Prolonged hospitalization can reduce opportunities for independent activity, choice, and control and may contribute to passivity, low mood, anxiety, and distress in some older adults. Zenctuary VR+ is a seated, nature-based virtual reality program that combines calming environments with simple, low-demand activities. The active program allows participants to make choices, move between predefined locations, and influence elements of the virtual environment. Trained staff supervise every session and provide support when needed.
The trial evaluates whether the interactive version of Zenctuary VR+ reduces psychological distress more than passive exposure to the same virtual environments. A total of 100 hospitalized adults aged 60 years or older will be randomly assigned to the interactive VR condition or the passive VR condition. Eligible participants are expected to remain hospitalized for at least four weeks following enrolment. Both groups will receive six sessions over three weeks. Psychological distress and related psychological factors will be assessed before the first session, immediately after the three-week intervention period, and four weeks after the final session.
Aged 60 years or older
Diagnosed with at least one chronic medical condition
Currently receiving inpatient hospital care
Expected to remain hospitalized for at least four weeks following enrolment
Cognitive impairment, defined as a score below 18 on the Montreal Cognitive Assessment (MoCA)
Impaired consciousness or reduced alertness that would prevent meaningful participation
Current or previous diagnosis of a psychotic disorder
Current substance use disorder that would interfere with participation in the study procedures
Parallel
Interactive nature-based virtual reality intervention
DeviceAn immersive, head-mounted-display-delivered virtual reality intervention presenting nature-based virtual environments with interactive, low cognitive load tasks. Participants make simple choices, navigate between virtual locations, and influence elements of the environment while seated, with the goal of supporting agency, perceived control, and successful action. Delivered in six sessions over three weeks (twice weekly), each guided by a trained operator using a standardized least-assistance approach.
Passive nature-based virtual reality exposure
DeviceAn immersive, head-mounted-display-delivered virtual reality experience presenting the same nature-based virtual environments as the active intervention, without interactive elements. Participants passively observe the virtual scenery while seated, with no opportunity for choice, navigation, or environmental interaction. Delivered in six sessions over three weeks (twice weekly), matching the active intervention in schedule, apparatus, and visual content, differing only in the absence of interactivity.
Change From Baseline in Psychological Distress as Measured by the Hospital Anxiety and Depression Scale Total Score
The Hospital Anxiety and Depression Scale is a 14-item self-report measure comprising seven anxiety items and seven depression items. The total score ranges from 0 to 42, with higher scores indicating greater psychological distress.
Change From Baseline in Self-Esteem as Measured by the Rosenberg Self-Esteem Scale
The Rosenberg Self-Esteem Scale is a 10-item self-report measure of global self-esteem. The total score ranges from 0 to 30, with higher scores indicating higher self-esteem.
Change From Baseline in General Self-Efficacy as Measured by the General Self-Efficacy Scale
The General Self-Efficacy Scale is a 10-item self-report measure assessing perceived ability to manage difficult or novel situations. The total score ranges from 10 to 40, with higher scores indicating greater general self-efficacy.
Change From Baseline in Depressive Symptoms as Measured by the Geriatric Depression Scale
The 30-item Geriatric Depression Scale is a self-report measure of depressive symptoms in older adults. The total score ranges from 0 to 30, with higher scores indicating greater depressive symptom severity.
Change From Baseline in Hopelessness as Measured by the Beck Hopelessness Scale
The Beck Hopelessness Scale is a 20-item self-report measure assessing negative expectations and beliefs about the future. The total score ranges from 0 to 20, with higher scores indicating greater hopelessness.
Change From Baseline in Anxiety Symptoms as Measured by the Hospital Anxiety and Depression Scale Anxiety Subscale
The anxiety subscale of the Hospital Anxiety and Depression Scale consists of seven items. The subscale score ranges from 0 to 21, with higher scores indicating greater anxiety symptom severity.
Change From Baseline in Depressive Symptoms as Measured by the Hospital Anxiety and Depression Scale Depression Subscale
The depression subscale of the Hospital Anxiety and Depression Scale consists of seven items. The subscale score ranges from 0 to 21, with higher scores indicating greater depression symptom severity.
Change From Baseline in Learned Helplessness as Measured by the Learned Helplessness Scale
The Learned Helplessness Scale is a 20-item self-report measure assessing beliefs and experiences related to helplessness and perceived lack of control. The total score ranges from 20 to 80, with higher scores indicating greater learned helplessness. The Hungarian-language version is undergoing cultural adaptation and psychometric evaluation; findings from this outcome will therefore be interpreted as exploratory and mechanism-related.
Participant Experience, Acceptability, and Agency-Related Processes Identified Through Semi-Structured Interviews
Brief semi-structured interviews will be conducted after each virtual reality session in both study conditions. The interviews will explore participants' immediate experiences, emotional responses, perceived benefits, difficulties, barriers to engagement, intervention acceptability, perceived control, and experiences of active participation or passive observation. A final semi-structured interview conducted after the sixth session will explore the participant's overall experience across the intervention period, perceived changes over time, and future-oriented reflections associated with the virtual reality sessions. Qualitative data will be analyzed using thematic analysis. The analysis will identify recurring patterns related to participant experience, emotional responses, engagement, acceptability, perceived benefits, difficulties, barriers to use, perceived control, choice, self-initiated action, successful action, passivity, help-seeking, and future-oriented intentions. Findings
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