Working under pressure: How virtual reality and psychoeducation shape stress and moral distress responses in nurses.

INTRODUCTION: Nurses face high levels of stress, particularly in high-pressure environments, such as hospitals. Digital interventions, including virtual reality (VR), offer promising avenues for educating frontline workers, monitoring momentary distress, and delivering evidence-based stress-reduction programs. OBJECTIVES: This study examined: (1) the tolerability, realism, and utility of a VR simulation for eliciting and monitoring stress among nurses; (2) within- (repeated measures) and between- (demographics) participant differences in stress and moral distress responses throughout the VR simulation and across runs; (3) knowledge retention of psychoeducation content; and (4) perceived success and helpfulness of stress-reduction strategies. METHODS: Nursing professionals (N = 99) completed two runs of a hospital-based VR simulation interspersed with an 8-minute psychoeducation video regarding moral distress and stress-reduction techniques. Stress and moral distress were assessed in real-time during the simulation, alongside post-VR questionnaires assessing presence and cybersickness, and two interviews (debriefing and exit), analyzed using a qualitative coding schema. The STROBE checklist guided results reporting. RESULTS: The VR simulation elicited distinct non-linear trajectories of acute stress and moral distress across simulation checkpoints and runs. The intervention was well-tolerated with low cybersickness (VRSQ: M = 13.29), high general presence (IPQ: Mdn = 5.00), and moderate spatial presence and realism (IPQ: Mdn = 3.00). Most participants recalled at least two of the three stress-reduction techniques with high ratings of perceived understanding and helpfulness. However, objective assessments revealed overestimations of conceptual understanding, highlighting gaps in knowledge retention and indicating that tailored, multi-modal psychoeducation may be necessary to ensure consistent uptake and effectiveness across the nursing workforce. CONCLUSION: Our hospital-based immersive VR simulation is a feasible and ethically sound method for inducing and monitoring stress and moral distress in nurses. Findings underscore the importance of triangulating self-report and objective measures to assess intervention effectiveness and inform future digital health education strategies.