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.
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.
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.
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.
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.
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.
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).
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.