness of technology-enhanced relaxation techniques for military medical warriors. Military Medicine, 2011; 176:1065–1070.

Loranger

, Bouchard

. Validating a virtual environment for sexual assault victims. Journal of Traumatic Stress, 2017; 30:157–165.

10.

Dascal

, Reid

, Ishak

, et al. Virtual reality and medical inpatients: a systematic review of randomized, controlled trials. Innovations in Clinical Neuroscience, 2017; 14:14–21.

11.

Freeman

, Reeve

, Robinson

, et al. Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 2017; 47:2393–2400.

12.

Bates

(2013a, July 22) APS EQIP information sheets—anxiety overview. http://eqip.psychology.org.au/information-sheets/anxiety (accessed Dec. 1, 2015).

13.

Bates

(2013b, July 29) APS EQIP information sheets—stress. http://eqip.psychology.org.au/information-sheets/stress (accessed Dec. 1, 2015).

14.

Ando

, Morita

, Akechi

, et al. The efficacy of mindfulness-based meditation therapy on anxiety, depression, and spirituality in Japanese patients with cancer. Journal of Palliative Medicine, 2009; 12:1091–1094.

15.

Arias

, Steinberg

, Banga

, et al. Systematic review of the efficacy of meditation techniques as treatments for medical illness. Journal of Alternative & Complementary Medicine, 2006; 12:817–832.

16.

Riva

, Baños

, Botella

, et al. Positive technology: using interactive technologies to promote positive functioning. Cyberpsychology, Behavior, and Social Networking, 2012; 15:69–77.

17.

Casey

, Liang

. (2014, October) Stress and wellbeing in Australia survey 2014. www.psychology.org.au/Assets/Files/2014-APS-NPW-Survey-WEB-reduced.pdf (accessed Dec. 1, 2015).

18.

Fotinatos-Ventouratos

, Cooper

. (2015) The economic crisis and occupational stress. Cheltenham: Edward Elgar Publishing.

19.

Kalia

Assessing the economic impact of stress—The modern day hidden epidemic. Metabolism, 2002; 51:49–53.

20.

O'Connell

, Kung

. The cost of employee turnover. Industrial Management, 2007; 49:14–19.

21.

Smith

, Gardner

. Factors affecting employee use of work-life balance initiatives. New Zealand Journal of Psychology, 2007; 36:3.

22.

Mamidenna

, Viswanatham

. Burnout and retaliatory behaviour intents in the workplace—an exploratory study. ASCI Journal of Management, 2014; 44:54–65.

23.

Pines

, Aronson

. (1988) Career burnout: causes and cures. New York: Free Press.

24.

Beauregard

TA.

Fairness perceptions of work–life balance initiatives: effects on counterproductive work behaviour. British Journal of Management, 2014; 25:772–789.

25.

Chen

, Spector

. Relationships of work stressors with aggression, withdrawal, theft and substance use: an exploratory study. Journal of Occupational & Organizational Psychology, 1992; 65:177–184.

26.

Merecz

, Andysz

. Burnout and demographic characteristics of workers experiencing different types of work-home interaction. International Journal of Occupational Medicine and Environmental Health, 2014; 27:933–949.

27.

Bystritsky

Treatment-resistant anxiety disorders. Molecular Psychiatry, 2006; 11:805–814.

28.

Chlan

Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart & Lung: The Journal of Acute and Critical Care, 1998; 27:169–176.

29.

Giglioli

IAC

, Pallavicini

, Pedroli

, et al. Augmented reality: a brand new challenge for the assessment and treatment of psychological disorders. Computational & Mathematical Methods in Medicine, 2015; 2015:1–12.

30.

Arksey

, O'Malley

. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 2005; 8:19–32.

31.

Dodemaide

, Joubert

, Merolli

, et al. Exploring the therapeutic and nontherapeutic affordances of social media use by young adults with lived experience of self-harm or suicidal ideation: a scoping review. Cyberpsychology, Behavior, and Social Networking, 2019; 22:622–633.

32.

Cikajlo

, Cizman Staba

, Vrhovac

, et al. A cloud-based virtual reality app for a novel telemindfulness service: rationale, design and feasibility evaluation. JMIR Research Protocols, 2017; 6:e108.

33.

Maarsingh

, Bos

, Van Tuijn

, et al. Changing stress mindset through stressjam: a virtual reality game using biofeedback. Games for Health Journal, 2019; 8:326–331.

34.

Watson

, Clark

, Tellegan

. Development and validation of brief measures of positive and negative affect: the PANAS scales. Journal of Personality and Social Psychology, 1988; 54:1063–1070.

35.

Spielberger

, Gorsuch

, Lushene

, et al. (1983) Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press.

36.

Rockstroh

, Blum

, Göritz

. Virtual reality in the application of heart rate variability biofeedback. International Journal of Human—Computer Studies, 2019; 130:209–220.

37.

Straßmann

, Eimler

, Arntz

, et al. (2019) Relax yourself-using virtual reality to enhance employees' mental health and work performance. In Extended Abstracts of the 2019 CHI Conference on Human Factors in Computing Systems. Glasgow, Scotland: ACM, p. LBW0286.

38.

Anderson

, Mayer

, Fellows

, et al. Relaxation with immersive natural scenes presented using virtual reality. Aerospace Medicine and Human Performance, 2017; 88:520–526.

39.

Ahmaniemi

, Lindholm

, Muller

, et al. (2017) Virtual reality experience as a stress recovery solution in workplace. In Life Sciences Conference (LSC). IEEE, Sydney, Australia: pp. 206–209.

40.

Kanehira

, Ito

, Suzuki

, et al. (2018) Enhanced relaxation effect of music therapy with VR. In 2018 14th International Conference on Natural Computation, Fuzzy Systems and Knowledge Discovery (ICNC-FSKD). Huangshan, China: IEEE, pp. 1374–1378.

41.

Gao

, Zhang

, Zhu

, et al. Exploring psychophysiological restoration and individual preference in the different environments based on virtual reality. International Journal of Environmental Research and Public Health, 2019; 16:3102.

42.

Hedblom

, Gunnarsson

, Schaefer

, et al. Sounds of nature in the city: no evidence of bird song improving stress recovery. International Journal of Environmental Research and Public Health, 2019; 16:1390.

43.

Wang

, Shi

, Zhang

, et al. The influence of forest resting environments on stress using virtual reality. International Journal of Environmental Research and Public Health, 2019; 16:3263.

44.

Blum

, Rockstroh

, Göritz

. Heart rate variability biofeedback based on slow-paced breathing with immersive virtual reality nature scenery. Frontiers in Psychology, 2019; 10:2172.

45.

Kiefl

, Figas

, Bichlmeier

. (2018) Effects of graphical styles on emotional states for VR-supported psychotherapy. In 2018 10th International Conference on Virtual Worlds and Games for Serious Applications (VS-Games). Piscataway, NJ: IEEE eXpress Conference Publishing, pp. 1–4.

46.

Koinuma

, Ohkura

. (2019) Comparison of relaxation effect from watching images between 2D and head-mounted displays. In Fukuda

, ed. Advances in affective and pleasurable design. AHFE 2018. Advances in intelligent systems and computing, Vol. 774. Cham: Springer, pp. 269–276.

47.

Kosunen

, Salminen

, Järvelä

, et al. (2016) RelaWorld: neuroadaptive and immersive virtual reality meditation system. In Proceedings of the 21st International Conference on Intelligent User Interfaces. New York, NY: Association for Computing Machinery, pp. 208–217.

48.

Liszio

, Graf

, Masuch

. The relaxing effect of virtual nature: immersive technology provides relief in acute stress situations. Annual Review of Cybertherapy and Telemedicine, 2018; 2018:87.

49.

Perhakaran

, Yusof

, Rusli

, et al. (2016) A study of meditation effectiveness for virtual reality based stress therapy using EEG measurement and questionnaire approaches. In Chen YW, Torro C, Tanaka S, Howlett R, Jain LC, eds. Innovation in Medicine and Healthcare. Cham: Springer, pp. 365–373.

50.

Soyka

, Leyrer

, Smallwood

, et al. (2016) Enhancing stress management techniques using virtual reality. In Proceedings of the ACM Symposium on Applied Perception. New York, NY: Association for Computing Machinery, pp. 85–88.

51.

Thoondee

, Oikonomou

. (2017) Using virtual reality to reduce stress at work. In 2017 Computing Conference. Piscataway, NJ: IEEE eXpress Conference Publishing, pp. 492–499.

52.

Huang

, Yang

, Jane

, et al. Trees, grass, or concrete? The effects of different types of environments on stress reduction. Landscape and Urban Planning, 2020; 193:103654.

53.

Yin

, Arfaei

, MacNaughton

, et al. Effects of biophilic interventions in office on stress reaction and cognitive function: a randomized crossover study in virtual reality. Indoor Air, 2019; 29:1028–1039.

54.

Tinga

, Nyklíček

, Jansen

, et al. Respiratory biofeedback does not facilitate lowering arousal in meditation through virtual reality. Applied Psychophysiology and Biofeedback, 2019; 44:51–59.

55.

Higgins

JPT

, Green

, eds. (2008) Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Book Series. Chichester, UK: John Wiley & Sons Ltd.

56.

Stroop

JR.

Studies of interference in serial verbal reactions. Journal of Experimental Psychology, 1935; 18:643–662.

57.

Kirschbaum

, Pirke

, Hellhammer

. The “Trier Social Stress Test”–a tool for investigating psychobiological stress responses in a laboratory setting. Neuropsychobiology, 1993; 28:76–81.

58.

Naylor

, Morrison

, Ridout

, et al. Augmented experiences: investigating the feasibility of virtual reality as part of a workplace wellbeing intervention. Interacting with Computers, 2019; 31:507–523.

59.

Zhu

, Tian

, Xu

, et al. (2019) Design and evaluation of the mental relaxation VR scenes using forehead EEG features. In 2019 IEEE MTT-S International Microwave Biomedical Conference (IMBioC). Piscataway, NJ: IEEE eXpress Conference Publishing, pp. 1–4.