Combining Virtual Reality with Horticulture Therapy for Shift Work Disorder among Healthcare Security Personnel

HR: Heart rate, HT: Horticulture therapy, PSQI: Pittsburgh sleep quality index, PSS: Perceived stress scale, VR:Virtual reality, WHO: World health organization. 

Terming “graveyard shift” in the 18^th century considering the eerie stillness of the night and dimly lit hospitals mostly the healthcare sectors predominantly work during the night time. The current research works on securities in healthcare sectors whose job location is mostly exposed to outdoor environments and working night shifts. The India times states that working against the natural body clock the security personnel encounter compounding effect of health issues which requires immediate attention (Anujha Jaisal, 2024). The complicated work nature of the security personnel working at night settings where visibility is profoundly low makes them exceptionally vigilant and anxious as stated by the Great Britain statistics in 2020. The irregular work hours seclude them from their families and isolate them causing loneliness and depression besides disrupting their sleep pattern leading to shift work disorder and fatigue impacting mental health (Lee, 2024). Globally heightened non communicable disease occurrence like diabetes, cardiovascular diseases and chronic inflammatory conditions affecting public health (Bajaj and Sharma, 2024) is observed and the night workers facing shift work disorder will be prone to it easily due to their irregular eating habits working at irregular hours.
       
Horticulture therapy a form of complementary and alternative medicine that offers clients remedial (Son et al., 2016) through a trained therapist involves plants and horticulture making them distinguishable. Comprehensive pieces of literature have proven that nature-based programs through gardening have cured many mental health-related problems and are recognized as a multi-component approach that has affected a broad range of health and well-being outcomes (Paniru  et al., 2024). Chamomiles, lemon balm, theanine, Valerian, St. Johns wort, Rhodiola are some of the horticultural herbal plants used as nervine stimulants to act on the nervous system for sleep promotion as recommended by the US department of veteran affairs (Minichiello, 2023). Traditional Indian medicine relies on a wide range of herbs and is called a “living tradition” in India because of their diverse pharmacological qualities and its bioactive phytomedicines making them therapeutic to treat various ailments (Murugan et al., 2021). The horticulture therapy involving plants and gardening needs to extend its hand to modern tools like virtual reality instruments which could aid participants who could not be approached for interventions at specific sites or at particular times. Blending virtual reality tools (Kim et al., 2019) with therapeutic horticulture in the current scenario can be used for specific participants who may be allergic to odor, pollens, age concerns and other safety issues like collisions and falls (Lin et al., 2020).
       
Being facing stressful situations on daily basis leads to stress and anxiety and these personnel’s need to find good ways to rest their mind and relax after work. One such good way is plant-based therapies and it is the role of managers, chief officers and companies to understand the challenges faced by them and provide support measures that are complementary and palliative. The research findings will provide a solution for considering the unnoticed populations in health care sectors where the securities were vulnerable to physical and mental health issues being prone to long working hours, exposure to unprecedented weather, continuous alertness and continuous standing.

Experimental design and site
 
The quantitative approach through static pre-test and post-test design (Fig 1) was selected where the experimental group is provided intervention and the control group lacks the intervention. The advantage of having a control group helps to estimate the casual impact of intervention and avoids threats on selection bias, attrition and regression to mean and both groups are comparable at the baseline.  The virtual reality therapy and the garden therapy were conducted at the urban farm center (UFC), SRM Institute of Science and Technology in Chengalpattu, Tamil Nadu, India which has a diverse landscape environment providing scope for the therapy and the research was conducted from 2022 to 2024. Non-probability purposive sampling technique was used for the study (Fig 2) with 30 individuals working in the night shifts who satisfied the sampling criteria were included in the study as an experimental group and 30 individuals working in night shifts is considered as control.




 
Research tools and techniques
 
The scales used in the study are the standard research tools and earlier literature have advocated the tools used as having adequate internal consistency, test–retest reliability and validity across different populations. The questioners used for the study include the perceived stress scale (10-item scale) developed by Cohen  et al. in 1983, pittsburgh sleep quality index (PSQI) a self-rated questionnaire by Buysse, D.J.,  et al., 1989, Personal Well-being index scale (PWI) developed by International well-being group in 2013 endorsed by WHO and the 18-item version Psychological Well-Being Scale (Ryff and Keyes, 1995) followed by the subjective feedback on therapeutic interventions that includes a five-point Likert scale for satisfaction. The PSQI tool used is a valid tool used across globally by researchers on sleep issues studies and the minor limitation of the tool is, the psychometric properties may vary across different populations and it is a self reported tool. The research tools used include the VR, BP monitor, essential oil and tea bags. The features of the Virtual reality equipment include the Meta Quest 3 headset featuring updated hardware with the elements of Quest Pro. The blood pressure and heart rate were monitored through Dr. Morepen bp 02 which is clinically tested and often used in research for its accuracy and friendliness. The lavender-based essential oil was obtained along with potpourris and reeds as carriers for elevating sleep. The standard Chamomile-based teas bags were obtained and provided to the participants. Fig 3 explains the interventions provided to the security guards.


 
Statistical analysis
 
Data’s were collected by contacting the Head of security to understand the shift work assignment and the number of securities working in the health care sector. The acquired data was analyzed using descriptive and inferential statistics. The impact of horticulture therapy was tested for stress and sleep in securities using Paired t-test (inferential statistics).

The factors related to shift work amongst the security guards is presented in Table 1. The question regarding the number of night shifts per week states nearly 41.6% work more than five night shifts, while 45% of the population works three to five-night shifts. Working continuous night shifts affected their ability to sleep (51.7%) and 61.6% claimed working night shifts had an impact on the day and 55% of the securities answered that they were dissatisfied with working in night shifts. The questions regarding income depict that 33.3% were satisfied that they receive some mere additional money than day shifts, while 51.7% were not happy with the income they receive. 65% of the securities preferred to work day shifts and 50% per cent thought that it frequently caused stress. The securities felt bad (40%) about not spending quality time with their family, while 36.7 per cent said they were fine with it. The results of the factors related to night shift work have issues to be addressed regarding the implications of well-being at the workplace, i.e., in the 24 hour work cycle the maximum of time spent by a security officer in the health sector is around 10-12 long hours per day and the employers expect that the well being should be carried out only during their resting periods or after hours as the health sector work nature demands it. With 51.7% of the population expressed dissatisfaction on their income the solution and cure for their sleep medications should be less and thus utilization of the natural methods will cut the costs and being accessible to the common man and the less earner (Niwas et al., 2024).


       
The physiological scores for the blood pressure and pulse rate were recorded before the intervention and also taken after two months of the intervention period and presented in Table 2. The blood pressure results for the treatment group has a pre-test value of 138.30±21.02 and after the intervention period it has decreased to 127.93±14.80 with a mean difference of 10.36±10.04, for the Diastolic and for the systolic pressure the values are 85.13±12.59 for the pre-test period and 81.90±11.07 during the post-test period with a mean difference of 3.23±3.97 and both the values are significant at 1% interval. The heart rate during the pre-test period is 79.16±18.67 and it has decreased to 77.76±15.25 after intervention with a difference 0f 1.45.30 with 1% significance.  As the security personnel involved for this research was in the health sector and the amount of anxiousness and depression is tagged with job nature as they have to be vigilant all the time to avoid any error concerning other life and the results over the control group states that the therapy has created a way of relaxation, calmness (Xiaoyi,  L.,  et al., 2024) and thus reducing the blood pressure and heart rate.


       
The scores for the perceived stress scale have a value of 23.03±3.69 which has been reduced to 17.10±4.38 after intervention with 5.93±5.22 and the score boards of the control group is also presented in Table 3. Working in a night shift-facing environment kept them anxious and stressed and working in gardening activities for two months have decreased the stress level, thus the PSS scores have a good reduction score. Exposing the securities to nature scenes through VR had mediated the negative mood states and brought in positive emotions (Berto, 2014) and reduced their stress (Felix  et al., 2019).


       
The personal well being scores has a good improvement with value increasing from 32.86±9.30 to 51.60±9.35 with a difference of 18.73±8.32 and the t value is 11.32 and significant at 1%. The thought of sharing time, being noticed and having interactions with them specifically has made them feel better personally and mentally as the scores of personal and psychological well-being has improved and this is one of the best therapeutic approaches of gardening.
       
The psychological well being scores have good improvement during the post-test with a score of 80.83±9.69 from 74.60±9.33 with a difference of 6.23±5.41 which is significant at 1%. All the scores were compared with a control group and presented in Table 2. The psychological problem concerning stress, anxiety and depression are global public health issues accompanied with sleep issues (Wainberg et al., 2017) and the research has produced positive outcomes
       
Table 3 values for the effect of horticulture interventions over sleep improvement, with lower the value higher the sleep improvement indicating a score of 6.10±2.23 from 13.27±2.38 with a difference of 7.17±1.90. In the seven components, the values are not significant for sleep duration and sleep medication and habitual sleep efficiency. The core aspect the research focused was on sleep improvement and the influence of aromatic oils with lavender base and chamomile teas for sleep improvement in combination have got better results over the sleep schedule and we could see the PSQI scores have improved after the interventions were provided. The Lavandula species possess a significant therapeutic potential due to the presence of a variety of bioactive compounds, such as linalool and retinol, which are utilized in a variety of pharmaceutical applications. Consequently, it is imperative that additional research be conducted to explore the potential of these multi-therapeutic active compounds (Mohamed  et al., 2024).
       
The results of the subjective feedback on the different horticulture interventions after treatment collected from the security personnel’s are depicted in Fig 4. The feedbacks for the VR therapy is highest among all the horticulture interventions with 43% scoring followed by pot painting and potpourri making with each 37% in completely satisfied category. Among the therapies the VR was found to be a fascinating technology liked by the security as it immersed them into a different world reliving the depression and stress. The VR though synthetic, given them the experience of being in the existing world and makes them incarnated making their body feel they are in the virtual world (Riva et al., 2016) and it makes them forget their worries and gives a sense of being in another physical environment forgetting their physical in their real world. Though VR has been used to reduce stress (Naylor  et al., 2019) its application through a combination of various therapies at work place settings is still unexplored and there is a gap in literature of using these technologies in workplace. The potpouris are colourful and made out of dry flowers which are everlasting, eco-friendly and biodegradable which can be treasured for years and an attractive charm for the employee (Pooja et al., 2023). The pot paintings are interesting income generating hobbies and as most of securities are in senior category these potting up plants heals geriatric problems and focus on multisensory experience engaging all senses (Steffi and Sreedaya, 2024).


       
The approach of a combination of VR technology and different horticulture interventions as therapy had significant physiological and psychological effects on the security over shift work and sleep issues (Hernandez  et al., 2022). The therapies to be effective among the securities should be cost-effective, approachable, popular, non-arousing nature scenes (Pizzoli et al., 2019), providing quality immersive experiences (Huygelier et al., 2019) and at the same time the therapy should improve the overall sleep (Gonzalez, M.T. and Kirkevold, M., 2014) and these were achieved through the combination of VR and HT. 
               
The significance of the study is the research worked on the influence of horticulture therapy addressing the shift work disorder has accessed the under noticed working personnel’s in the working community who were prone to severe threats physically and mentally. Further no studies have concentrated on considering the securities as sample for the research, though they are the integral workforce in maintaining the orderlies in the health sector avoiding chaos. Hence the aim of the study addressed the sleep disorder among the securities through a combination of virtual reality and other HT bringing in sleep improvement and wellbeing. The limitations includes as most of the horticulture studies are nature (Boersma  et al., 2023) based and controlled by environmental factors, to have effective interventions the study population cannot concentrate on more than 30 numbers per horticulture therapist. As being in the racing society especially in the field of health sector we cannot neglect working in night shifts hence care must be taken as to improvise the sleep through stress reliving activities like VR and sleep-promoting therapies through horticulture which should be made available to the night shift workers by providing plenty of relaxing time to recover from sleep issues. The shift work disorders are combination of various morbidities and hence cannot be cured with single interventions and a combination of various horticulture therapies with technology will thus drive away the multiple factors and thus making the research stand unique. The research findings hence will guarantee that the future horticulture therapy should focus and work together with different therapeutic approaches and having in mind that the core concept of horticulture therapy is nature based interventions.

The health and safety executive states that in 2020 around 51% of illness was due to work related stress and 17.9 million working days were lost. Thus the study concentrated on the sustainable solutions for meeting out the wellbeing of the working community, specifically the horticulture therapies were effective in alleviating the stress among the night workers with higher stress issues. The VR technology has given them a sense of living along with the technologically driven world and the satisfactory levels were too good for the VR. In conclusion the combination of VR, aromatic oils, sleep inducing tea bags, visually attractive indoor plants and gardening activities have reduced the stress and improved the well-being and issues regarding shift work.

The present study was supported by self: No funding received.
 
Disclaimer
 
The views and conclusions expressed in this article are solely those of the authors and do not necessarily represent the views of their affiliated institutions. The authors are responsible for the accuracy and completeness of their information provided but do not accept any liability for any direct or indirect losses resulting from the use of this content.
 
Informed consent
 
Approved by the institution ethics committee (IEC), School of Public Health, SRM Medical College Hospital and Research Institute, Kattankulathur, Chengalpattu district, with reference number 0043/IEC/2023, dates 11.12.2023.

The authors declare that there are no conflicts of interest regarding the publication of this article. No funding or sponsorship influenced the design of the study, data collection, analysis, decision to publish or preparation of the manuscript.