. 2024 May 6:13:e54180.

doi: 10.2196/54180.

Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study

Josh Martin¹, Alice Rueda¹, Gyu Hee Lee¹, Vanessa K Tassone¹, Haley Park¹, Martin Ivanov², Benjamin C Darnell^{3

4}, Lindsay Beavers^{5

6}, Douglas M Campbell^{5

7

8

9}, Binh Nguyen², Andrei Torres¹⁰, Hyejung Jung¹¹, Wendy Lou¹¹, Anthony Nazarov¹², Andrea Ashbaugh¹³, Bill Kapralos¹⁰, Brett Litz^{3

4}, Rakesh Jetly¹⁴, Adam Dubrowski¹⁰, Gillian Strudwick^{15

16

17}, Sridhar Krishnan², Venkat Bhat^{1

18}

Affiliations

¹ Interventional Psychiatry Program, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
² Department of Electrical, Computer, and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada.
³ Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, United States.
⁴ Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States.
⁵ Allan Waters Family Simulation Program, Unity Health Toronto, Toronto, ON, Canada.
⁶ Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.
⁷ Neonatal Intensive Care Unit, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁸ Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁹ Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ maxSIMhealth Group, Ontario Tech University, Oshawa, ON, Canada.
¹¹ Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
¹² MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, ON, Canada.
¹³ School of Psychology, University of Ottawa, Ottawa, ON, Canada.
¹⁴ Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada.
¹⁵ Centre For Addiction & Mental Health, Toronto, ON, Canada.
¹⁶ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
¹⁷ Arthur Labatt Family School of Nursing, Western University, London, ON, Canada.
¹⁸ Department of Psychiatry, University of Toronto, Toronto, ON, Canada.

PMID: 38709554
PMCID: PMC11106701
DOI: 10.2196/54180

Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study

Josh Martin et al. JMIR Res Protoc. 2024.

. 2024 May 6:13:e54180.

doi: 10.2196/54180.

Authors

Affiliations

¹ Interventional Psychiatry Program, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
² Department of Electrical, Computer, and Biomedical Engineering, Toronto Metropolitan University, Toronto, ON, Canada.
³ Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, United States.
⁴ Department of Psychiatry, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States.
⁵ Allan Waters Family Simulation Program, Unity Health Toronto, Toronto, ON, Canada.
⁶ Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.
⁷ Neonatal Intensive Care Unit, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁸ Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
⁹ Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ maxSIMhealth Group, Ontario Tech University, Oshawa, ON, Canada.
¹¹ Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
¹² MacDonald Franklin OSI Research Centre, Lawson Health Research Institute, London, ON, Canada.
¹³ School of Psychology, University of Ottawa, Ottawa, ON, Canada.
¹⁴ Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada.
¹⁵ Centre For Addiction & Mental Health, Toronto, ON, Canada.
¹⁶ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
¹⁷ Arthur Labatt Family School of Nursing, Western University, London, ON, Canada.
¹⁸ Department of Psychiatry, University of Toronto, Toronto, ON, Canada.

PMID: 38709554
PMCID: PMC11106701
DOI: 10.2196/54180

Abstract

Background: Staffing and resource shortages, especially during the COVID-19 pandemic, have increased stress levels among health care workers. Many health care workers have reported feeling unable to maintain the quality of care expected within their profession, which, at times, may lead to moral distress and moral injury. Currently, interventions for moral distress and moral injury are limited.

Objective: This study has the following aims: (1) to characterize and reduce stress and moral distress related to decision-making in morally complex situations using a virtual reality (VR) scenario and a didactic intervention; (2) to identify features contributing to mental health outcomes using wearable, physiological, and self-reported questionnaire data; and (3) to create a personal digital phenotype profile that characterizes stress and moral distress at the individual level.

Methods: This will be a single cohort, pre- and posttest study of 100 nursing professionals in Ontario, Canada. Participants will undergo a VR simulation that requires them to make morally complex decisions related to patient care, which will be administered before and after an educational video on techniques to mitigate distress. During the VR session, participants will complete questionnaires measuring their distress and moral distress, and physiological data (electrocardiogram, electrodermal activity, plethysmography, and respiration) will be collected to assess their stress response. In a subsequent 12-week follow-up period, participants will complete regular assessments measuring clinical outcomes, including distress, moral distress, anxiety, depression, and loneliness. A wearable device will also be used to collect continuous data for 2 weeks before, throughout, and for 12 weeks after the VR session. A pre-post comparison will be conducted to analyze the effects of the VR intervention, and machine learning will be used to create a personal digital phenotype profile for each participant using the physiological, wearable, and self-reported data. Finally, thematic analysis of post-VR debriefing sessions and exit interviews will examine reoccurring codes and overarching themes expressed across participants' experiences.

Results: The study was funded in 2022 and received research ethics board approval in April 2023. The study is ongoing.

Conclusions: It is expected that the VR scenario will elicit stress and moral distress. Additionally, the didactic intervention is anticipated to improve understanding of and decrease feelings of stress and moral distress. Models of digital phenotypes developed and integrated with wearables could allow for the prediction of risk and the assessment of treatment responses in individuals experiencing moral distress in real-time and naturalistic contexts. This paradigm could also be used in other populations prone to moral distress and injury, such as military and public safety personnel.

Trial registration: ClinicalTrials.gov NCT05923398; https://clinicaltrials.gov/study/NCT05923398.

International registered report identifier (irrid): DERR1-10.2196/54180.

Keywords: COVID-19; VR; digital health implementation; distress; moral distress; nursing; oura ring; stress; virtual reality; wearable; web-based platform.

©Josh Martin, Alice Rueda, Gyu Hee Lee, Vanessa K Tassone, Haley Park, Martin Ivanov, Benjamin C Darnell, Lindsay Beavers, Douglas M Campbell, Binh Nguyen, Andrei Torres, Hyejung Jung, Wendy Lou, Anthony Nazarov, Andrea Ashbaugh, Bill Kapralos, Brett Litz, Rakesh Jetly, Adam Dubrowski, Gillian Strudwick, Sridhar Krishnan, Venkat Bhat. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 06.05.2024.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: JM, AR, HP, VKT, GHL, MI, BCD, LB, DMC, BN, AT, HJ, WL, AN, AA, BK, BL, RJ, AD, GS, and SK declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. VB is supported by an Academic Scholar Award from the Department of Psychiatry, University of Toronto, and has received research support from the Canadian Institutes of Health Research, Brain & Behavior Foundation, Ministry of Health Innovation Funds, Royal College of Physicians and Surgeons of Canada, Department of Defence (Canada), New Frontiers Research Fund, American Foundation for Suicide Prevention, University of Toronto Connaught Funds, University of Toronto EMH Seed Fund, and investigator-initiated trials from Roche Canada, Eisai Canada, Novartis, Associated Medical Services Inc Healthcare, and the National Research Council of Canada.

Figures

**Figure 1**
Phase 2 study schema. Brief MIOS: (clinical version) MIOS-4; GAD-2/7: Generalized Anxiety Disorder-2/7 item scale; IPQ: Igroup Presence Questionnaire; MIOS-4: Moral Injury Outcomes Scale; PHQ-2/9: Patient Health Questionnaire-2/9 item scale; SUDS: Subjective Units of Distress Scale; UCLA-3: UCLA 3-item loneliness scale; UEQ: User Experience Questionnaire; VR1: Virtual Reality Simulation Run 1; VR2: Virtual Reality Simulation Run 2; VRSQ: Virtual Reality Sickness Questionnaire Scale.

**Figure 2**
User interface displaying an example of a participant response.

**Figure 3**
Design of the virtual reality (VR) experimental session. All scales during the VR session will be completed in the immersive virtual environment. Brief MIOS: (clinical version) MIOS-4; IPQ: Igroup Presence Questionnaire; MIOS-4: Moral Injury Outcomes Scale; SUDS: Subjective Units of Distress Scale; VR1: Virtual Reality Simulation Run 1; VR2: Virtual Reality Simulation Run 2; VRSQ: Virtual Reality Sickness Questionnaire Scale.

**Figure 4**
Physiological data collected during the virtual reality (VR) session and debrief. The image shows representative tracings of (from top to bottom): respiratory impedance (RI), photoplethysmography, electrocardiogram, and electrodermal activity (EDA) signals.

**Figure 5**
A block diagram representation of the proposed statistics, information theory, and data-driven (SID) pipeline (adapted from Nguyen et al [38], with permission from the Institute of Electrical and Electronics Engineers [IEEE]). DPP: digital phenotype profile.

See this image and copyright information in PMC

References

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Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study

Affiliations

Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study

Authors

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Abstract

Conflict of interest statement

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References

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Grants and funding

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