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 aGer the intervention ended), and long term follow-up (> 12 months aGer 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.
BACKGROUND: From the viewpoint of human factors and ergonomics (HFE), errors often occur because of the mismatch between the system, technique and characteristics of the human body. HFE is a scientific discipline concerned with understanding interactions between human behavior, system design and safety.
OBJECTIVE: To evaluate the effectiveness of HFE interventions in improving health care workers' outcomes and patient safety and to assess the quality of the available evidence.
METHODS: We searched databases, including MEDLINE, EMBASE, BIOSIS Previews and the CBM (Chinese BioMedical Literature Database), for articles published from 1996 to Mar.2015. The quality assessment tool was based on the risk of bias criteria developed by the Cochrane Effective Practice and Organization of Care (EPOC) Group. The interventions of the included studies were categorized into four relevant domains, as defined by the International Ergonomics Association.
RESULTS: For this descriptive study, we identified 8, 949 studies based on our initial search. Finally, 28 studies with 3,227 participants were included. Among the 28 included studies, 20 studies were controlled studies, two of which were randomized controlled trials. The other eight studies were before/after surveys, without controls. Most of the studies were of moderate or low quality. Five broad categories of outcomes were identified in this study: 1) medical errors or patient safety, 2) health care workers' quality of working life (e.g. reduced fatigue, discomfort, workload, pain and injury), 3) user performance (e.g., efficiency or accuracy), 4) health care workers' attitudes towards the interventions(e.g., satisfaction and preference), and 5) economic evaluations.
CONCLUSION: The results showed that the interventions positively affected the outcomes of health care workers. Few studies considered the financial merits of these interventions. Most of the included studies were of moderate quality. This review highlights the need for scientific and standardized guidelines regarding how HFE should be implemented in health care.
BACKGROUND: Organisational-level workplace interventions are thought to produce more sustainable effects on the health of employees than interventions targeting individual behaviours. However, scientific evidence from intervention studies does not fully support this notion. It is therefore important to explore conditions of positive health effects by systematically reviewing available studies. We set out to evaluate the effectiveness of 39 health-related intervention studies targeting a variety of working conditions.
METHODS: Systematic review. Organisational-level workplace interventions aiming at improving employees' health were identified in electronic databases and manual searches. The appraisal of studies was adapted from the Cochrane Back Review Group guidelines. To improve comparability of the widely varying studies we classified the interventions according to the main approaches towards modifying working conditions. Based on this classification we applied a logistic regression model to estimate significant intervention effects.
RESULTS: 39 intervention studies published between 1993 and 2012 were included. In terms of methodology the majority of interventions were of medium quality, and four studies only had a high level of evidence. About half of the studies (19) reported significant effects. There was a marginally significant probability of reporting effects among interventions targeting several organisational-level modifications simultaneously (Odds ratio (OR) 2.71; 95% CI 0.94-11.12), compared to those targeting one dimension only.
CONCLUSIONS: Despite the heterogeneity of the 39 organisational-level workplace interventions underlying this review, we were able to compare their effects by applying broad classification categories. Success rates were higher among more comprehensive interventions tackling material, organisational and work-time related conditions simultaneously. To increase the number of successful organisational-level interventions in the future, commonly reported obstacles against the implementation process should be addressed in developing these studies.
BACKGROUND: Flexible working conditions are increasingly popular in developed countries but the effects on employee health and wellbeing are largely unknown. OBJECTIVES: To evaluate the effects (benefits and harms) of flexible working interventions on the physical, mental and general health and wellbeing of employees and their families. SEARCH STRATEGY: Our searches (July 2009) covered 12 databases including the Cochrane Public Health Group Specialised Register, CENTRAL; MEDLINE; EMBASE; CINAHL; PsycINFO; Social Science Citation Index; ASSIA; IBSS; Sociological Abstracts; and ABI/Inform. We also searched relevant websites, handsearched key journals, searched bibliographies and contacted study authors and key experts. SELECTION CRITERIA: Randomised controlled trials (RCT), interrupted time series and controlled before and after studies (CBA), which examined the effects of flexible working interventions on employee health and wellbeing. We excluded studies assessing outcomes for less than six months and extracted outcomes relating to physical, mental and general health/ill health measured using a validated instrument. We also extracted secondary outcomes (including sickness absence, health service usage, behavioural changes, accidents, work-life balance, quality of life, health and wellbeing of children, family members and co-workers) if reported alongside at least one primary outcome. DATA COLLECTION AND ANALYSIS: Two experienced review authors conducted data extraction and quality appraisal. We undertook a narrative synthesis as there was substantial heterogeneity between studies. MAIN RESULTS: Ten studies fulfilled the inclusion criteria. Six CBA studies reported on interventions relating to temporal flexibility: self-scheduling of shift work (n = 4), flexitime (n = 1) and overtime (n = 1). The remaining four CBA studies evaluated a form of contractual flexibility: partial/gradual retirement (n = 2), involuntary part-time work (n = 1) and fixed-term contract (n = 1). The studies retrieved had a number of methodological limitations including short follow-up periods, risk of selection bias and reliance on largely self-reported outcome data. Four CBA studies on self-scheduling of shifts and one CBA study on gradual/partial retirement reported statistically significant improvements in either primary outcomes (including systolic blood pressure and heart rate; tiredness; mental health, sleep duration, sleep quality and alertness; self-rated health status) or secondary health outcomes (co-workers social support and sense of community) and no ill health effects were reported. Flexitime was shown not to have significant effects on self-reported physiological and psychological health outcomes. Similarly, when comparing individuals working overtime with those who did not the odds of ill health effects were not significantly higher in the intervention group at follow up. The effects of contractual flexibility on self-reported health (with the exception of gradual/partial retirement, which when controlled by employees improved health outcomes) were either equivocal or negative. No studies differentiated results by socio-economic status, although one study did compare findings by gender but found no differential effect on self-reported health outcomes. AUTHORS' CONCLUSIONS: The findings of this review tentatively suggest that flexible working interventions that increase worker control and choice (such as self-scheduling or gradual/partial retirement) are likely to have a positive effect on health outcomes. In contrast, interventions that were motivated or dictated by organisational interests, such as fixed-term contract and involuntary part-time employment, found equivocal or negative health effects. Given the partial and methodologically limited evidence base these findings should be interpreted with caution. Moreover, there is a clear need for well-designed intervention studies to delineate the impact of flexible working conditions on health, wellbeing and health inequalities.
BACKGROUND: Many health behaviors and physiologic indicators can be used to estimate one's likelihood of illness or premature death. Methods have been developed to assess this risk, most notably the use of a health-risk assessment or biometric screening tool. This report provides recommendations on the effectiveness of interventions that use an Assessment of Health Risks with Feedback (AHRF) when used alone or as part of a broader worksite health promotion program to improve the health of employees.
EVIDENCE ACQUISITION: The Guide to Community Preventive Services' methods for systematic reviews were used to evaluate the effectiveness of AHRF when used alone and when used in combination with other intervention components. Effectiveness was assessed on the basis of changes in health behaviors and physiologic estimates, but was also informed by changes in risk estimates, healthcare service use, and worker productivity.
EVIDENCE SYNTHESIS: The review team identified strong evidence of effectiveness of AHRF when used with health education with or without other intervention components for five outcomes. There is sufficient evidence of effectiveness for four additional outcomes assessed. There is insufficient evidence to determine effectiveness for others such as changes in body composition and fruit and vegetable intake. The team also found insufficient evidence to determine the effectiveness of AHRF when implemented alone.
CONCLUSIONS: The results of these reviews indicate that AHRF is useful as a gateway intervention to a broader worksite health promotion program that includes health education lasting > or =1 hour or repeating multiple times during 1 year, and that may include an array of health promotion activities. These reviews form the basis of the recommendations by the Task Force on Community Preventive Services presented elsewhere in this supplement.
OBJECTIVES: The aim of the study was to investigate whether different types of health promotion intervention in the workplace reduce depression and anxiety symptoms.
METHODS: A systematic review and meta-analysis of the literature was undertaken on workplace health promotion published during the period 1997-2007. Studies were considered eligible for inclusion if they evaluated the impact of an intervention using a valid indicator or specific measure of depression or anxiety symptoms. The standardized mean difference was calculated for each of the following three types of outcome measures: depression, anxiety, and composite mental health.
RESULTS: Altogether 22 studies were found that met the inclusion criteria, with a total sample size of 3409 employees postintervention, and 17 of these studies were included in the meta-analysis, representing 20 intervention-control comparisons. The pooled results indicated small, but positive overall effects of the interventions with respect to symptoms of depression [SMD 0.28, 95% confidence interval (95% CI) 0.12-0.44] and anxiety (SMD 0.29, 95% CI 0.06-0.51), but no effect on composite mental health measures (SMD 0.05, 95% CI -0.03-0.13). The interventions that included a direct focus on mental health had a comparable effect on depression and anxiety symptoms, as did the interventions with an indirect focus on risk factors.
CONCLUSIONS: When the aim is to reduce symptoms of depression and anxiety in employee populations, a broad range of health promotion interventions appear to be effective, although the effect is small.
CONTEXT: Most adults do not achieve adequate physical activity levels. Despite the potential benefits of worksite health promotion, no previous comprehensive meta-analysis has summarized health and physical activity behavior outcomes from such programs. This comprehensive meta-analysis integrated the extant wide range of worksite physical activity intervention research.
EVIDENCE ACQUISITION: Extensive searching located published and unpublished intervention studies reported from 1969 through 2007. Results were coded from primary studies. Random-effects meta-analytic procedures, including moderator analyses, were completed in 2008.
EVIDENCE SYNTHESIS: Effects on most variables were substantially heterogeneous because diverse studies were included. Standardized mean difference (d) effect sizes were synthesized across approximately 38,231 subjects. Significantly positive effects were observed for physical activity behavior (0.21); fitness (0.57); lipids (0.13); anthropometric measures (0.08); work attendance (0.19); and job stress (0.33). The significant effect size for diabetes risk (0.98) is less robust given small sample sizes. The mean effect size for fitness corresponds to a difference between treatment minus control subjects' means on VO2max of 3.5 mL/kg/min; for lipids, -0.2 on the ratio of total cholesterol to high-density lipoprotein; and for diabetes risk, -12.6 mg/dL on fasting glucose.
CONCLUSIONS: These findings document that some workplace physical activity interventions can improve both health and important worksite outcomes. Effects were variable for most outcomes, reflecting the diversity of primary studies. Future primary research should compare interventions to confirm causal relationships and further explore heterogeneity.
According to the most recently available Labour Force Survey for 2004-2005, 509,000 individuals in the UK believed they were suffering from stress, depression or anxiety and these conditions were caused or made worse by their current or past work. This resulted in an estimated 12.8 million working days lost with an average of 30.9 days off over a 12 month period. Those employed in the public sector had some of the highest rates of self-reported stress, anxiety and depression. In particular those with heavy workloads, tight deadlines, lack of support at work, in a threatening environment are recognised as being at an increased risk of stress, depression or anxiety. This review aims to determine which workplace interventions are effective and cost-effective in improving mental wellbeing.
OBJECTIVE: To systematically review studies of the effects of the Compressed Working Week on the health and work-life balance of shift workers, and to identify any differential impacts by socio-economic group. METHODS: Systematic review. Following QUORUM guidelines, published or unpublished experimental and quasi-experimental studies were identified. Data were sourced from 27 electronic databases, websites, bibliographies, and expert contacts. RESULTS: Fourty observational studies were found. The majority of studies only measured self-reported outcomes and the methodological quality of the included studies was not very high. Interventions did not always improve the health of shift workers, but in the five prospective studies with a control group, there were no detrimental effects on self-reported health. However, work-life balance was generally improved. No studies reported differential impacts by socio-economic group; however, most of the studies were conducted on homogeneous populations. CONCLUSION: This review suggests that the Compressed Working Week can improve work-life balance, and that it may do so with a low risk of adverse health or organisational effects. However, better designed studies that measure objective health outcomes are needed.
OBJECTIVE: To systematically review the health and psychosocial effects (with reference to the demand-control-support model) of changes to the work environment brought about by task structure work reorganisation, and to determine whether those effects differ for different socioeconomic groups. DESIGN: Systematic review (QUORUM) of experimental and quasi-experimental studies (any language) reporting health and psychosocial effects of such interventions. DATA SOURCES: Seventeen electronic databases (medical, social science and economic), bibliographies and expert contacts. RESULTS: Nineteen studies were reviewed. Some task-restructuring interventions failed to alter the psychosocial work environment significantly, and so could not be expected to have a measurable effect on health. Those that increased demand and decreased control tended to have an adverse effect on health, while those that decreased demand and increased control resulted in improved health, although some effects were minimal. Increases in workplace support did not appear to mediate this relationship. CONCLUSION: This systematic review suggests that task-restructuring interventions that increase demand or decrease control adversely affect the health of employees, in line with observational research. It lends support to policy initiatives such as the recently enforced EU directive on participation at work, which aims to increase job control and autonomy.
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 aGer the intervention ended), and long term follow-up (> 12 months aGer 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.
Systematic Review Question»Systematic review of interventions
