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Abstract

Objectives

Forensic psychiatric patients (FPS) face reduced life expectancy due to somatic comorbidities and unhealthy lifestyles. Exercise improves mental and physical health but is hindered by low patient motivation and constraints posed by forensic psychiatric settings. Virtual cycling (VC) programs could enhance motivation and address FPS’ needs but remain understudied. This study aimed to explore how patients and staff experience and interact through a VC intervention in a closed forensic psychiatric setting and how these interactions may inform the development of more meaningful and motivating exercise interventions.

Methods

The study was conducted in a gym located in a medium secure forensic psychiatric ward at a university hospital in Denmark. Participants in VC included five male forensic inpatients (aged 20–50) and four physiotherapists (three men and one woman, aged 20–50). The data comprised eight sessions of participant observation during VC, informal conversations with patients and staff, and one focus group interview with eight staff members. A constructivist grounded theory method was used.

Results

We found that VC stimulated four interaction types that were used by staff to address patient motivations. These included outcome-focused (goal- and performance-oriented), distributive (teaching and leadership-driven), relationship-focused (emotionally supportive), and accommodating (non-demanding, gently motivating) interactions. We conceptualized them in an overall theory. Each interaction type involved distinct motivations, foci, goals, and communication forms, often unfolding in micro-moments.

Conclusions

Our theoretical categories demonstrate how VC interactions between staff and patients accommodate several often challenging conditions essential to personal recovery. Virtual-cycling-based interventions in forensic psychiatry may enhance motivation by addressing patients’ unique needs. Staff must understand virtual biking dynamics to adapt their interactions to promote therapeutic recovery potential and support the further development of such interventions. We recommend integrating staff training in interaction strategies specific to virtual exercise contexts. Future research should explore the long-term impact of VC on patient recovery trajectories.

Keywords

Forensic psychiatry physical exercise recovery mental health care technology

Introduction

Patients with severe mental illness (SMI) have increased somatic comorbidity and shorter life expectancy.^1–4 Poor nutrition and lack of exercise contribute to overall health deterioration. Many are overweight or obese, associated with medical treatment⁵ and substance abuse disorder.⁶

This mortality gap is even more significant among forensic psychiatric patients (FPS). A register-based study⁶ found that during a 19-year follow-up, 44% of male FPS had died, compared to 36% of matched non-FPS and only 15% of the general male population, highlighting the markedly elevated mortality risk faced by FPS. Even though somatic comorbidity of FPS is less studied, research shows that FPS generally have an unhealthy lifestyle,¹ and somatic comorbidity is noted as typical in forensic psychiatry.^7–10 Mortality associated with physical health inequalities can be reduced through modifiable lifestyle factors such as improved diet, regular physical activity, smoking cessation, reduced substance use, and better management of metabolic conditions like hypertension and diabetes. Among these, physical activity plays a central role, with substantial evidence linking exercise to improved physical and mental health outcomes in individuals with SMI.^7,11,12 SMI research outside forensic psychiatry shows that exercise can improve cognitive function,¹³ as well as alleviate the adverse effects of existing physical disorders^9,14 and psychiatric symptoms.^15,16 The main barrier to physical activity is a lack of motivation and medical side effects that often include sedation and decreased metabolism, leading to rapid weight gain.¹⁷ Research shows that FPS usually experience boredom during lengthy hospitalizations and find existing activities lacking in meaning.^18,19 Staff play a crucial role in engaging FPS in exercise interventions, but research suggests they may lack the necessary knowledge and skills.^9,14,20,21 Staff needs intervention knowledge tailored to the physical and mental health needs of this complex patient group⁹ and an understanding of patients’ need for meaningfulness, as it enhances motivation.^14,22 Increasing physical exercise in caring for patients with SMI is crucial for improving psychiatric, medical, and recovery outcomes,^2,10,24–26 and this includes FPS admitted to secure wards.^27,28 Addressing low participation by enhancing staff skills to create motivating, meaningful exercise programs tailored to patients’ unique needs is essential. To address these challenges, exercise interventions must not only support physical health but also enhance meaning, structure, and social connection. However, conventional activities often fall short in motivating patients or fostering a sense of engagement. This situation calls for innovative solutions that can overcome environmental limitations and increase both patient and staff engagement.

Cycling may promote positive health outcomes,²⁹ and virtual cycling programs (e.g. Zwift^©, i.e. cycling indoors on a specialized stationary bike with a monitor displaying real-time tours and results in a virtual environment) are gaining increased attention.^30–33 Virtual cycling programs enable users to cycle indoors, meeting the needs of those with limited outdoor access (e.g. FPS). Supriyanto and Liu³² suggest that virtual cycling (VC) with tracked individual and social scores can stimulate the Köhler effect, providing health benefits. Moreover, studies by Westmattelmann et al.³⁰ have underlined that virtual cycling programs such as Zwift may offer a flexible social platform, allowing users to tailor further exercise programs to unique individual and social needs. According to Reed et al.,³¹ they may also provide users with a critical capacity to negotiate the meaningfulness of the exercise with other users. Limited research exists on using virtual cycling in forensic psychiatric wards, leaving gaps in understanding how patients and staff negotiate meaningfulness in interventions to support motivation. This study explores a joint virtual cycling intervention in a Danish forensic psychiatric unit. The intervention, called “E-cycling,” started in 2020 to increase physical and mental health for inpatients following WHO recommendations.³⁴

Aim

This study aims to explore the interactions between forensic inpatients and staff during VC. Specifically, we aim to develop a theoretical understanding of the interactions that stimulate meaningfulness for patients in a VC intervention. Our findings will inform and potentially enhance VC exercise interventions in forensic psychiatry, offering a promising avenue for improving patient–staff interactions.

Method

Research design

We used the constructivist grounded theory (GT) approach. This qualitative research methodology involves systematically collecting and analyzing data “to construct theories grounded in the data themselves”.³⁵ Departing from symbolic interactionism,³⁶ GT holds that human beings construct the meaning of reality in interactions with self and others.^35,37 It suggests that human actions are inseparable from their social context, where symbolic interactions shape behavior. Thus, GT is ideal for studying complex processes, understanding core social-psychological patterns, and developing theories.³⁵ Acknowledging researcher subjectivity and involvement in data construction and interpretation is central to GT.³⁵

Sample and setting

The study was performed at a Danish medium secure forensic psychiatric hospital totaling 32 rehabilitative forensic beds and 16 forensic psychiatric beds for remand prisoners or persons undergoing a forensic psychiatric examination. The majority of patients have received a sentence to treatment for violent offenses and are diagnosed with a psychiatric disorder and comorbid substance use disorder. The participants (N = 11) were inpatients (n = 5) and staff (n = 6) (Table 1). Following GT,³⁵ we used a three-step open, selective, and theoretical sampling procedure until conceptual density was achieved.

Table 1.

Descriptive information of the participants.

ID	Participant role	Sex	Age	“E-cycling” months	Observations	Data collection
P1	Patient	M	30–40	18	8	O + informal dialogues
P2	Patient	M	40–50	4	7	O + informal dialogues
P3	Patient	M	30–40	4	8	O + informal dialogues
P4	Patient	M	20–30	18	8	O + informal dialogues
P5	Patient	M	20–30	18	8	O + informal dialogues
P6	Physiotherapist	M	20–30	18	8	O + F
P7	Physiotherapist	M	20–30	18	7	O + F
P8	Physiotherapist	M	40–50	18	6	O + F
P9	Physiotherapist	F	20–30	0	3	O + F
P10	Nurse	F	30–40	0	0	F
P11	Nurse	F	50–60	0	0	F

Note. O = participant observation; F = focus group interview.

Virtual cycling

VC is performed as an indoor activity and combines road cycling and spinning.³⁸ The bicycle races are simulated in 3D on a virtual platform.³⁹ Each bike has a tablet with routes of varying difficulty, displaying the rider's avatar alongside others. The five participating inpatients and four physiotherapists named their VC group “Team Grupetto.” Two additional nurses (who participated in the focus group interview) provide motivational and organizational support for the intervention on the ward, but did not participate in the physical intervention. The VC group focuses on increasing physical activity and promoting weight loss. Furthermore, a therapeutic goal is to create a sense of team spirit among staff and patients to stimulate prosocial behavior. Patients who join the group must be able to complete a cycle route of 25–30 kilometers. Each rider earns virtual currency (virtual “drops of sweat”), which allows the biker to buy accessories for the avatar or upgrades for the virtual bike. A physiotherapist is a licensed Bachelor (BSc) with 3.5 years of training⁴⁰

Each VC session lasted approximately 90–100 minutes and followed a semi-structured format. Sessions typically began with participants preparing their equipment and selecting a route. Patients and staff cycled simultaneously, each on an individual bike, but encouraged each other as a group. The intervention allows for both individual and team efforts, with spontaneous social interaction, competition, and cooperation emerging naturally during the sessions. Staff members alternated between participating actively in cycling, offering encouragement, and supporting technical or motivational needs of the patients.

Data collection

We sampled three data types from September 2022 to January 2023: participant observation in a gym during VC, including five patients and four physiotherapists; informal interviews during researchers’ participation in daily walks with five patients. Furthermore, from a focus group interview with four physiotherapists and two nurses who help coordinate the intervention. Data were collected by the first authors. We used a three-step sampling procedure following constructivist GT principles. Initially, we performed open sampling by observing all available patients participating in Team Grupetto (with consent), without excluding anyone based on seniority or participation length.

During ongoing data collection, we applied purposive sampling, focusing on participants who were particularly relevant for exploring emerging concepts related to VC interactions. Participants shared a common activity, e-cycling, and apart from the natural dichotomy between professional staff and patients, no substantial differences were observed between the two groups during the intervention. In the later stages, we employed theoretical sampling during the extended mini-tours and the focus group interview. Here, we deliberately selected participants who differed in professional backgrounds (including nurses, a head nurse, and physiotherapists) to achieve greater diversity of perspectives and to refine developing theoretical categories.

Conceptual density was considered reached after eight observations and one focus group interview, as no new categories or significant variations appeared during the constant comparative analysis.

Photo of e-bikes

Following Spradley,⁴¹ we delimited the observations and informal interviews with the patients and physiotherapists to the social situations raised before, during, and after VC. Data were collected through gym observations, informal conversations at the ward, and during a morning hospital walk.

First authors chose a moderate level of participation.⁴¹ One researcher actively participated in VC, while the other researcher was available to help, for example, fetching water. Each gym observation session lasted 90–100 minutes, with field notes taken simultaneously. Analytical memo writing and analysis, using a constant comparative method and principles of GT,³⁵ began immediately after the termination of the sessions. We conducted eight observations of VC sessions totaling approximately 17 hours. Informal interviews lasted approximately 15 minutes each time, totaling around 120 minutes. The two informal interviews were conducted during two morning walks with patients, each lasted about 30 minutes (60 minutes total). Finally, we conducted one focus group interview lasting 115 minutes. Altogether, the data collection covered approximately 1045 minutes.

A semi-structured interview guide was prepared to explore the data.⁴² The focus group interview was recorded and lasted 130 minutes. One first author performed the interview, and the other first author acted as an observer of non-verbal behavior and social interaction. Staff participants were encouraged to elaborate on their thoughts on, for example, motivation and health or to enlighten underlying motives of behavior.

Data analysis

Departing from GT, we analyzed data using an abductive approach involving a constant comparative method with three phases: an initial, a selective, and a theoretical coding phase. (Figure 1)

Figure 1.

Illustration of data collection and phases of analytical coding.

After each observation and interview, researchers analyzed the data and developed preliminary themes. From the selective coding, two main themes emerged: social community and health. Using the two main themes in a crosstab, we analyzed four categories of patient–staff interactions that encapsulated patient motivation and staff responses (Figure 2).

Figure 2.

Patient–staff interactions.

Further observations and interviews explored emerging categories. Ongoing analysis guided adjustments in probing and follow-up, following GT principles of theoretical sampling.³⁵ The constant comparative method within GT was applied to establish analytic distinction and thus make comparisons at each level of analytic work. Data were compared with data and incidents with incidents to find similarities and differences in interviews and observations. (Table 2).

Table 2.

Analytic process.

Data	Initial coding	Selective coding	Theoretical coding
"I don't rush. I don't care. I know they want me to bike faster, but I do 30 km as agreed”. P4	Not in a hurry but keeps appointments and complete.	Individual support. Waiting for readiness for change.	Accommodative interaction
“Today, I've been driving with an average pulse of 152. I've lost 8 kg and reduced my blood pressure medication”. P2	Attention to pulse.	Physical focus.	Outcome focused interaction
“Being a part of e-cycling is fun. We tease and challenge each other, and we dress as a team. It's cool.” P5	Weight and medicine reduction.	Team spirit. Equalized roles.	Relationship focused interaction
“E-cycling promotes healthy interests and provides a transferability to everyday life. Patients experience that they can bike without getting a heart attack. When they leave the hospital, they are not dependent on a taxi or public transport”. P6	Healthy interests. Integrated into everyday life. Transportation.	Develops healthy skills. Increased independence	Distributed interaction

To promote theory generation, we created a “memo bank.” Memos were regularly written during data analysis for analytic purposes.^35,43 Memos involved writing up high-level ideas about the codes and served to define the categories from the data analyses and their theoretical relationships.^35,43 After 8 participant observations and one focus group interview, no new properties of our theoretical categories emerged through the constant comparative method, and the data collection ceased. The analysis process involved moving backward and forward from one level of abstraction to another using coding and constant comparison.

Data were coded by the first authors, and theoretical categories were developed and discussed with the research team (Table 2).

Reflexivity and rigor

The research team comprised five researchers: three with a nursing background, one MD, and one anthropologist. We pursued credibility by collecting rich data through multiple data collection methods and undertook a substantial effort to be a part of the team.³⁵ We regularly met in the research team to discuss sampling methods, data generation, codes, and analytical categories. To verify the findings, we presented them to four participating staff members. A final literature search was integrated into the findings.³⁵ As a constructivist GT study, we acknowledge the co-construction of data between researchers and participants. The researchers’ dual role as both observers and occasional participants in the VC sessions inherently influence participants’ behavior and responses. This involvement is acknowledged as building trust and enables richer interpretive data collection. In GT, the interpretation of interactions is shaped by the researchers’ professional backgrounds and prior experiences. To support analytical rigor and reflexivity in the interpretative process, multiple researchers participated in coding and analysis, and findings were discussed regularly within the research team to. In keeping with the GT framework we view subjectivity not as bias to eliminate, but as a lens through which meaning is constructed in interaction with participants.

Ethics

This study follows the 1964 Helsinki Declaration.⁴⁴ Following the Promulgation of the Law on Ethical Management of Health Science Research Projects and according to the Danish National Committee on Health Research Ethics, formal ethical approval was not required as the project was not a biomedical research project.⁴⁵ All participants received oral and written information about the project, and all were guaranteed anonymity. Written informed consent was obtained from all participants.

Results

The observations and interview revealed that VC promoted specific and varied patient–staff interactions, stimulating meaningfulness and motivation.

We identified four different types of interactions promoted by VC, which we labeled:

(1) distributive interaction, (2) outcome-focused interaction, (3) relationship-focused interaction, and (4) accommodating interaction.

Each VC interaction category was driven by distinct motivations, focus, goals, and communication approaches. VC promoted motivation through negotiated focus and goals for all participants. While patients typically fit into specific categories, they sometimes shifted categories between or within sessions. All participants shared an idea of obtaining better health. Rather than describing individual outcomes, our analysis is grounded in interactional processes and shared patterns across the dataset. Table 3 provides a synthesized overview of the four categories and their core dimensions.

Table 3.

The theory: VC – together for a healthier life.

Subcategories	Categories of interactions
Subcategories	Distributed	Outcome-focused	Relationship-focused	Accommodating
Motivation	Distributed responsibility	Results	Social community	Diversion
Focus	Physical, mental, and social development	Physical well-being	Development of identity	Readiness
Goal	Independence	Physical health	Social skills	Participation
Communication	Distributed communication	Instructing	Comradely	Acknowledge

As a result, our analysis found that being together for a healthier life represented the grounded patterns of the participant's behavior and main goal resulting from the VC intervention. Therefore, we labeled the theory VC – Together for a Healthier Life (Table 3). In the following, we unfold the four interaction categories in our theory.

VC and distributed interaction

In the “Distributed interactions,” the staff used VC to collaborate with patients and empower them by boosting their independence and personal competencies. Staff used VC to promote relational equality, encouraging patients to develop as cycling experts. Through micro-communicative interactions, staff would encourage patients to instruct new participants, including new staff, or let patients assume these roles independently. As one example demonstrates:

“A new physiotherapist arrives to participate in VC. A patient spontaneously takes initiative and responsibility by supporting the new team member. The physiotherapist smiles and accepts the patient's help as a kind gesture. The patients teach him how to understand the technology of the bike.” (Field notes - P1/P9)

Patients were encouraged to suggest routes and tactics, taking on leadership in VC sessions through strategizing, cheering, and motivating teammates. Those in distributed interactions independently prepared for VC, with clothes washed and ready without staff prompting. In the focus group, a staff member noted increased patient independence and responsibility:

There is a motivation for e-cycling. If you work on a weekend, I see patients in their cycling clothes asking for e-cycling. It's cool to see that they back each other up as a team, but they also do it individually. (Focus group interview—P11)

Distributed interactions became key motivators for both patients and staff. Physical progress, new social skills, and independent mastery drove patients. Among staff, such motivation was heavily promoted by the staff interactions with patients and feedback mechanisms offered by VC. One physiotherapist explained:

I don’t think they started motivated. It's something we have pushed them towards. In time, patients experience improvement in their heartbeats, and they observe it on the monitor when biking. That's motivating. We can't offer those measurements and feedback in other activities. (Informal interview—P8)

VC's ability to offer such feedback and the staff's distributed interaction approach did promote patient self-monitoring and evaluation of health progress during the intervention. One example demonstrates this.

After cycling, a patient looks at the tablet to see his average heart rate during the session and how many Kilo Joules he has burned. The patient proudly concludes that he has cycled with an average heart rate of 152 during the session and has burned half a bag of crisps. (Observation)

The staff viewed this capacity building as a step toward broader life mastery, fostering autonomy and encouraging patients to take greater responsibility for their recovery. For some patients, this resonated, and One patient even mentioned buying a regular bike for rides outside the hospital in an informal interview:

“The idea of buying my own bike came after I started e-cycling. Now I understand that cycling gives me the freedom to get around, and it's good for my body.” (Informal interview—P2)

VC and outcome-focused interaction

In “Outcome-focused interactions,” staff will use VC to center on physiological outcomes. They leveraged the VC software's individual metrics and competitive elements to boost motivation and support patients’ physical health goals. Several patients sought staff advice on improving their results, citing weight loss and fitness as key motivations. Staff used VC's measurement tools to assess performance and provide targeted guidance during cycling. One such example from observations exemplifies this form of staff instruction of a patient:

We are now at the point where you usually have a crisis. I'll help you, okay! Switch your gear, and drive with 80 watts. Your pulse is fine. Stay behind in the slipstream. You can do it. (Field note—P6/P3)

In this category, staff would also act as instructors for VC and broader health improvements, including eating and weight control guidance. Patients would appreciate learning that symptoms like heart palpitations and breathlessness during exercise were typical and to be expected.

Some patients reported increased body awareness and satisfaction from overcoming physical challenges. A patient said:

It's good to feel your body and feel that it works. It's peaceful and gives me comfort. (Informal interview—P2)

We found that the visual features of VC were a motivating factor. They all expressed joy and pride in achieving new “levels” during exercise or earning virtual points to buy new equipment for the bike or their avatar. The field notes exemplify this when a patient is close to achieving a new level:

The patient exhibits excitement, raises his arms, and jumps joyfully as a sign of victory. The physiotherapist helped him find out what he had achieved. (Field note—P5/P6)

VC also gave opportunities for competition, which was motivating to some patients. Staff encouraged them to participate in sprints, and the goal of finishing first drove patients. A patient reflected on what the competition meant:

The competition is important to me. Usually, I finish as the best or second best. He smiles. (Informal interview—P1)

The interactions were characterized by staff cheering and encouraging patients to focus on physical outcomes. Here, the staff specifically gave their feedback to patients relying heavily on idioms like “Come on, we are machines” or “Every cloud has a silver lining.”

Micro-moments would also arise through the virtual environment. We observed that when a participant reached a new “level” or gained access to a collected support tool, staff provided guidance on how best to use a “feather,” which temporarily reduces a rider's weight. For one rider, it made sense to use the feather during a sprint, while another benefitted more from it on a steep climb. The data showed that patients received and applied the instructions appropriately. During one VC session, the following interaction was observed:

A staff member gave a thumbs-up to a patient via the screen after seeing him use a support tool. The patient smiled in return (P6/P1).

VC and relationship-focused interaction

Relationship-focused interactions involved staff using VC to enhance social qualities and identities among patients and between patients and staff. Both patients and staff agreed that being part of the VC team (Team Gruppetto) was a strong motivator and fostered closer relationships compared to other times on the ward. One patient expressed it like this:

“To me, the most important thing is being together as a team.” (Informal interview—P3.)

We observed strong camaraderie communication among participants; staff used terms like “riders” to foster equality and reduce power differences with patients. A staff member stated:

There is no difference between being a patient or staff. Here we are all cyclists. (Focus group interview—P8)

This approach also included actively wearing team uniforms (which had been designed and bought for the intervention). A nurse expressed it like this:

You probably can't get around the fact that it can change the relationship a little when you see each other in cycling clothes. (Focus group interview—P10)

Participants felt that VC's virtual world enhanced their experience. Avatars for staff and patients minimized staff–patient differences, boosting motivation, social skills, and a sense of community. VC allowed them to view each other in races, emphasizing individual and team strengths and building unity. Patients and staff cheered with shared idioms, enhancing relationships and community. Introduced by staff to help patients build identities as riders and teammates, the idioms were adopted by patients, reflecting a growing sense of social equality.

The patients have adopted the language, which gives us a special communication in the relation. (Focus group interview—P6)

Such micro-moments would often emerge through the virtual environment, having a motivating effect on the sense of community between patients and professionals. This was evident in observations where patients described experiencing a sense of togetherness with the team during the virtual race. As one patient expressed during a mini-tour:

“What you can see on the screen creates a kind of togetherness, but also allows you to ride individually. The screen means you can push yourself more, and that you support each other as a team” (P1).

The team culture affected the patients’ and staff's behavior alike. Both patients and the staff said they felt obliged to show up for training, not to let the team down. A patient expressed it like this:

“Sometimes I don't feel like it, but something happens when I put on my clothes, and then I feel ready” (Informal interview—P3).

We found that the staff who participated in VC expressed having a different relationship with the patients and had more accessible access to talk to patients about broader topics than other staff members.

VC and accommodating interaction

This category of interactions occurred when patients showed a willingness to participate but demonstrated low effort, dedication, or teamwork. Here, staff made notable efforts to support patients’ motivation to participate, however minor. In this category, we identified the patient's motivation as a diversion from everyday life in the forensic psychiatric ward. Despite having a bad day or not enjoying VC, patients continued the exercise as it provided a break from the ward. A patient reported:

I'm not particularly interested in cycling (…). I participate because I want to do physical activity. I'd just be bored in the ward if I weren't here. (Informal interview—P4)

We identified this interaction category as mutual accommodation behavior between staff and patients, despite occasional differences in engagement and effort during VC, which sometimes disappointed the staff. However, The staff's goal became to recognize this divergence and sustain patient participation in VC sessions by addressing their need for a break from daily ward routines and removing barriers to their engagement in the intervention. A nurse expressed such support strategies:

Before e-cycling, we pay attention and ask if they aren't dressed in cycling clothes; “Shouldn't you be e-cycling today? Do you need help? Or haven't you washed?” Some patients have difficulty getting in their cycling pants or washing their clothes on time. They often need support. We help. (Focus group interview—P10)

In this category, staff worked to maintain a good atmosphere on the team, also through their communication with patients. Staff would compliment even minor patient contributions to the team effort. It often took the form of small gestures in patient–staff interactions. Exemplified here:

A group of two physiotherapists and four patients is on their way to the gym. A physiotherapist carefully looks at a patient who walks alone. The physiotherapist calmly approaches the patients with eye contact and a smile, saying: “Thank you for coming today.” The patient looks up and smiles back. (Field notes—P6/P5)

These interactions also included situations where patients exhibited adverse behaviors, such as persistently seeking answers on guidelines, treatment, or private topics. In these situations, we found that staff also accommodated the patients’ persistence by mutually changing contact with the patients to establish a better atmosphere when necessary.

In this category, patients and staff created mutual space for each other's engagement. A patient expressed his accommodating of the staff expectations in this way:

I don't rush. I don't care. I know they want me to bike faster, but I do 30 km as agreed. (Informal interview-P4)

Discussion

Our study shows that patients’ motivation and individual needs are critical to meaningful intervention experiences, requiring tailored staff–patient interactions. Through micro-moments, we revealed key interaction patterns between patients and staff during VC. We showed how staff used four interaction types to address patients’ motivations and support them accordingly. We conceptualized a theory in which we categorized the interactions as (1) distributive interaction, (2) outcome-focused interaction, (3) relationship-focused interaction, and (4) accommodating interaction. Our theory reveals that specific forms of communication were demonstrated for each interaction type. The discussion shows how our four theoretical categories align with forensic psychiatry research on recovery barriers and enablers.

VC—physical ability and self-perception

A significant challenge in exercise interventions may stem from patients’ fear of poor results due to negative body perceptions.¹⁰ Our study, demonstrating that some patients found motivation in competition and physical progress, suggests that such bodily self-perception may be positively promoted through VC. The insight aligns with Bentvelzen et al.,⁴⁶ showing that VC can drive competition toward personal goals; for some FPS, it inspired a desire to improve physical results, using team members as benchmarks. Our study of VC thus illustrates an example of the Köhlert effect,⁴⁷ where individuals are driven to work harder to support the group or match stronger members. We argue that this effect is amplified by VC's virtual feedback, which continuously displays team and individual results. We share this insight with other studies of VC.³² Our study suggests that through relevant accommodation strategies, staff can use VC to foster positive body perception through social affirmation, with VC mechanics as a powerful motivator.

VC and sociality

Our study showed that some patients saw VC as enhancing sociality, building community, and fostering positive relationships, critical motivators for participation. In forensic psychiatry, building strong social relationships within communities is essential for patient recovery and a key focus for staff support.^48–50 Wharewera-Mika et al.⁵¹ suggest that solid social relations help highlight patients’ strengths, reduce isolation, and foster “self-transcendence,” building a positive social identity that supports recovery. However, building solid social relations is often hindered by the environment of secure wards.^48,50,52,53 Our findings suggest that, if supported by staff, VC could help overcome these challenges, fostering a shared identity as participants rather than as patients and staff, which may encourage prosocial behavior. The relational motivations offered by VC align with Bentvelzen et al.,⁴⁶ who found that VC fosters prosocial behavior by creating a sense of community and a shared mindset. Patients’ prosocial aspirations, found in our study, underscore VC's potential in forensic psychiatry, indicating that exercise gains improve when social motivation is accommodated. Additionally, this approach may foster social benefits essential to recovery.

VC and boredom

Boredom has often been emphasized as a central, well-known challenge to recovery for patients in forensic psychiatric secure institutions,^54–56 and if unaddressed may promote increased aggression and willingness to abscond.^56,57 Our study found that some patients experienced feelings of combating boredom through VC as a central motivator and experience. This finding resonates with studies by Westmettlemann et al.³⁰ emphasizing how a program like Zwift may offer breakaway environments promoting subjective feelings of diversion and variety (Hedonic benefits). We, therefore, infer that for patients experiencing pronounced feelings of boredom, VC as a general intervention could act as a critical motivational engine for positive change, diminishing boredom in secure wards. Whether this will result in less absconding or aggression should be a topic of additional studies.

VC and staff–patient power relations

Some patients’ motivation to gain recognition for key competencies in VC, empowering them, and redefining power dynamics with staff are significant to recovery discussions in forensic psychiatry. Empowerment and power distribution from staff to patients through recognition of capabilities have long been emphasized as crucial to patient recovery.^48,51 Such efforts are challenging in forensic psychiatry, where the constant focus on risk prevention means that staff must maintain a custodial role to protect patients, staff, and society.⁵⁸⁻⁶¹ Our study reveals moments of shared power between staff and patients, aligning with VC studies outside forensic psychiatry³¹ and emerging research on e-sports interventions in forensic settings.⁵³ It suggests further study of virtual computer-based interventions to enhance patient motivation in forensic psychiatry.

Implications for future practices

FPS encounter barriers to lifestyle changes like weight loss and exercise in secure wards, which are essential for recovery.^9,10 Research highlights the need to foster intrinsic motivation,^10,62,63 suggesting that various motivations require flexible interventions. Supporting patients’ diverse needs requires understanding their perspectives and using flexible approaches to enhance exercise interventions.^9,10 We argue that the VC intervention and our theory, VC - Together for a Healthier Life, address these two core components to inform future FPS interventions. Our theory suggests that the four categories reveal the motives guiding patients in the VC intervention. Therefore, our theory shows clinicians that, with proper conceptualization, a single intervention can address diverse patient motivations, making them both understandable and actionable. Our study also encapsulates the demand for flexibility in intervention approaches as called for in the literature. According to Reed et al.,³¹ VC, Zwift, should be seen as an assemblage whose combined meaning emerges through ongoing practices and negotiations. Following Reed et al., our theory shows how, despite delineating motivational categories, VC also fosters flexibility among categories observed in the fluctuations between categories within and between sessions. To guide future intervention, it is crucial to note that this flexibility was also supported by the staff, who play an essential role in supporting patients’ intentions for behavioral change toward a healthier life.^62,63 In future interventions, staff should monitor patient motivations, individually and as a team, and adjust support accordingly—a response requiring awareness and attention to micro-moments and interactions that, recognized as influencing recovery,⁶⁴ are easily overlooked in daily practice. We argue that robust responses often occur in micro-moments through affirming words, gestures, humor,⁵⁸ or practical support, such as assisting with schedules, timely arrivals, or washing training clothes. Therefore, to accommodate patients’ needs and boost motivation, it is essential to recognize the dynamic relationship between need and response, promoted in micro-moments during and between sessions, to address individual, changing needs. These micro-moments were clearly illustrated in the data. For example, when a staff member gave a virtual thumbs-up to a patient who had successfully used a tool in the virtual environment, the patient smiled in return, reinforcing a moment of connection and affirmation. Or when in another case, a patient expressed a sense of togetherness when describing how the screen supported both individual effort and group unity. Such moments of affirmation, subtle encouragement, and playful interaction may help build motivation, belonging, and trust which are core elements of recovery-oriented care. The technical features of VC, such as real-time feedback on performance, avatar representation, and gamified achievements (e.g. earning virtual rewards), may play a strong role in fostering micro-moments of engagement and motivation among participants. These immediate visual feedback mechanisms may help enable spontaneous reinforcement from staff and peers, supporting emotional connection and sustained participation. Therefore, future interventions should look increasingly at VC as it exhibits virtual and technical elements essential for fostering such supportive micro-moments.

Situated within the broader context of forensic psychiatric care, VC interventions may complement existing therapeutic modalities. A review by Dumont et al.⁶⁵ observed that most interventions in forensic psychiatry remain rooted in cognitive approaches such as cognitive behavioral therapy (CBT) and cognitive remediation. The review noted that few interventions explicitly focused on personal recovery dimensions such as social functioning, quality of life, and individualized goals, outcomes that are closely tied to motivation and empowerment. In this context, VC may serve a complementary role. It aims to promote engagement, build social interaction skills, and foster a sense of agency, while uniquely combining these aspects with physical activity and virtual, gamified elements that may particularly appeal to patients with low baseline motivation for traditional therapies. Moreover, VC offers structured, measurable progress that can enhance feelings of achievement and empowerment. Thus, VC interventions could be integrated as a supplementary strategy alongside established therapeutic programs to support motivation, physical health, and social connectedness in forensic psychiatric settings.

Strengths and limitations

Our has certain limitations. It focused solely on the intervention as it unfolded in practice. While we theorize about VC's potential for patient recovery, we did not track patients outside the intervention, so we cannot confirm if the benefits observed extended into their broader treatment and recovery. Future studies should incorporate longitudinal assessments to evaluate the sustained effects of VC on patient recovery, physical health, and psychosocial well-being. Studying outcomes beyond the immediate intervention period could provide valuable insights into the long-term therapeutic potential and recovery trajectories associated with VC interventions in forensic psychiatric settings.

Terkildsen et al.⁵³ emphasize integrating patient perspectives in developing forensic psychiatric interventions.⁶⁶ In this study, informal conversations were chosen to explore patient perspectives in a manner that respected patients’ readiness and emotional state. Conversations were conducted in informal settings when patients were able and willing to engage, to avoid putting pressure on them. While informal conversations provided valuable insights, they were conducted based on patients’ readiness to engage. Therefore, they may not capture the full breadth of patient experiences. Future studies should include semi-structured interviews or focus groups to achieve a more comprehensive understanding. This study did not assess clinical outcomes. Future studies should use quantitative or mixed methods to investigate the sustained impact of VC on health and recovery using statistical outcome measures.

Conclusion

VC-based interventions may effectively support patient motivation and engagement in forensic psychiatry by addressing individual and social needs. Adequate theoretical conceptualization and understanding may help staff promote and sustain patient motivation by adjusting their interaction responses to patients’ changing needs. VC's virtual features can further enhance prosocial behavior and competitiveness, emphasizing the potential of VC for therapeutic use.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076251349629 - Supplemental material for Virtual cycling as an exercise intervention in forensic psychiatry: A qualitative study

Supplemental material, sj-docx-1-dhj-10.1177_20552076251349629 for Virtual cycling as an exercise intervention in forensic psychiatry: A qualitative study by Britta Bech Kramer, Susanne Frydensberg Højholt, Dorthe Sørensen, Lisbeth Uhrskov Sørensen and Morten Deleuran Terkildsen in DIGITAL HEALTH

Supplemental Material

sj-docx-2-dhj-10.1177_20552076251349629 - Supplemental material for Virtual cycling as an exercise intervention in forensic psychiatry: A qualitative study

Supplemental material, sj-docx-2-dhj-10.1177_20552076251349629 for Virtual cycling as an exercise intervention in forensic psychiatry: A qualitative study by Britta Bech Kramer, Susanne Frydensberg Højholt, Dorthe Sørensen, Lisbeth Uhrskov Sørensen and Morten Deleuran Terkildsen in DIGITAL HEALTH

Footnotes

ORCID iDs

Britta Bech Kramer

Susanne Frydensberg Højholt

Dorthe Sørensen

Lisbeth Uhrskov Sørensen

Morten Deleuran Terkildsen

Ethical considerations

Our study followed the 1964 Helsinki Declaration. Following the Promulgation of the Law on Ethical Management of Health Science Research Projects and according to the Danish National Committee on Health Research Ethics, formal ethical approval was not required as the project was not a biomedical research project. All participants received oral and written information about the project, and all were guaranteed anonymity. Written informed consent was obtained from all participants.

Author contributions

BBK, SH, DS, LU, and MDT conceptualized the study. BBK and SH carried out interviews. Participation observations were undertaken by BBK and SH. BBK and SH conducted the initial analysis and discussed and refined it with DS, LU, and MDT. BBK and SH drafted the manuscript. MDT, DS, and LU critically revised manuscript draft. All authors edited, reviewed, and approved the final manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Department of Forensic Psychiatry, Aarhus University Hospital Psychiatry, and Psychiatric Research Foundation, Central Denmark Region, funded the paper.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Guarantor

MDT.

Data availability statement

Research data are not shared due to privacy or ethical restrictions.

Supplemental material

Supplemental material for this article is available online.

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