Abstract

Background

Healthcare workers can suffer from work‐related stress as a result of an imbalance of demands, skills and social support at work. This may lead to stress, burnout and psychosomatic problems, and deterioration of service provision. This is an update of a Cochrane Review that was last updated in 2015, which has been split into this review and a review on organisational‐level interventions. 

Objectives

To evaluate the effectiveness of stress‐reduction interventions targeting individual healthcare workers compared to no intervention, wait list, placebo, no stress‐reduction intervention or another type of stress‐reduction intervention in reducing stress symptoms. 

Search methods

We used the previous version of the review as one source of studies (search date: November 2013). We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Web of Science and a trials register from 2013 up to February 2022.

Selection criteria

We included randomised controlled trials (RCT) evaluating the effectiveness of stress interventions directed at healthcare workers. We included only interventions targeted at individual healthcare workers aimed at reducing stress symptoms. 

Data collection and analysis

Review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We categorised interventions into ones that:

1. focus one’s attention on the (modification of the) experience of stress (thoughts, feelings, behaviour); 

2. focus one’s attention away from the experience of stress by various means of psychological disengagement (e.g. relaxing, exercise); 

3. alter work‐related risk factors on an individual level; and ones that

4. combine two or more of the above. 

The crucial outcome measure was stress symptoms measured with various self‐reported questionnaires such as the Maslach Burnout Inventory (MBI), measured at short term (up to and including three months after the intervention ended), medium term (> 3 to 12 months after the intervention ended), and long term follow‐up (> 12 months after the intervention ended). 

Main results

This is the second update of the original Cochrane Review published in 2006, Issue 4. This review update includes 89 new studies, bringing the total number of studies in the current review to 117 with a total of 11,119 participants randomised. 

The number of participants per study arm was ≥ 50 in 32 studies. The most important risk of bias was the lack of blinding of participants. 

Focus on the experience of stress versus no intervention/wait list/placebo/no stress‐reduction intervention

Fifty‐two studies studied an intervention in which one's focus is on the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (standardised mean difference (SMD) ‐0.37, 95% confidence interval (CI) ‐0.52 to ‐0.23; 41 RCTs; 3645 participants; low‐certainty evidence) and medium term (SMD ‐0.43, 95% CI ‐0.71 to ‐0.14; 19 RCTs; 1851 participants; low‐certainty evidence). The SMD of the short‐term result translates back to 4.6 points fewer on the MBI‐emotional exhaustion scale (MBI‐EE, a scale from 0 to 54). The evidence is very uncertain (one RCT; 68 participants, very low‐certainty evidence) about the long‐term effect on stress symptoms of focusing one's attention on the experience of stress.

Focus away from the experience of stress versus no intervention/wait list/placebo/no stress‐reduction intervention 

Forty‐two studies studied an intervention in which one's focus is away from the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (SMD ‐0.55, 95 CI ‐0.70 to ‐0.40; 35 RCTs; 2366 participants; low‐certainty evidence) and medium term (SMD ‐0.41 95% CI ‐0.79 to ‐0.03; 6 RCTs; 427 participants; low‐certainty evidence). The SMD on the short term translates back to 6.8 fewer points on the MBI‐EE. No studies reported the long‐term effect.

Focus on work‐related, individual‐level factors versus no intervention/no stress‐reduction intervention

Seven studies studied an intervention in which the focus is on altering work‐related factors. The evidence is very uncertain about the short‐term effects (no pooled effect estimate; three RCTs; 87 participants; very low‐certainty evidence) and medium‐term effects and long‐term effects (no pooled effect estimate; two RCTs; 152 participants, and one RCT; 161 participants, very low‐certainty evidence) of this type of stress management intervention. 

A combination of individual‐level interventions versus no intervention/wait list/no stress‐reduction intervention

Seventeen studies studied a combination of interventions. In the short‐term, this type of intervention may result in a reduction in stress symptoms (SMD ‐0.67 95%, CI ‐0.95 to ‐0.39; 15 RCTs; 1003 participants; low‐certainty evidence). The SMD translates back to 8.2 fewer points on the MBI‐EE. On the medium term, a combination of individual‐level interventions may result in a reduction in stress symptoms, but the evidence does not exclude no effect (SMD ‐0.48, 95% CI ‐0.95 to 0.00; 6 RCTs; 574 participants; low‐certainty evidence). The evidence is very uncertain about the long term effects of a combination of interventions on stress symptoms (one RCT, 88 participants; very low‐certainty evidence).

Focus on stress versus other intervention type 

Three studies compared focusing on stress versus focusing away from stress and one study a combination of interventions versus focusing on stress. The evidence is very uncertain about which type of intervention is better or if their effect is similar.

Authors' conclusions

Our review shows that there may be an effect on stress reduction in healthcare workers from individual‐level stress interventions, whether they focus one's attention on or away from the experience of stress. This effect may last up to a year after the end of the intervention. A combination of interventions may be beneficial as well, at least in the short term. Long‐term effects of individual‐level stress management interventions remain unknown. The same applies for interventions on (individual‐level) work‐related risk factors.

The bias assessment of the studies in this review showed the need for methodologically better‐designed and executed studies, as nearly all studies suffered from poor reporting of the randomisation procedures, lack of blinding of participants and lack of trial registration. Better‐designed trials with larger sample sizes are required to increase the certainty of the evidence. Last, there is a need for more studies on interventions which focus on work‐related risk factors. 

Author(s)

Sietske J Tamminga, Lima M Emal, Julitta S Boschman, Alice Levasseur, Anilkrishna Thota, Jani H Ruotsalainen, Roosmarijn MC Schelvis, Karen Nieuwenhuijsen, Henk F van derMolen

Abstract

Plain language summary

The effect of individual‐level interventions for reducing stress in healthcare workers

Key messages

‐ Individual‐level interventions in which one’s attention is on the experience of stress (like focusing on thoughts, feelings, behaviour) or away from the experience of stress (like exercising, relaxing) may reduce stress among healthcare workers up to one year after the intervention.

‐ A combination of individual‐level interventions may reduce stress up to a couple of months after the intervention. 

‐ We do not know if interventions that focus on work‐related risk factors on an individual level have any effect on stress.

What is stress?

There is currently no clear definition of (work‐related) stress. This review is about healthcare workers with low levels of stress to moderate distress and burnout, which might lead to depression and anxiety but does not have to. People with stress can experience physical symptoms like headaches, muscle tension or pain, but also mental symptoms, like impaired concentration. They can also have behavioural problems (like conflicts with other people) and emotional problems (like emotional instability).

What can be done about stress among healthcare workers?

Stress among healthcare workers can be tackled at an organisational level, but also at an individual level. Stress management interventions at the individual‐level aim to:

‐ focus one’s attention on the experience of stress (thoughts, feelings, behaviour), for example by cognitive‐behavioural therapy or coping skills training;

‐ focus one’s attention away from the experience of stress, for example by yoga, Tai Chi, drawing, or acupuncture; 

‐ alter work‐related risk factors on an individual level, such as alterations in work demands.

What did we want to find out?

We wanted to find out if various types of individual‐level stress management interventions are better than no intervention (or another intervention) to reduce stress among healthcare workers currently working as such.

What did we do

We searched for studies that looked at stress management interventions in healthcare workers and reported on stress symptoms. The healthcare workforce comprises a wide variety of professions and occupations who provide some type of healthcare service, including direct care practitioners and allied professionals. 

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and study size.

What did we find?

We found a total of 117 studies that involved a total of 11,119 healthcare workers. Most studies followed their participants up to three months and some up to 12 months, but only few longer than a year. 

We found that there may be an effect on stress reduction in healthcare workers from stress management interventions, whether they focus one's attention on or away from the experience of stress. This effect may last up to a year after the end of the intervention. A combination of interventions may be beneficial as well, at least in the short term. The long‐term effects of stress management interventions, longer than a year after the intervention has ended, remain unknown. The same applies for interventions on (individual‐level) work‐related risk factors.

What are the limitations of the evidence?

The estimates of the effects of individual‐level stress management interventions may be biassed because of a lack of blinding of the participants in the included studies. Furthermore, many studies were relatively small. Taken together, our confidence in the effects we found is reduced.  

How up to date is this evidence?

The evidence is up‐to‐date to February 2022.

Author(s)

Sietske J Tamminga, Lima M Emal, Julitta S Boschman, Alice Levasseur, Anilkrishna Thota, Jani H Ruotsalainen, Roosmarijn MC Schelvis, Karen Nieuwenhuijsen, Henk F van derMolen

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

Our review shows that there may be an effect on stress in healthcare workers from individual‐level stress interventions, whether they focus one's attention on or away from the experience of stress. This effect may last up to a year after the end of the intervention. A combination of interventions might be beneficial as well, at least in the short term. The long‐term effects, longer than a year after the intervention ended, of individual‐level stress interventions remain unknown. The same applies for interventions focussed on modifying work‐related risk factors. 

The estimates of the effects of individual‐level stress interventions may be biased because of a lack of blinding of the participants in the studies. The true effect of interventions in which one's attention is directed on or away from the experience of stress is likely to be close to the estimate of the effect, but there is a possibility that the effect is substantially different (e.g. due to placebo effect). The effect could be potentially smaller than our synthesis of the available evidence indicated. Our confidence in the effect of combinations of interventions is limited, and the true effect may be substantially different from the estimate of the effect. We have very little confidence in the effect of individual‐level interventions in which the focus is on work‐related risk factors. Based on the included studies we cannot indicate whether or not there is any effect, even though this approach is often considered to be the most impactful and sustainable way to eliminate stress in the workplace. These interventions tend to be complex because they require changes in how the work is organised, designed and managed, which is often beyond the scope of the individual employee (Nielsen 2010). Also, difficulties in adequately measuring the effects might explain why this kind of intervention does not live up to the expectations researchers have of them based on theories. 

Country‐specific policies and legislation can influence what types of interventions are implemented. In most countries, there is some legislation on health and safety at work, but the extent and quality varies between countries according to a report by the World Health Organization (Burton 2010). The minimum variant is protecting workers from injuries or illness, but more refined legislation is in place in many countries requiring aspects such as a risk assessment, and the implementation and monitoring of measures. However, examining whether such legislation is effective is beyond the scope of our review.

Implications for research 

The findings of this review show the need for methodologically better designed and executed studies. Trials of this type are required as nearly all included studies suffered from lack of blinding of participants and personnel. We acknowledge the difficulty of blinding in stress reduction interventions. Nevertheless, in 14 studies attempts were made to blind participants to group assignment, thus showing that blinding is not impossible. Better design and execution of studies also include providing details on the randomisation process and study protocol or trial registration.

Furthermore, there is a need for more studies on interventions in which the focus is on work‐related risk factors both at the individual and organisational level. With more participants the optimal information size can be reached and conclusions can be drawn. 

We believe it would be helpful to investigate and identify unpublished data (potentially showing no effect or a harmful effect) of individual‐level stress management interventions. Large studies on this topic might also help resolve this small‐study issue. 

The long‐term effects of individual‐level stress management interventions are unknown due to the total absence of studies or paucity of data. Studies following the participants for more than a year after the intervention has ended are needed to be able to draw conclusions about the long‐term benefits, if any, on stress reduction of interventions aimed at reducing stress in healthcare workers. 

Designing interventions to reduce stress amongst high‐risk populations should be preferably based on working mechanisms or underlying biological or behavioural change models.

We found a preliminary indication for a higher standardised mean difference (SMD) when using a wait list control group compared to a non‐intervention control group, which has been corroborated by previous research (Faltinsen 2022). Further research is needed to determine how each control arm could affect the SMD. 

When studying the effect of an intervention focusing on the experience of stress compared to no intervention, wait list control group, placebo, or no stress‐reduction intervention, we recommend future research to have at least 116 participants per study arm at follow‐up. This calculation is based on the SMD of analysis 1.1 (α 0.05, power 80%, difference between two independent means) (Faul 2017). When studying the effect of an intervention focusing away from the experience of stress compared to no intervention, wait list control group, placebo, or no stress‐reduction intervention, we recommend future research to have at least 53 participants per study arm at follow‐up. Again, this calculation is based on the SMD of analysis 1.2 (α 0.05, power 80%, difference between two independent means) (Faul 2017). 

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