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Conceptualizations of E-recruitment: A Literature Review and Analysis

14 Department of Computer Science, Namibia University of Science and Technology, 13 Jackson Kaujeua Street, Windhoek, Namibia

Irwin Brown

15 Department of Information Systems, University of Cape Town, Rondebosch, Cape Town, 7701 South Africa

There is diversity in understanding of electronic recruitment (e-recruitment) which results in confusion on the meaning and use of the term. The purpose of this paper is to bring conceptual clarity by investigating the alternative conceptualizations of e-recruitment in academic literature. Using Grounded Theory Methodology (GTM) techniques we analyzed literature to reveal five alternative conceptualizations; these being: (1) E-recruitment as a Technology Tool, (2) E-recruitment as a System, (3) E-recruitment as a Process, (4) E-recruitment as a Service, and (5) E-recruitment as a Proxy. The conceptualizations map to the scope of the definition and utilization of e-recruitment. Identifying conceptualizations of e-recruitment sets a platform for further research. Further research may include determining the relationships between the conceptualizations and determining conceptualizations in different settings among many other possible research focus topics.

Introduction

E-recruitment has many labels that include; internet recruitment, online recruitment, web-recruitment and many others. Unlike traditional recruitment, e-recruitment makes use of information technology to handle the recruitment processes. Breaugh et al. [ 1 ] defined a recruitment model that presents the recruitment process at a macro level with the following activities: Setting recruitment objectives, developing a strategy, performing the recruitment activity and obtaining and evaluating recruitment results. Recruiters compete with each other for candidates (jobseekers suitable for available jobs), while jobseekers compete for jobs; which drives both groups to adopt information technologies at accelerated rates in order to take the strain out of some of the recruitment activities [ 2 – 7 ]. “ For most job seekers, the Internet is where the action is ” [ 3 , p. 140]. Thus, to get candidates, recruiters need to move swiftly to locate and hire, which may require use of a multitude of information technologies in the process [ 8 , p. 130].

There is evidence in research papers that academic disciplines and stakeholders have varied definitions of e-recruitment. The variety of definitions of e-recruitment is expected because it is part of e-HRM (electronic Human Resource Management) that has in itself different definitions depending on the context [ 6 , p. 26], [ 9 , p. 98]. Studies based on these definitions tend to reveal overlapping and contradictory results due to the overlaps or differences in definitions [ 9 , p. 100]. The differences in definitions, aside from being problematic, is evidence of the variety in conceptualization of e-recruitment. Thus to find a standard definition of e-recruitment, conceptualizations of e-recruitment need to be known. To our knowledge, no research paper in e-recruitment has focused on conceptualization of e-recruitment, however there are studies in other areas of information systems (IS) that have focused on conceptualization [ 10 – 19 ]. Most view conceptualization as the formulation of a view about the nature of a phenomenon. The research questions to be answered are:

• What conceptualizations of e - recruitment exist in literature?
• How can the conceptualizations be described and explained?

Methodology for Reviewing Literature

Because of the large number of research papers on e-recruitment we aimed at selecting papers for review that would embrace the full variety of conceptualizations of e-recruitment. Also, we wanted a flexible review methodology that would allow for selection and analysis of papers simultaneously, as the conceptualizations emerged, rather than a sequential review methodology that required all research papers to be selected beforehand. Such flexibility is provided for by applying grounded theory methodology (GTM) as a suitable review methodology [ 20 ]. GTM techniques used in this study included open coding to identify concepts, constant comparative analysis to refine and differentiate conceptualizations, and theoretical sampling to identify further relevant literature [ 21 , 22 ].

Figure  1 is a flowchart depicting how the literature was processed from search until conceptualizations of e-recruitment were identified, saturated and completed.

GTM for reviewing literature

Searching for Articles

We used the web search engine Google Scholar to search electronically for the articles. We fed keywords synonymic with the word e-recruitment into the searching tool. These are: e-recruiting, e-HRM, e-Human Resource Management, electronic HRM, electronic Human Resource Management, e-recruiting, e-recruitment, internet recruiting, internet recruitment, online recruiting, online recruitment, recruiting online, recruiting on the internet, recruiting on the web, recruitment online, web-based recruiting, web-based recruitment, web recruiting, web recruitment [ 20 ].

After an initial search on Google Scholar and filtering of articles for relevancy based on paper titles and abstracts we had 445 journal articles and conference papers published in the period 1998 to 2019 in approximately 145 sources. The search process provided a set of many articles, but it did not qualify all of them as useful for the review. The selection process had to take place to sample useful and relevant articles for the review.

Theoretical Sampling of Articles

Ideally all papers on e-recruitment needed to be included in the review. Alternatively, papers included in the analysis had to be a representative sample of all papers in e-recruitment that were relevant for the developing conceptualizations. However with the vast amount of research in e-recruitment and the huge number of articles from our search and filtering it would be difficult or time consuming to include all relevant e-recruitment research articles for the review. The alternative of having a representative sample was viable and using GTM’s theoretical sampling [ 21 ] was feasible for the objectives of this research to be met.

An initial article to be analyzed was picked from the population of 445 articles. Picking of subsequent articles for inclusion in the sample was informed by the emerging conceptualizations. Theoretical sampling was performed until all the conceptualizations got saturated and completed. Glaser [ 22 ] defines saturation as a state where new data does not bring new properties to the concepts. In an effort to attain completeness a check was done to make sure all conceptualizations were included. Theoretical sampling ended when saturation and completeness was achieved. This is the point at which the number of research articles involved in identifying conceptualizations in e-recruitment were counted. In the end 26 research articles were relevant for identifying and explaining conceptualizations of e-recruitment.

Analyzing Articles

Analysis of the articles that let conceptualizations of e-recruitment emerge (see Fig.  1 ) required that constant comparison be applied by comparing codes to codes and concepts to concepts to find and note their relationships and further develop the labelled conceptualizations [ 21 , 22 ]. The emerging conceptualizations served as a framework for further selection of articles and using systematic deduction from the emerging conceptualization possibilities and probabilities were determined to guide the next cycle of article selection. Memos were created to note the emergent ideas. Memoed ideas also served to direct which article to sample next.

Every sampled article was investigated for its perspective on the essence of e-recruitment or the most essential or most vital part that embodied the conceptualization of e-recruitment. Indicators in the article brought forth the conceptualizations. The moment of departure from the analysis to getting another article for analysis came only after the article was fully analyzed. The resulting conceptualizations are detailed in the next section.

Conceptualizations of E-recruitment

Five conceptualizations of e-recruitment emerged from extent literature, namely: e-recruitment as a technology tool, e-recruitment as a system, e-recruitment as a process, e-recruitment as a service and e-recruitment as a proxy. Although many of the articles had a mixture of conceptualizations, one or two stood out in each article and for each conceptualization Table  1 gives example research articles. After the presentation in Table  1 each of the conceptualizations is described and explained in sub-sections that follow.

Table 1.

E-recruitment as a Technology Tool

E-recruitment as a technology tool is a conceptualization of e-recruitment as a technical artefact [ 19 ]. This means is demonstrated by Faliagka et al. [ 23 ] who presented a tool to automate the ranking of applicants in recruitment.

E-recruitment as a System

Studies that view e-recruitment as a system conceptually divide e-recruitment into independent but interrelated elements, at the core of which is information technology, society, organizations, etc. The system view allows each component to receive input from the other elements and produce input for other components [ 25 ]. The system view of e-recruitment assigns all automating functions to the IT artefact of the system while organizational recruitment experts evaluate the outcome [ 24 ]. While some stakeholders view e-recruitment as a system, others view it as a process.

E-recruitment as a Process

Instead of focusing on entities, the process view of e-recruitment focuses on e-recruitment activities [ 37 ]. There is no attempt to set boundaries between the IT artefact, society and organization, but activities are clearly identified and can be performed by either the IT artefact or by human actors. Examples include e-recruitment being seen as data collection activity using an online system [ 33 ]. However recruitment activities can be performed by human actors too [ 37 ]. With the process view of e-recruitment the end goal is the execution of all the recruitment activities.

E-recruitment as a Service

The view exists that e-recruitment is a service to recruiters and job-seekers. Many e-recruitment platforms are independent of the organizations or societies they serve. Sub-views of e-recruitment as a service include: e-recruitment as a repository, e-recruitment as a medium, and e-recruitment as a program.

E-recruitment as a repository.

Some studies portrayed e-recruitment as a repository for data about jobs, recruiters and employers [ 40 ]. In another study online forms were filled in by jobseekers and the data provided on the forms was stored for recruiters and other stakeholders to retrieve [ 33 ]. While the view of e-recruitment as a repository is usually held when e-recruitment is newly adopted, other services follow suit.

E-recruitment as a medium is another view held, e.g. Bartram [ 41 ] portrays e-recruitment as a facilitator of communication between jobseekers and organizations. Traditional media like newspaper [ 42 ] are sometimes found inconvenient thus e-recruitment takes their place. Some organizations employ e-recruiters who form part of e-recruitment and serve to link the IT artefact and other elements in recruitment. Although e-recruitment as a medium improves communication speed it also comes with a downside, e.g. information overload [ 37 ].

E-recruitment as a program is a view that associates e-recruitment with calculations and logical interpretation and processing of data. One study included, as an algorithmic module, a Pre-screening Management System to automatically assess the extent of match between an applicant’s qualification and job requirements [ 25 ]. Such module or similar modules are found in many e-recruitment systems given the high volumes of applications associated with e-recruitment. Therefore, many studies espouse the view that e-recruitment serves to provide a convenient matching program.

E-Recruitment as a Proxy

Orlikowski and Iacono [ 19 ] reveal the pervasiveness of the proxy view of the IT artefact in IS literature. E-recruitment may act to present the image of the company, culture of the company, etc. Braddy et al. [ 45 ] examined the effects of website content features on people’s perceptions of organizational culture. Their study implies that e-recruitment, especially the IT artefact (website) acts on behalf of some corporate image management entity in the organization. Some studies focused on website content [ 45 ], while others focused on website characteristics [ 46 ].

Contribution and Implications of Conceptualizations of E-recruitment

Conceptualizations of e-recruitment contribute to understanding of e-recruitment and have implications for both practice and research as discussed in this section.

Contribution of the Research

This study mapped the scope of the definition of e-recruitment by explaining the diversity in understanding. This mapping was done by identifying five conceptualizations of e-recruitment and labelling them as: E-recruitment as a Technology Tool, E-recruitment as a System, E-recruitment as a Process, E-recruitment as a Service and E-recruitment as a Proxy. Taking note of conceptualizations provides practitioners with a tool to enhance productivity while allowing researchers to have more focus in their research.

Implications of Conceptualizations of E-recruitment

The implications of conceptualizations of e-recruitment stem from being able to attach a label to the said stakeholders’ conceptualizations and put it to their trade or scholarly pursuits. Labelling conceptualizations provides a pathway to standardization of e-recruitment. The benefits of such standardization include having common understanding of concepts, and ease of communication. While these are overarching implications, some implications are specific to practice or research.

Implications for Practice.

Labelled and well defined conceptualizations of e-recruitment sets bounds on what practitioners should expect in their practice and strive towards when they adopt a particular conceptualization. Well defined conceptualizations as ones in this study provide alternative conceptualization options that practitioners can adopt depending on their needs. Practitioners can always adopt a conceptualization that best reflects their situation. As there are implications for practice, there are implications for research as well.

Implications for Research.

Through this identification, description and explanation of conceptualizations of e-recruitment, there are a number of conceptualizations to consider. Therefore, focus on a specific conceptualization or focus on specific conceptualizations is possible. Such focus allows the researcher to delimit research.

Conclusion and Further Research

The study highlighted the problem of diversity in understanding of e-recruitment that goes without explicit attention in literature and proposed that identifying and labelling the varied conceptualizations of e-recruitment can be part of better articulation of the diversity. Using GTM, literature on e-recruitment was reviewed and conceptualizations of e-recruitment were identified. Taking note of conceptualizations provides practitioners with a tool to enhance productivity while allowing researchers to have more focus in their research. In addition this study provides insight into directions for potential further study.

Further Research

While this research contributes to understanding of e-recruitment, further research related to it can respond to several issues which are not addressed herein. Understanding of relationships between conceptualizations helps to avoid conceptual chaos. Therefore, further research aimed at relating the conceptualizations is essential. Conceptualizations of e-recruitment may be compared to conceptualizations of other forms of e-phenomena, and hence to the development of more general understanding of IS and the IT artefact.

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The skills needed in many roles are continually changing—and sources of talent are too.

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E-Recruitment and the Impact of Digital Age on Recruitment: A Critical Literature Review

• First Online: 19 April 2022

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• Ana Beatriz Alves Fernandes 3 &
• Carolina Feliciana Machado 3 , 4  

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This chapter has as its main aim the understanding of the concept and evolution of e-recruitment and the study of its advantages and disadvantages in relation to traditional recruitment methods. This brief summary of the literature also seeks to understand which digital tools are available to human resources technicians, tools that are increasingly sought after by professionals in the field. Through this collection of scientific production, it was possible to conclude that e-recruitment, in growing valuation, is a methodology adopted by human resources professionals that, even if it faces some obstacles, can be used in a useful and effective way in the recruitment processes of organizations, since it is less expensive and time-consuming than traditional processes, also having more coverage in the disclosure of vacancies and the company itself.

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Fernandes, A.B.A., Machado, C.F. (2022). E-Recruitment and the Impact of Digital Age on Recruitment: A Critical Literature Review. In: Machado, C., Davim, J.P. (eds) Organizational Innovation in the Digital Age. Springer, Cham. https://doi.org/10.1007/978-3-030-98183-9_8

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Hiring professionals need a quick transition to virtual platforms in response to the novel severe respiratory syndrome coronavirus 2 (COVID-19) pandemic's immediate need for social distance and widespread disruption in industries and organizations. This led to various creative and remotely accessible practices to address the new limitations of face-to-face interactions between applicants and hiring professionals. It took a lot of work for recruiters to replace in-person interactions with virtual platforms since they were trying to reproduce as much of the in-person experience as possible. Limitations on in-person and visiting offices for interview purposes, the role of virtual interviews has a significant opportunity for organizations and recruitment specialists. A variety of methods have been used to engage applicants, including telephonic discussions, web-based interviews, chatbots, and online assessments. The case study aims to focus on the hiring methods used by a commercial recruiting agency in the year 2020 during the coronavirus epidemic when the governments of many countries decided to go into lockdown and restricted in-person interactions, which led to making physical contact rare. As a result of the restriction on physical collaboration, organizations began to adopt new or alternative modes of working by making modifications to their policies, structures, and practices. To meet the immediate hiring needs brought on 204by the coronavirus epidemic, recruitment agencies and other organizations have shifted to e-recruitment during the pandemic. The case study examines how a private recruiting firm met the recruitment needs despite the difficulties of operating during the novel severe respiratory syndrome coronavirus 2 (COVID-19) outbreak.

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Skills-based success: 10 recruiting case studies

The working world has been turned on its head with the pandemic, the Great Reshuffle, and the resulting skills shortage. Companies are searching for a powerful, sustainable way to recruit and retain talent, and 81% of them are now opting for skills-based hiring practices.

Skills-based recruitment practices are for everyone. Don’t believe us? We've put together 10 recruiting case studies that demonstrate how different individuals, industries, and regions have successfully implemented skills-based hiring.

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What's the purpose of a recruiting case study, 3 personal recruiting case studies, 3 recruiting case studies by industry, 4 recruiting case studies by region, looking for more recruiting case studies, the state of skills-based hiring 2024.

Read TestGorilla's annual report to discover why over 81% of companies are choosing to adopt skills-based hiring methods in 2024.

In recruitment, case studies are helpful tools for employers seeking to build, develop, or optimize their recruitment processes. They can be great sources of information and inspiration. By understanding the successes and failures others have had with their hiring processes, hiring managers can take any relevant learnings without having to make the same mistakes that others have.

To make these recruiting case studies relevant for as many people as possible, we've divided them into personal case studies, case studies by industry, and case studies by region. Let's dive in.

Let’s first look at the personal stories of some stellar individuals who were recruited into their ideal industries using skills-based practices. These people didn’t have traditional backgrounds, but because of their unique skills, they got into amazing roles. All that was needed was a chance to prove those skills during recruitment.

1. Justin Hutchinson

Justin Hutchinson wanted a future in football, but he was faced with a hard choice at age 14: Focus on his career prospects or take care of his father with cancer.

Justin, of course, chose his father and has never regretted that choice, but it did mean giving up the chance of achieving his dream job.

After his father’s passing, Justin attended a community college to fulfill his father’s wish for him to get a degree. To pay rent and living expenses, Justin got a job at a smoothie franchise.

His aim was to simply support his cost of living by making fast food – but it turns out Justin’s real skill was people and communication.

Justin would study the cars that drove up, memorize their orders, and have them ready so he could spend time talking and getting to know the customers instead of making drinks.

One of Justin’s customers was a chief executive of a marketing company and was so impressed with his people skills, he offered Justin an internship.

It wasn’t long before Justin used his soft skills to turn that internship into a full-time position. He dropped out of college, poured his heart and soul into the role, and attained the role of Director of Business Development.

Justin attributes his success to his best skills:

Workplace empathy

Strategic and critical thinking

Sales management

Justin didn’t have a typical marketing background – his experience was a partial college education with no degree, on-the-job experience (and not a traditionally “relevant” job), and his internship.

Not everyone can find the perfect marketer in a charismatic smoothie server, but online skills testing holds the same principles: Look at abilities first and ask questions later.

Sales and marketing are industries that are uniquely dependent on soft skills, which makes skills-based hiring an obvious choice for recruiting. For information on how it helps with the tricky subject of ramp time, read our article on skills-based hiring and ramp time.

2. Latisha Carter

Latisha Carter had a dream of excelling in corporate America, but she never got the opportunity to attend college.

At age 17, Latisha became a single mother. This put her dreams of college on hiatus for the foreseeable future.

Three years later, after having another child, Latisha got a job as a nursing assistant. But she still couldn’t shake her desire to make it in the corporate world.

She secured a call center job with NCR, a software company, driven by their offer of extensive employee training. 

Offering extensive upskilling and reskilling is one of the best things you can put on the table for potential candidates. A study by Lorman showed that 59% of Millennials believe that development opportunities are extremely important when deciding whether to apply for a position.

Latisha used her experience at NCR to get a role in customer service at the software company Sage.

With determination and hard work, she continued to work her way up for 20 years until she became a director at Xero, an accounting technology company.

Latisha is now proudly a director in corporate America with no college degree. Her company is reaping the benefits of her presence and skills. 

In the second half of 2021, Xero’s approach to skills-based hiring and its emphasis on diversity pushed a 7% increase in racial and ethnic diversity.

Jana Galbraith, the executive general manager for people experience partnering for Xero, says: “ [H]istorically, hiring based on degree exclusively has perpetuated discrimination .”

This boost is great news for Xero because the benefits of diversity are broad and include increased productivity, innovation, and financial performance.

Latisha’s struggle to succeed is unfortunately common for working mothers. To learn more about this, read our article on the motherhood penalty .

3. Cindy Veach

Cindy Veach didn’t have a traditional background. She had all the tech know-how, but she only had experience involving massage therapy and social services.

But she had the skills and she knew it. Cindy says it was a happenstance that she stumbled upon her perfect role; she just wanted a role where she could use her best talents.

“I was looking for jobs I had the right skills for, organizational skills in particular,” said Cindy.

She happened upon a tech administration apprenticeship program at IBM. Before then, she saw her tech skills as just a hobby and never imagined herself in the tech industry – but she applied and was accepted.

Cindy had a steep learning curve ahead of her. She possessed the base tech skills but needed the training to reach the right level.

She attributes much of her success to the flexibility of her mentors. They continually told her that if a path “didn’t feel right,” she was welcome to experiment and try something new.

At the end of the apprenticeship, she applied for a network operations technician role and was hired. She took a position with flexible work options so she could still care for her two children comfortably. 

Skills-based hiring made this outcome possible. Cindy’s communication skills, digital expertise, and problem-solving abilities helped her secure her role, and the focus on continuous improvement is helping her develop it .

She says that the combination of her appetite for learning and her employer’s support for her success is the perfect duo for creating limitless growth.

We’ve heard plenty of people say “skills-based hiring doesn’t work in my industry.” But that’s just yet another myth we’ve debunked . Let’s take a look at a handful of case studies about how companies within certain industries have succeeded with skills-based recruitment initiatives.

4. Healthcare

Healthcare administration is an industry that’s notoriously difficult to get into. Between receiving a bachelor’s degree and completing a master’s program, it can take six to eight years of rigorous commitment.

However, more opportunities are arising that allow equally qualified candidates to get in without obtaining specific educational requirements.

Sam Saucedo-Hernandez had a tumultuous life, but she only ever wanted a solid career. As a child of parents who emigrated from Mexico, she wanted to be the first generation in her family to attain a degree.

Sam watched her parents struggle with low-wage jobs and promised herself she would do better for herself.

Her first attempt was at law school where she spent several years studying hard. Sam was ecstatic to get her degree and begin a career in law.

But two weeks after she got her associate of science degree, the school got shut down for fraud, leaving Sam jobless and $60,000 in debt.

Sam faced many challenges, but the turning point in her story was the day she received a letter promoting a no-cost medical administrative assistant job training program from JVS.

JVS is a program that helps people build skills and find solid career connections – particularly in the healthcare industry.[1]

JVS has seen amazing success with over 500 employer partners and an emphasis on promoting diversity: 88% of their participants are Black, Hispanic, Asian, or a wide range of other ethnicities.

Sam applied for the program and was accepted. She secured a position as a medical administrative assistant, but her training has led her to her current role in the audiology department.

Though she’s fortunate for her position, Sam says she’s still looking forward, wondering where her skills can take her from here. 

Programs like JVS are working tirelessly to make more stories like this possible. With a focus on skills over experience, they bring in valuable candidates to industries that may otherwise be restricted to them.

5. Manufacturing

Steelcase, a furniture manufacturing company, wanted to build a fairer place for employment opportunities and encourage better representation for employees of color. So they adopted skills-based hiring practices.

They’re far from the only ones. According to TestGorilla’s State of Skills-Based Hiring report, 85% of businesses in 2023 had the goal to increase diversity.

And companies are succeeding at this by implementing skills-based hiring: 91% of organizations saw an increase in diversity due to skills-based hiring.

Steelcase realized that if they truly wanted to boost their DE&I initiatives , traditional hiring methods wouldn’t do.

They decided their hiring processes needed to be revamped for the better, so they adopted some new practices:

Prioritizing skills over resume and pedigree

Removing experience requirements wherever possible

Favoring continuous improvement over perfection

Revamping job descriptions to reduce biased language

Prioritizing diversity among equally qualified candidates

Steelcase decided that practices like these would enable them to reach diverse talent organically, and it worked. Since the program started, Steelcase’s new hires are 55% women and 30% racial or ethnic minorities.

Steelcase’s initiatives are amazing, so we encourage similar active moves to boost diversity. To read more about this topic, read our blog on why being intentional about workplace diversity is non-negotiable .

6. Software

ADP, an HR management software company, adopted a recruiting strategy to focus on skills , rely less on credentials, and make an effort to provide opportunities for candidates with nontraditional backgrounds.

This strategy included training talent acquisition professionals on best practices, hiring specific diversity recruiters, removing degree requirements from high-volume recruiting roles, and leveraging better training and mentorship for new hires.

What were the results? ADP saw great success in one year:

An increase in the number of candidates with no college degree

An increase in Black representation in the candidate pool

An increase in Hispanic representation in the candidate pool

This program was heavily inspired and backed by Maria Black, the chief executive of ADP, and her strong belief in corporate social responsibility.

She has a strong passion for supporting working women, veterans, and other underrepresented talents.[2]

Maria is an excellent example of the power of leading from the top. When your company’s leadership supports a great cause, it benefits both employees and company alike and builds a better organizational culture .

Next, let’s take a look at some case studies about the regions and countries that are taking on skills-based recruitment practices. For more on this subject, check out our post on skills-based hiring around the world .

7. Maryland, USA

In 2022, the state of Maryland dropped four-year degree requirements for thousands of jobs in the government sector.

The aim of this initiative was to draw attention to the value of alternative credentials and experience. State officials want to give people a better shot at securing a stable, fulfilling job.

Governor Larry Hogan was quoted as saying:

“[W]e are ensuring qualified, non-degree candidates are regularly being considered for these career-changing opportunities.”[3]

Over 38,000 people work for the state of Maryland and it’s estimated that more than half of those jobs can be performed by people whose alternative skill routes can easily substitute for a college education.

These alternative routes include:

Life experience

Non-relevant job experience

Hobbies and volunteer work

Alternative training

Community college education

Maryland estimates that about 47% of its working population are STARs (skilled through alternative routes). That’s 2.8 million workers, and these people need solid opportunities – opportunities that they can access through skills-based hiring.

To learn more about how unnecessary degree requirements are holding top talent back, read our blog on degree inflation .

8. Indiana, USA

Indiana’s tech leaders are struggling to attract and retain great talent. They’re facing a major skill shortage and they can’t solve it with the “usual” hiring methods.

Traditional recruiting methods exclude over 95% of Indiana’s workforce.

Indiana has a workforce of 3,332,239 people, but consider this:

A four-year degree requirement removes 75%

Biases can eliminate up to 30% of the pool

Requiring specific past experience removes 93% of the talent pool

With all of that in mind, a pool of more than three million candidates is reduced to just over 42,000.

Indiana’s Office of Technology (IOT) realized that skills-based hiring practices could fix this problem and solve their shortage.

They started by removing degree requirements from most job descriptions, then took the next step and started offering reskilling opportunities to workers from alternative industries, such as line cooks and truck drivers.

Tracy Barnes, IOT’s chief information officer, said that the results of the program have been positive and they’re “very pleased” so far. She also said that she’s equally excited to see the positive life impacts for the candidates involved.

9. Asia-Pacific

Skills-based hiring is quickly gaining traction in the Asia-Pacific area.

One study showed that 79% of businesses in the Asia-Pacific area look for skills when hiring versus the 21% that prioritize education and experience.[4]

The same study found that internal mobility is more important than ever and that companies want to prioritize gender equality and disability inclusion . These points can also be accomplished by adopting skills-based hiring.

Asia-Pacific is looking to skills-based practices to improve the future of their recruitment processes, but Singapore-based TruTrip is already reaping the benefits .

TruTrip is a business travel management company that needed help assessing candidate skills and hiring the best candidates, so they gave TestGorilla a try.

Here are a few ways that TestGorilla’s pre-employment skills testing helped TruTrip’s recruitment processes:

Gives them a way to objectively assess applicants’ skills and knowledge

Helps them eliminate bias from the hiring process

Enables them to consistently make better hiring decisions

Reduces their reliance on resume screening

Enhances teamwork and communication

Improves the employee experience of new hires

According to Hugh Batley, the founder of TruTrip, their new hires are a better fit. These employees become great contributors and have a better initial experience with the company.

TestGorilla also helps TruTrip save thousands of dollars by reducing the chances of a costly mis-hire. 

This isn’t unusual. According to TestGorilla’s State of Skills-Based Hiring report, 92.5% of organizations using skills-based practices saw a reduction in mis-hires in 2022.

10. The UK and the EU

The UK and the EU have developed a strong focus on skills over the past few years.

Interest in skills-based hiring in the UK rose 63% from 2021 to 2022 . This drastic increase is due to employers wanting a wider talent pool and candidates prioritizing and valuing their alternative experience.

This move is helping job opportunities reach the 73.6% of people in the United Kingdom who don’t possess a four-year degree. [5]

As for the European Union, they developed the “Pact For Skills” program in 2020. This program was created to encourage and fund better upskilling and reskilling while also promoting greater diversity and gender equality.[6]

A good example from both areas is the British-Lithuanian bank, Revolut.

Revolut adopted skills-based hiring by using TestGorilla’s skills tests and, as a result, improved their time-to-hire by 40% .

Among many other benefits, Revolut found TestGorilla’s language tests life-saving. Assessing language proficiency is essential for a multinational company, but traditional methods are time-consuming and laborious.

TestGorilla’s language tests help Revolut to quickly and easily evaluate their candidates’ reading, writing, listening, and speaking skills. This helped them to nearly fully automate their screening process, improving time-to-hire greatly.

To read more case studies and success stories about skills-based hiring, check out our 10 stories that demonstrate the power of skills-based hiring or our collection of customer case studies .

Here are 3 top picks from our case studies:

Revolut improves time-to-hire by 40% using TestGorilla

Design Pickle uses TestGorilla to boost application completion rate by 25%

TestGorilla helps TruTrip to save money and improve employee experience

If you’d like to acquaint yourself with a solid skills-based hiring practice, browse our test library and review our skills tests.

“JVS 2022 Impact Report”. (2022). JVS . Retrieved March 6, 2023. https://impact2022.jvs.org/

“Maria Black, president and CEO”. (n.d). Business Roundtable. Retrieved March 6, 2023. https://www.businessroundtable.org/about-us/members/maria-black-president-and-ceo-adp

McGraw, Mark. (April 4, 2022). “Dropping Degree Requirements: Do Employers Still Care About Education?”. World at Work . Retrieved March 6, 2023. https://worldatwork.org/resources/publications/workspan-daily/dropping-degree-requirements-do-employers-still-care-about-education

“The Future of Talent”. (2021). LinkedIn . Retrieved March 6, 2023. https://business.linkedin.com/content/dam/me/business/en-us/talent-solutions/resources/pdfs/future-of-talent-whitepaper.pdf

“Overview of the education system”. (2022). Education GPS . Retrieved March 6, 2023. https://gpseducation.oecd.org/CountryProfile?primaryCountry=GBR&treshold=10&topic=EO

“Pact for Skills”. (November 10, 2020). European Commission . Retrieved March 6, 2023.  https://ec.europa.eu/social/main.jsp?catId=1517&langId=en

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Annie Hayes

Read more about Annie Hayes

• December 9, 2004

Case Study: E-recruitment gets Nike on track

• By Annie Hayes

The issue Nike currently receives around 800 CVs each month. It has on average 100 to 120 open positions at any one time at Nike’s EMEA Headquarters (HQ) in Hilversum, the Netherlands. These volumes used to place considerable pressure on the resourcing function to reduce the administration and lead-time in the recruiting process. Handling the inflow of applications became challenging as the regional HQ grew dramatically in size. This resulted in high numbers of CVs circulating in the business whilst the company had little capability of tracking their progress or handling enquiries from job applicants. “We have a firm policy that each applicant is a potential employee and customer and so we must respond appropriately, in an individual letter where possible,” commented Rolien Hoogers, EMEA staffing manager at Nike. “With only four people on the team, we were finding it increasingly hard to do that, and we were losing track of where CVs were in the company. We became concerned about how well we were protecting applicants’ personal information, and there were mistakes, such as us calling someone in for an interview who was already due to come in later that day.” The action These problems led Nike to review their HR processes. The assessment demonstrated that the company had to standardise its HR processes in an attempt to reduce duplication of effort. Reducing the cost per hire and improving the overall quality of talent hired into the business were key goals. Nike felt that achieving these objectives and improving effectiveness would help to boost the company image. Faster response times to applicants together with consistency in handling the administration associated with each appointment would lead to improved internal effectiveness and efficiency. The solution Jobpartners provided Nike with an e-recruitment solution, ActiveRecruiter, which has been designed to help companies manage the entire recruitment process more effectively and quickly resulting in a better relationship between the company and its candidates. The solution was chosen by Nike as it offered flexibility and simplicity, was cost effective and could be easily integrated with the existing programmes from PeopleSoft. A number of avenues are now open to candidates who wish to apply for jobs at Nike. External applicants can apply for specific roles or for more general speculative job opportunities directly via the Nike website. Electronic links have also been established with external web-based recruitment organisations including Monsterboard. Conventional resourcing processes including newspaper advertising and head-hunting , particularly for more senior positions supplement these e-methods. Nike employees can also directly apply for jobs posted on the intranet. The majority of applicants apply to Nike via the web site (www.nikebiz.com) and can attach their resume after filling in their profile enabling line managers to review applications online. Paper copy CVs are no longer required. ActiveRecruiter makes the first match between the job requirements and the competencies and experience of the candidate. The system then retains a pool of applicants on file, which ensures Nike has a readily available supply of CVs for open positions. The number of CVs currently held on the database is in the region of 8500. Each registered applicant is automatically asked to update their CV every six months in order to remain active on the system. The system is then able to search an expanding database of future interest when open positions arise. This helps to reduce the costs of recruitment. ActiveRecruiter also provides the ability to search for specific competencies when a short-listing for open positions is being run. This ensures a better quality of candidate. The result Hoogers comments: “Savings of around 54% in recruitment costs have been identified since the system was first introduced in July 2002, and there has been far less reliance on external recruitment and search agencies due to the ‘future interest’ database.” From June 2003 to May 2004, a total of 556 positions were filled with 235 internal Nike candidates, 144 from the Nike database, 60 through the internal referral bonus programme, and 35 via headhunting organisations. The remainder came from job adverts and recruitment consultancy, Adecco. The average time to fill vacancies has fallen from 62 days to 42 days. The cost per hire has also been reduced. Nike believes that ActiveRecruiter has given a return on investment in just six months. Lessons learnt The three key learning points identified by Nike during the process of change management include:

• 1.The importance of involving recruiters in the development and implementation process from an early stage.
• 2. The benefit of ensuring that recruiters have a place in the project to help get buy-in
• 3.The role of communication. Internal customers and users of the system have to see benefits, not just to the business as a whole, but also in terms of helping them to achieve their recruitment targets by attracting quality people with the necessary skills and attributes.

Future Trends Nike feels that even greater potential exists in improving the quality of the overall resourcing process as ActiveRecruiter is developed further in the EMEA region. The vision for ActiveRecruiter at Nike is for it to become a ‘one-stop-shop’ for quality recruiting. This will help ensure that increased time can be put into improving the capability of line management in interviewing techniques, and that the resourcing group can be freed up to play a more consulting and advisory role. Nike is planning to continue to measure and improve the effectiveness of its resourcing processes, which can only enhance its employer brand in the market place.

One Response

What kind of E recruitment What kind of E recruitment techniques followed by NiKE

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13+ HR Case Studies: Recruiting, Learning, Analytics, and More

Reposting a piece from the blog over at Lighthouse Research because I know not all of you subscribe over there!

While much of the work we do at Lighthouse Research & Advisory focuses on quantitative research studies, we do a fair amount of qualitative research as well. We’ve collected case studies over time (and continue to) that highlight interesting approaches and examples of innovation within human capital management. The list below offers a wide variety of industries, examples, and flavors for you to learn from.

Want to see another topic or example not listed here? Comment below and and I will see what we can do to find that for you!

Wal-Mart, Automation, and Compassion Training

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Chipotle: How Internal Mobility Reduced Turnover by 64%

Internal promotion-how Chipotle reduced turnover by 64%

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Research Article

Effectiveness of a Virtual Reality rehabilitation in stroke patients with sensory-motor and proprioception upper limb deficit: A study protocol

Roles Conceptualization, Data curation, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

Affiliations Instituto Polibienestar, University of Valencia, Valencia, Spain, Department of Psychology, University of Bologna, Bologna, Italy

Roles Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Psychology, University of Bologna, Bologna, Italy

Roles Conceptualization, Investigation

Affiliation UOC di Medicina Riabilitativa e Neuro-riabilitazione, IRCCS Istituto delle Scienze Neurologiche di Bologna, Azienda USL Bologna, Bologna, Italy

Roles Conceptualization

Affiliation Department of Biomedical and Neuromotor Sciences–DIBINEM, University of Bologna, Bologna, Italy

Affiliation Instituto Polibienestar, University of Valencia, Valencia, Spain

Roles Conceptualization, Funding acquisition, Investigation, Methodology

• Sara Ventura, 
• Alessia Tessari, 
• Sara Castaldini, 
• Elisabetta Magni, 
• Andrea Turolla, 
• Rosa Baños, 
• Giada Lullini

• Published: August 12, 2024
• https://doi.org/10.1371/journal.pone.0307408
• Reader Comments

Introduction

Stroke is the second leading cause of death in Europe. In the case of stroke survival (almost 70%), only 25% of patients recover completely, while the remaining 75% will undergo a rehabilitation phase that varying from months to years. The primary outcomes of a stroke involve motor impairment in the upper limbs, resulting in a partial or complete inability to move the limb on the right or left side, depending on the affected hemisphere. Furthermore, the motor deficit distorts the proprioception of the body and the embodiment ability of the injured limb. This could be rehabilitated through the paradigm of body illusion that modulates the motor rehabilitation. The present protocol aims to investigate the effectiveness of a Virtual Reality system for sensorimotor and proprioception upper limb deficit compared to a traditional upper limb rehabilitation program.

This study has a randomized and controlled design with control and experimental groups, and 4 measurement times: pre-intervention, immediately after the intervention, and two follow-ups (at 6 and 12 months). The inclusion criteria are: (a) Being 18 to 85 years old, both males and females; (b) Suffering from ischemic or haemorrhagic stroke; (c) The stroke event must have occurred from two to eighteen months before recruitment; (d) Patients must have moderate to severe upper limb motor deficit, and the alteration of sensorimotor and proprioception abilities of the injury upper limb; (e) Patients must understand and sign the written consent for enrolment. The rehabilitation last four weeks with three sessions per week at Bellaria Hospital of Bologna (Italy). The VR protocol uses two types of technology: immersive and non-immersive, and the control group follow the traditional rehabilitation program.

Citation: Ventura S, Tessari A, Castaldini S, Magni E, Turolla A, Baños R, et al. (2024) Effectiveness of a Virtual Reality rehabilitation in stroke patients with sensory-motor and proprioception upper limb deficit: A study protocol. PLoS ONE 19(8): e0307408. https://doi.org/10.1371/journal.pone.0307408

Editor: Shu Morioka, Kio University, JAPAN

Received: January 18, 2024; Accepted: July 2, 2024; Published: August 12, 2024

Copyright: © 2024 Ventura et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

Funding: This work was supported by the Margarita Salas postdoctoral fellowship, Ministry of Universities of the Government of Spain (European Union NextGeneration EU, ref. UP2021-044). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

According to the European Cardiovascular Disease Statistics, stroke is the second leading cause of death in Europe. It mainly occurs after age 55, with 75% of cases in people over 65 [ 1 ]. After a stroke, 20–30% of people die in the first month from the event and 40–50% within the first year. For those who survive, only 25% experience full recovery, with the remaining 75% entering a rehabilitation phase that spans from several weeks to several months or even years. Published randomized control trials that adopted various rehabilitative programs including technology have demonstrated that, at the end of the rehabilitation period, the patient may experience full recovery or remain in a state of permanent disability [ 2 – 4 ].

The primary outcomes of a stroke encompass motor impairment in the upper limbs, leading to a partial or total inability to move either the right or left limb based on the affected hemisphere [ 5 ]. In particular, patients experience difficulty performing reaching tasks due to a lack of motor coordination or an inability to control grip and finger strength when manipulating objects [ 6 ]. In everyday life, the impairment in the upper limbs manifests as an inability to independently eat, dress, maintain personal hygiene, and engage in other self-care activities, resulting in a reliance on a caregiver. Consequently, consistent rehabilitation to restore motor skills becomes crucial for both the patient and their family members [ 7 ].

From a neuroscience standpoint, deficiencies in the planning, preparation, and execution of movements may arise due to impairment in the primary motor cortices or areas responsible for praxis control, particularly those situated in the parietal regions [ 8 – 11 ], which alter proprioceptive and kinaesthetic signals and the perception of peripersonal space [ 12 ]. Proprioception refers to the sense of the relative position of one’s own body parts and strength of effort being employed in movement, which can be impaired after a stroke [ 13 ]. As a result, patients present distorted body representations and an alteration in the sense of embodiment, in terms of ownership, location, and agency. In particular, people who have survived a stroke experience apparent changes in their bodies, such as altered sensations, impaired limb function, uncoordinated movements and disrupted proprioception [ 14 – 16 ]. Furthermore, sensation, emotions, and perception are some of the characteristics of self-consciousness assimilated into the physical body thanks to the sense of embodiment [ 17 ], and that in stroke patients is compromised. The somatosensory deficit that affects this sample of patients refers to an impairment or loss of sensation related to touch, pressure, temperature, or pain on the side of the body affected by the stroke. This deficit occurs due to damage to the brain regions responsible for processing sensory information and patients maintain various delusional beliefs regarding the ownership of their paralyzed limbs [ 14 , 18 , 19 ]. This lack of awareness or recognition of the body can impact the sense of ownership and may lead to difficulties in coordinating movements or adjusting to changes in body perception [ 20 ].

Taking into account the concept of neural plasticity, which refers to the brain’s capacity to adapt and facilitate functional activities [ 21 ], recent research indicates that intervening with the illusion of the bodily self in hemiplegic patients could enhance the rehabilitation of the affected limb [ 22 , 23 ]. One of the methods to induce the limb illusion is the mirror box. In this apparatus, the patient sees the reflection of their healthy arm in the mirror, and if the illusion is successfully induced, they perceive the reflected arm as their own instead of the injured one [ 24 ]. This process could be possible because the embodiment of the hand reflected by the mirror would improve the reorganization of body representation in patients with post-stroke motor deficits (Tosi et al., 2018). The paradigm of the body illusion was then translated into the Virtual Reality (VR) system [ 25 ].

Over the past decades, VR has been widely used in upper limb motor rehabilitation following a stroke, yielding significant results compared to a traditional rehabilitation program [ 26 , 27 ]. VR is an advanced technology that provides interactive environments that reproduce the surrounding reality. It is divided into immersive and non-immersive systems; the former projects the three-dimensional environment through a Head Mounted Display wear by participants, often incorporate other sensory feedback, such as spatial audio and sometimes haptic feedback, to enhance the feeling of presence within the virtual environment [ 28 , 29 ]; the latter, on the other hand, projects the virtual environment into a screen and the patient can interact with it through devices such as joysticks or cyber-gloves [ 30 ]. Previous literature in the field of post-stroke rehabilitation through VR demonstrated its effectiveness in improving neuroplasticity and motor recovery thanks to several aspects such as real-time feedback, customization of exercises according to the patient’s cognitive and motor abilities, the immersive and interactive experience that the technology offers, and a faithful simulation of real-world activities [ 31 – 33 ]. VR has demonstrated its effectiveness in upper limb rehabilitation, but little is known about how integrating the illusion of one’s limb can benefit rehabilitation. Previous study found that inducing a strong feeling of ownership of a virtual body that could perform movements of any complexity and duration might contribute to restoring motor functions in stroke patients. In this line, a recent systematic review demonstrated the significant modulating role of body ownership illusion through VR to restore motor abilities after stroke [ 34 ]. Furthermore, the VR technique can provide interaction between virtual objects and body motion using motion tracking. This technique has proven to be suitable for proprioception rehabilitation due to its ability to manipulate the visual feedback of virtual objects [ 35 ]. The VR proprioceptive paradigm is innovative because this type of exercise system cannot be easily provided in traditional therapy. That is, for healthy individuals, the central nervous system integrates multiple modes of sensory information, especially vision and proprioception, to perform motor tasks. In stroke patients, however, the integration of multiple sensory inputs is impaired, and they can only rely on intact visual information rather than somatosensory input [ 36 ]. In this case, visual influence becomes predominant when afferent input from other sources is reduced, and the predominant influence of visual input constitutes a natural compensatory strategy for coping with initial stroke damage [ 37 ]. According to the theory of neural plasticity cited above, the brain has the ability to reorganize itself by forming new neural connections in response to sensory inputs and repetitive practice [ 21 ]. Even if the sensory feedback in VR is an illusion, it can still promote neural plasticity similarly to real sensory signals [ 38 ]. For this reason, VR could be an efficacious medium to improve the proprioception abilities and the motor rehabilitation after stroke. However, new study protocols are needed.

Therefore, considering the high incidence of stroke, the disability it entails, and the need for timely and constant rehabilitation, together with the promising data of VR as an effective tool for sensorimotor and proprioceptive rehabilitation, the present project aims to investigate the effectiveness of a VR system for sensorimotor and proprioception upper limb deficit compared to a traditional upper limb rehabilitation program.

2. Objectives and hypothesis

Considering the sensorimotor deficits after a stroke and the relate difficulty to build an internal representation of the own body, plus the significative feature of VR to induce a body illusion, the present protocol aims to investigate the effectiveness of a Virtual Reality rehabilitation program to restore the sensorimotor and proprioceptive abilities of the injured upper limb after a stroke, compared with the treatment as usual (TAU). Moreover, the feature of the exergame of VR would engage the patients and motivate them to pursue the rehabilitation program and overcome the drop-out from the rehabilitation.

2.1. Hypothesis 1

VR rehabilitation programs will generally be as effective as TAU in increasing the motor abilities of the injured upper limb after a stroke.

2.2. Hypothesis 2

The VR rehabilitation program will be more effective than TAU in the proprioception abilities of the injured upper limb.

2.3. Hypothesis 3

The TAU will be the least satisfying rehabilitation program for the patient, with a higher probability of abandonment compared to VR.

2.4. Hypothesis 4

The same results will be found across the follow-up assessments (6 and 12 months after intervention).

The Local Ethics Committees approved the project protocol (ASL_BO n. 0115481 provided on 18/10/2022) before commencing the recruitment and registered to ClinicalTrials.com (ID: NCT06164054) The study is performed according to the principle of the Helsinki Declaration. The study results will be disseminated in peer-reviewed scientific journals and in abstract format at scientific events.

3.1. Study design

A single-blind (the patient is blind to group assignment) two-arm randomized controlled trial is proposed with a blocking randomization [ 39 ]. Participants who have had a stroke are randomly allocated to: (1) 4 weeks traditional rehabilitation program (control group), or (2) 4 weeks to Virtual Reality rehabilitation program (experimental group). The study design presents 4 measurement times: pre-intervention, immediately after the intervention, and two follow-ups (at 6 and 12 months; see Fig 1 ). The rehabilitation programs, both experimental and control, will be performed at the Bellaria Hospital of Bologna (Italy). Moreover, participants must sign written consent forms for study participation and personal data handling and management.

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https://doi.org/10.1371/journal.pone.0307408.g001

3.2. Participants

The participants’ groups involve people with stroke selected according to inclusion and exclusion criteria and keen to participate in the study. Patients are enrolled in the Neurorehabilitation Unit of the Institute for Neurological Sciences of Bologna (Istituto delle Scienze Neurologiche di Bologna, ISBN). Furthermore, the potential participants are informed about participation in the study during the check-up visits scheduled by ISNB medical doctors referring the patients.

3.2.1. Inclusion criteria.

Patients must have all the following inclusion criteria: (a) Being 18 to 85 years old, both males and females; (b) Suffering from ischemic or haemorrhagic stroke; (c) The stroke event must have occurred from two to eighteen months before recruitment [ 40 ]; (d) Patients must have moderate to severe upper limb motor deficit established by a score of ≤ 80 on the Motricity Index [ 41 ], and the alteration of sensorimotor and proprioception abilities of the injury upper limb, established by the failure in 3 proofs up to 4 of the Thumb Location Test [ 19 ]; (e) Patients must understand and sign the written consent for enrolment.

3.2.2. Exclusion criteria.

Patients presenting at least one of the following exclusion criteria are not eligible to be enrolled in the study: (a) Severe psychiatric (e.g., psychosis, depression, apathy) and behavioral disorders (e.g., severe psychomotor agitation), cognitive disorders, or a state of confusion defined by temporal and/or spatial disorientation detected during an ordinary conversation. A simple confusion state assessment test (4AT) is administered in case of doubt [ 42 ]; (b) Severe upper limb motor deficit with the following score at Motricity Index Scale: gripper <11, elbow flexion <14, shoulder abduction <14 [ 41 ]; (c) Verbal comprehension ability with a score of <2 at Token Test [ 43 ]; (d) Severe spatial neglect with a score of >3 at Barrage test [ 44 ].

3.3. Assessment

The basic information, including age, sex, lesion side of the brain, stroke type, and duration after stroke onset, was recorded. The clinical outcomes include motor assessment, which examines the motor function of the patients’ injured upper limb, as well as neuropsychological assessment to evaluate cognitive abilities for the eligibility criteria and to investigate if the rehabilitation program could also impact the patient’s cognition. Additionally, patient’s self-efficacy and satisfaction toward the treatment are also evaluate.

3.3.1. Motor assessment.

• The Fugl-Meyer is subscale included 33-item upper limb activities. Each item was rated on a 0 to 2 ordinal scale. The maximum score of the FMA-UL subscale was 66 [ 45 ].
• The Motricity Index for upper limb with a scores ranging from 0 to 100. It evaluated the shoulder abduction, the elbow flexion, and the “grip and pinch” abilities [ 41 ].
• The Box and Blocks test which contains 150 wooden cube blocks (1 inch). The participants were told to move one-by-one blocks as many as possible from a rectangular box container to the other of equal size within 60 seconds. Both hands’ scores of the BBT were calculated, respectively, by the number of blocks transferred [ 46 ].

3.3.2. Neuropsychological assessment.

• Multidimensional Assessment of Interoceptive Awareness (MAIA) [ 47 ]: the self-report assesses the following eight interoceptive dimensions: (1) noticing (i.e., tendency to be aware of one’s body sensations, regardless of their (dis)comfort); (2) not-distracting (i.e., tendency to not ignore uncomfortable sensations in the body or pain), (3) not-worrying (i.e., tendency to not worry about uncomfortable sensations in the body or pain); (4) attention regulation (i.e., ability to pay attention to sensations from the body); (5) emotional awareness (i.e., extent to which emotions are perceived as connected to bodily sensations); (6) self-regulation (i.e., ability to use attention to sensations from the body to regulate distress); (7) body listening (i.e., listening actively to the body for insight); and (8) trusting (i.e., degree to which the body is experienced as safe).
• Thumb Location Test [ 19 ] to evaluate the ability of individuals to accurately locate their thumbs without visual cues. During the test, the individual typically closes their eyes or is blindfolded, and the examiner moves the person’s thumb to different positions. The individual is then asked to indicate the location of their thumb by pointing to it with their other hand or verbally describing its position and it is scored from 0 = not accurate to 2 = completely accurate.
• Rubber Hand Illusion [ 48 ] it is a self-report questionnaire that evaluate the participants’ ability to perceive a rubber hand as his/her own in term of ownership, location and agency. The test is administered after the rubber hand induction by a professional with patient’s injury limb. The scale is score from -3 (not at all) to +3 (completely).
• The Short screening test for ideo-motor apraxia (STIMA) [ 49 ] based on the presentation of separated lists of intransitives 18 meaningfulness gestures and 18 meaninglessness gesture score from 1 when the participant successfully imitates on the first attempt, and 2 at the second.
• The Raven progressive matrices [ 50 ] to measure the patient’s abstract reasoning and non-verbal intelligence. It consists of a series of visual pattern problems, where participants are asked to identify the missing piece that completes a pattern.
• The Trials Making Test (A and B) [ 51 ] to evaluate patient’s attention. It is composed of part 1 with a sheet of paper containing circles numbered from 1 to 25. The task is to connect the circles in numerical order as quickly as possible, and part 2 more complex and involves connecting circles that alternate between numbers and letters (e.g., 1-A-2-B-3-C, and so on) in ascending order. The individual is instructed to switch between numbers and letters while connecting the circles.
• Corsi Test (visuospatial) [ 52 ] used to measure visuospatial short-term memory and spatial span. During the assessment, the participant is presented with a series of blocks, typically arranged in a random pattern and often mounted on a board. The examiner taps a sequence of blocks, and the participant is then asked to reproduce the sequence in the same order. The test progresses in difficulty by increasing the length of the sequences. Performance is typically measured by the longest sequence of blocks that the participant can accurately reproduce.
• Monaco Test (or digit span forward and backward) [ 53 ] to assess the participant’s short-term memory and working memory capacity. It involves the participant repeating sequences of numbers, either forwards or backwards, immediately after they are presented. In the "Digit Span Forward" task, the participant is given a sequence of numbers and is asked to repeat them in the same order. For example, if the examiner says "2, 5, 7," the participant would respond with "2, 5, 7”. In the "Digit Span Backward" task, the participant is given a sequence of numbers and is asked to repeat them in the reverse order. Using the same example, if the examiner says "2, 5, 7," the participant would respond with "7, 5, 2." The test ends when the participant repeats in a wrong way for two consecutive times.
• Token Test [ 43 ] to evaluate the participant’s language comprehension. During the assessment, the participant is presented with a series of commands that involve manipulating tokens (e.g., coins, chips) according to specific instructions. The complexity of the commands gradually increases throughout the test. Performance on the Token Test is evaluated based on the participant’s ability to accurately follow the instructions, manipulate the tokens according to the commands, and demonstrate comprehension of various linguistic concepts such as spatial relationships, object attributes, and logical sequencing.
• Barrage [ 44 ] peripersonal neglect and measure the patient’s spatial and selective attention abilities.
• Visual object and space perception (VOSP) [ 54 ] assessment tool used to evaluate various aspects of visual perception, including object recognition and spatial processing. The test includes “object perception task” that assess the ability to recognize and discriminate between different objects. Examples include matching identical objects, discriminating between similar objects, and identifying fragmented objects; and “space perception task” to evaluate the spatial processing abilities, such as judging the orientation of objects in space, detecting spatial relationships between objects, and perceiving spatial patterns.
• Functional Independence Measure (FIM) [ 55 ] to evaluate the patients’ self-efficacy after a stroke. The test involves six aspects of daily function: self-care, sphincter control, transfer, locomotion, communication, and social cognition ability. It was made of 18 items, and each item was graded on a 1 to 7 ordinal scale. The total score ranged from 7 to 126.
• Stroke Self-Efficacy (SSEQ) [ 56 ] is a self-report measure designed to assess stroke survivors perceived self-efficacy in managing the various challenges they face during stroke recovery. Self-efficacy refers to an individual’s belief in their ability to successfully perform specific tasks and achieve desired outcomes in a given situation. It is composed by 13 items with a score between 0 = not at all to 3 = completely.
• Client Satisfaction Questionnaire (CSQ-8) [ 57 ], it is a self-report questionnaire that measure the patients’ satisfaction toward the rehabilitation program. It is composed by 8 items ranged from -1 = not at all to +4 = completely.

Table 1 shows the protocol’s assessment.

https://doi.org/10.1371/journal.pone.0307408.t001

3.4. Interventions

The rehabilitation will take place in the rehabilitative room at Bellaria Hospital of Bologna (Italy), which is intended for physical and neurological rehabilitation for people with brain injuries. It is equipped by traditional therapeutic tools and the Virtual Reality apparatus.

3.4.1. Virtual Reality rehabilitation setting.

The VR protocol uses two types of technology: three-dimensional (3D) and two-dimensional (2D). During the 3D session, patient sits on a chair and wear the head-mounted display (HMD) while performing some exercises. The exergames consist of tasks requiring precision movements, such as building some blocks, putting the virtual block in a specific position, moving the virtual object inside the environment, paint and colouring some proper figures ( Fig 2a ). The 2D session is performed by the Virtual Reality Rehabilitation System-Handbox (Khymeia Group, Noventa Padovana, Italy) technology for hand and wrist rehabilitation that tracks the patient’s hand and project it to a monitor without the need to wear any sensor or HMD. Patient sits on a chair, and the monitor screen is positioned at a 1.5 m distance in front of the patient ( Fig 2b ). Through the Handbox, the patient executes hand exergames based on the pinch, grasp, single finger coordination, wrist movements, customized according to the patient’s motor ability. For both technologies, 3D and 2D, the arm and fingers are captured and projected onto the screen through the Leap Motion Controller. This advanced motion sensor device uses infrared cameras and LEDs to detect and track the position, orientation, and movement of each finger and the hand as a whole. It captures movements at a high frame rate, ensuring smooth and responsive interaction, reproducing an effect similar to the traditional mirror box [ 58 ]. For the 3D condition, the Leap Motion Controller is incorporated into the HMD, while for the 2D condition, it is integrated into the Handbox. Both systems allow patients to interact with virtual objects in a natural and intuitive manner. For example, patients can reach out, grab, move, and manipulate virtual objects as they would in the real world. During both sessions, 3D and 2D, there is the constant supervision of the physiotherapist and researcher supervision that guide the patients, directing their focus on the exercises and providing encouragement throughout the tasks.

(a) 3D—Virtual Reality session; (b) 2D Handbox session.

https://doi.org/10.1371/journal.pone.0307408.g002

3.4.2. Experimental treatment.

Participants of the experimental group will undergo treatment with Virtual Reality, both IVR and HB. The intervention will consist of 12 sessions lasting about 1 hour each and carried out with a frequency of three days per week within four weeks. Before starting the rehabilitation, arm illusion with the Handbox is inducted to explore the ability of the patients to perceive the virtual arm as their own. During this task, patients sit on a chair with the injured arm inside the Handbox and are invited to perform slow movements with the hand, such as moving the fingers one at a time and moving the wrist up and down. Moreover, they are invited to keep their attention to the virtual arm project on the screen that follows their natural movements. The arm illusion lasts 3 minutes, and the embodiment questionnaire is administered. Then, the treatment starts with IVR and HB sessions ( Fig 2 ), which are counterbalanced to avoid the learning effect. During the IVR, patients sit on a chair and wear the HMD for the immersive experience while performing the abovementioned exercises. During the HB task, patients are sitting on a chair and invited to do some exergames projected on the Khymeia screen, such as inserting pegs into an abacus and pointing some targets, all with the injured arm. All tasks are administered in a complex sequence—the two IVR and HB sessions last half an hour each.

Furthermore, the therapist will establish the facilitation level for each exercise by fine-tuning the sensitivity of kinematic sensors, which range from 1 to 10 based on the patient’s motor impairment. This approach enables patients with minimal hand activity to successfully carry out the exercise. The personalization of exercises is determined by the patient’s baseline hand motor ability. Therefore, individuals with limited hand and arm capabilities will engage in exercises utilizing the Khymeia software’s high movement augmentation score, whereas those with more pronounced hand abilities will perform exercises with a lower augmentation facility score.

3.4.3. Control treatment.

Participants randomly assigned to the control group will receive rehabilitation treatment as per usual clinical practice. Specifically, patients will be directed to rehabilitation facilities according to standard clinical rehabilitation pathways. They will be assigned to a physiotherapist who will administer the rehabilitation treatment for the upper limb impairment. Patients in the control group will receive the same amount of rehabilitation for the recovery of upper limb impairment as the treatment group, which means 3 physiotherapy sessions lasting 1 hour 3 times a week for 4 weeks. Based on the treatment intensity, a physiotherapist ensured that the control group received the same level of treatment as the experimental group in terms of the physical effort required by patients.

3.5. Outcomes

In assessing the significance of outcome changes, several indicators are utilized. These include the p -value, which measures the probability that observed results are due to chance rather than the intervention itself. A p -value below a predetermined significance level, often 0.05 or 0.01, indicates statistical significance. Additionally, the confidence interval (CI) provides an estimate of the precision of treatment effects. A narrower CI suggests greater precision in estimating treatment effects. Finally, the Minimal Clinically Significant Difference (MCID) is utilized to assess the significant change perceived by patients regarding the treatment, evaluated through the satisfaction questionnaire.

3.5.1. Primary outcome.

The primary outcome measures will be the Fugl-Meyer for Upper Limbs [ 45 ] employed as a performance-based assessment to characterize motor recovery in research, has demonstrated outstanding reliability. This encompasses internal consistency, inter-rater reliability, intra-rater reliability, and test-retest reliability, particularly in the post-stroke context [ 59 ]. The assessment includes 33 items to evaluate upper extremity motor impairment and is scored between 0 and 2 (0 = unable, 1 = partly able, and 2 = fully able to complete movement) with a total score range of 0–66. The assessment will be performed before treatment (T1), after the conclusion of the treatment (T2), and after 6 months as a follow-up (T3).

3.5.2. Secondary outcome.

The secondary outcome will include timed tests that measure the improvement in the Box and Blocks Test [ 46 ] for the upper limb ability and motor coordination, MAIA test [ 47 ] and the Rubber Hand Illusion [ 48 ] for the patients’ proprioceptive ability; the Functional Independence Measure [ 55 ] and the Stroke Self-Efficacy [ 56 ] for the perceived and real ability in daily life activities. The assessment will be performed before treatment (T1), after the conclusion of the treatment (T2), and after 6 months as a follow-up (T3). Moreover, the satisfaction with the treatment received will also be assessed at T2.

3.5.3. Sample size.

A sample size of 30 participants per group has been determined using G*Power 3.1.3. This calculation was based on a repeated measures ANOVAs (within and between subjects), considering a small to medium effect size of 0.2 [ 60 ], as also reported in a two-arm Randomized Control Trial involving chronic stroke participants that also adopted as primary outcome measure the Fugl-Meyer scale [ 61 ]. The sample size determination also accounted for 20% attrition, with a significance level (α) set at 0.05 and a desired statistical power of 0.80, as outlined in the literature [ 62 ]. Additional, participants will be enlisted in the event of any dropouts.

3.5.4. Recruitment and randomization.

Patients considered eligible according to the inclusion criteria will be invited from the IRCCS Istituto delle Scienze Neurologiche di Bologna to participate in the study, explaining in detail the purposes and methods of the study. Before enrolment, informed consent will be obtained from patients. Then, to minimize the risk of bias, the Random Allocation Software 2.0 will be adopted to randomize participants and organize them into blocks of six, that is three participants receiving traditional rehabilitation and three participants receiving the Virtual Reality rehabilitation.

3.6. Data management

The participant center will send the case report form (CRF) to the data manager and the study’s principal investigator, and the file will be encrypted. Every patient will receive an alphanumeric identification code that prevents direct identification of the patient’s name. All data collected during the study will be stored and associated with this code. Only the data manager and authorized staff members can associate this code with the patient’s name. Once the data collection is terminated, they will be available from the following DOI: https://doi.org/10.6092/unibo/amsacta/7590 .

3.7. Statistical analysis

The data analysis follows the Per Protocol approach, that is only participants who have adhered to the study protocol, patients who dropped out of the study are excluded from the analysis. Analysis will be performed through the Statistical Package for Social Sciences (SPSS). Descriptive statistics for both the experimental and control groups will encompass measures such as the mean and standard deviation. The student t-test for independent samples will be used to evaluate the baseline. In case of excessive deviation from normality, a similar non-parametric test (Mann-Whitney) will be used. Changes in motor performance and proprioception between T1 and the subsequent longitudinal evaluations (T2, T3) will be assessed using the repeated measures Analysis of Variance (rmANOVA) with a mixed design 2×3, considering the group as "between subjects" factor and the time point measure as "within subjects" factor. Residual plots will be inspected to verify linearity, normality and homoscedasticity assumptions for all models as well as to identify potential influential outliers. According to the literature, for all inferential analyses the probability of type 1 error is a-priori fixed at alpha α = 0.05 and will include reporting the 95% Confidence Interval for each estimate [ 62 ].

4. Discussion

The present protocol describes the background and the design of a study that aims to evaluate the effectiveness of a rehabilitation program with VR in improving sensorimotor and proprioception upper limb ability in patients with stroke. The central hypothesis is that the VR rehabilitation program could increase motor facilitation and, as a consequence, improve upper limb control and function compared to the control condition.

The present protocol was developed because motor impairments are the main consequence of stroke, together with the alteration in body representation and the sense of embodiment that prevent limb movements. Much literature has proven VR’s efficacy in motor rehabilitation after a stroke [ 26 , 27 ]. However, less is known about the modulating role of the body ownership illusion in eliciting rehabilitation. In this line, a recent systematic review [ 34 ] demonstrated the significance of body illusion in promoting motor rehabilitation in patients with stroke, both for the upper [ 22 , 63 , 64 ] and lower limbs [ 23 ], compared to the control non-embodied condition. The enhanced feature of the embodied VR system, in contrast to conventional rehabilitation programs like the mirror box [ 58 ], lies in its ability to evoke motor imagery using computerized images. Additionally, the patient can receive remote feedback on their training, allowing them to ascertain the correctness of their rehabilitation tasks.

In the present protocol, the VR systems, IVR and HB, permit patients to see their real injured arm projected into the virtual environment, which is immersive for the IVR condition and augmented for the HB condition, stimulating the motor cortex [ 65 , 66 ]. Moreover, thanks to the feature that allows the virtual arm to be adjusted according to the patient’s motor abilities, it is possible to generate an augmented movement even if the patient has minimal ability. Moreover, in contrast to traditional rehabilitation programs, VR treatments are typically well-received by patients due to their immersive environment and increased flexibility in catering to the patient’s clinical characteristics and progress. Additionally, patients have the opportunity to track and record their motor performance [ 30 , 67 ].

The present protocol provides an integrated approach and requires a multi-professional team, from psychologists to physiotherapists and physiatrist, to plan a well-designed study with the possibility of correlating measures of functional outcomes and neuropsychological assessment.

To conclude, the induction of body ownership illusion in a VR rehabilitation program could be a step forward to traditional therapy that may enhance the upper limb motor recovery after a stroke, thus increasing the patients’ engagement with the treatment.

5. Limitations

Several limitations should be noted in the current clinical trial. Firstly, patient recruitment for stroke cases may prove challenging, given that the stroke unit at Bologna Hospital handles a relatively low number of cases. Secondly, the treatment’s duration—three days a week for four weeks—may pose a limitation, potentially impacting treatment adherence. Thirdly, patients, especially in the initial stages of stroke recovery, may experience clinical complications leading to treatment discontinuation or cessation. Lastly, we anticipate limitations on the technological front, such as technical issues or patients experiencing cybersickness, which could hinder their ability to complete the experimental sessions.

Supporting information

S1 checklist. the consort (consolidated standards of reporting trials) guidelines are a set of recommendations designed to improve the reporting of randomized controlled trials (rcts)..

The primary goal of CONSORT is to ensure transparency, completeness, and clarity in the reporting of trial results, which in turn helps readers assess the validity and applicability of the findings.

https://doi.org/10.1371/journal.pone.0307408.s001

S1 File. Protocol for ethics committee-English version.

https://doi.org/10.1371/journal.pone.0307408.s002

S2 File. Protocol for ethics committee-Italian version.

https://doi.org/10.1371/journal.pone.0307408.s003

https://doi.org/10.1371/journal.pone.0307408.s004

Acknowledgments

The authors thank Gabriele Perachiotti for the support provided in the physiotherapist assessment.

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