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: Presenteeism is highly prevalent and costly to employers. It is defined as being present at work, but limited in some aspect of job performance by a health problem.Workplace health promotion (WHP) is a common strategy used to enhance on-the-job productivity. The primary objective is to determine if WHP programs are effective in improving presenteeism. The secondary objectives are to identify characteristics of successful programs and potential risk factors for presenteeism.
METHODS: The Cochrane Library, Medline, and other electronic databases were searched from 1990 to 2010. Reference lists were examined, key journals were hand-searched and experts were contacted. Included studies were original research that contained data on at least 20 participants (≥ 18 years of age), and examined the impacts of WHP programs implemented at the workplace. The Effective Public Health Practice Project Tool for Quantitative Studies was used to rate studies. 'Strong' and 'moderate' studies were abstracted into evidence tables, and a best evidence synthesis was performed. Interventions were deemed successful if they improved the outcome of interest. Their program components were identified, as were possible risk factors contributing to presenteeism.
RESULTS: After 2,032 titles and abstracts were screened, 47 articles were reviewed, and 14 were accepted (4 strong and 10 moderate studies). These studies contained preliminary evidence for a positive effect of some WHP programs. Successful programs offered organizational leadership, health risk screening, individually tailored programs, and a supportive workplace culture. Potential risk factors contributing to presenteeism included being overweight, a poor diet, a lack of exercise, high stress, and poor relations with co-workers and management.
LIMITATIONS: This review is limited to English publications. A large number of reviewed studies (70%) were inadmissible due to issues of bias, thus limiting the amount of primary evidence. The uncertainties surrounding presenteeism measurement is of significant concern as a source of bias.
CONCLUSIONS: The presenteeism literature is young and heterogeneous. There is preliminary evidence that some WHP programs can positively affect presenteeism and that certain risk factors are of importance. Future research would benefit from standard presenteeism metrics and studies conducted across a broad range of workplace settings.
BACKGROUND: Anxiety disorders are associated with functional disability, sickness absence, and decreased productivity. Effective treatments of anxiety disorders can result in remission of symptoms. However the effects on work related outcomes are largely unknown. Exposure in vivo is potentially well fit to improve work-related outcomes. This study systematically reviews the effectiveness of exposure-in-vivo containing interventions in reducing work-related adverse outcomes in workers with anxiety disorders.
METHODS: A systematic study search was conducted in Medline, Cinahl, Embase and Psycinfo. Two reviewers independently extracted data and from each study assessed the quality of evidence by using the GRADE approach. We performed a meta-analysis if data showed sufficient clinical homogeneity.
RESULTS: Seven studies containing 11 exposure-in-vivo interventions were included. Four studies were focused on Obsessive Compulsive Disorder (OCD), two on Post Traumatic Stress Disorder (PTSD), and one on a mixed group of OCD and severe phobias. The studies were grouped according to type of anxiety disorder and subsequently according to type of comparisons. For OCD, exposure-in-vivo containing interventions can yield better work-related outcomes compared to medication (SSRIs) and relaxation but not better compared to response prevention. The results on anxiety outcomes were similar. The net contribution of exposure in vivo in two OCD intervention programs is also presented as a meta-analysis and shows significant positive results on work role limitations. The calculated pooled effect size with 95% confidence interval was 0.72 (0.28, 1.15). For PTSD, exposure-in-vivo containing interventions can yield better work-related and anxiety-related outcomes compared to a waiting-list but not better compared to imaginal exposure.
CONCLUSIONS: Exposure in vivo as part of an anxiety treatment can reduce work-related adverse outcomes in workers with OCD and PTSD better than various other anxiety treatments or a waiting-list. We recommend that it should be studied how the results of these studies can be transferred to the practice of occupational health professionals and how clinicians can make better use of them to improve work-related outcomes. In future research, priority should be given to high-quality randomised controlled trials (RCTs) in which exposure-in-vivo containing interventions are applied to a variety of anxiety disorders and compared with other clinical anxiety treatments such as SSRIs. Work-related outcomes, in particular work functioning and sickness absence, need to be assessed with reliable and valid measures.
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.
Organizational wellness programs are on or off-site services sponsored by organizations which attempt to promote good health or to identify and correct potential health related problems (Wolfe, Parker, & Napier, 1994). The authors conducted a meta-analysis on studies that examined the effects of participation in an organizational wellness program (fitness or comprehensive) on absenteeism and job satisfaction. The results revealed that participation in an organizational wellness program was associated with decreased absenteeism and increased job satisfaction. The type of wellness program (fitness only or comprehensive) and the methodological rigor of the primary studies were examined as moderators; however, no moderating effects were found. These results provide some empirical support for the effectiveness of organizational wellness programs.
A meta-analysis was conducted to determine the effectiveness of stress management interventions in occupational settings. Thirty-six experimental studies were included, representing 55 interventions. Total sample size was 2,847. Of the participants, 59% were female, mean age was 35.4, and average length of intervention was 7.4 weeks. The overall weighted effect size (Cohen's d) for all studies was 0.526 (95% confidence interval = 0.364, 0.687), a significant medium to large effect. Interventions were coded as cognitive-behavioral, relaxation, organizational, multimodal, or alternative. Analyses based on these subgroups suggested that intervention type played a moderating role. Cognitive-behavioral programs consistently produced larger effects than other types of interventions, but if additional treatment components were added the effect was reduced. Within the sample of studies, relaxation interventions were most frequently used, and organizational interventions continued to be scarce. Effects were based mainly on psychological outcome variables, as opposed to physiological or organizational measures. The examination of additional moderators such as treatment length, outcome variable, and occupation did not reveal significant variations in effect size by intervention type.
Ninety reports of systematic evaluations of job-stress interventions were rated in terms of the degree of systems approach used. A high rating was defined as both organizationally and individually focused, versus moderate (organizational only), and low (individual only). Studies using high-rated approaches represent a growing proportion of the job-stress intervention evaluation literature. Individual-focused, low-rated approaches are effective at the individual level, favorably affecting individual-level outcomes, but tend not to have favorable impacts at the organizational level. Organizationally-focused high- and moderate-rated approaches are beneficial at both individual and organizational levels. Further measures are needed to foster the dissemination and implementation of systems approaches to examining interventions for job stress.
OBJECTIVE: Systematic review of the health and psychosocial effects of increasing employee participation and control through workplace reorganisation, with reference to the "demand-control-support" model of workplace health. DESIGN: Systematic review (QUORUM) of experimental and quasi-experimental studies (any language) reporting health and psychosocial effects of such interventions. DATA SOURCES: Electronic databases (medical, social science and economic), bibliographies and expert contacts. RESULTS: We identified 18 studies, 12 with control/comparison groups (no randomised controlled trials). Eight controlled and three uncontrolled studies found some evidence of health benefits (especially beneficial effects on mental health, including reduction in anxiety and depression) when employee control improved or (less consistently) demands decreased or support increased. Some effects may have been short term or influenced by concurrent interventions. Two studies of participatory interventions occurring alongside redundancies reported worsening employee health. CONCLUSIONS: This systematic review identified evidence suggesting that some organisational-level participation interventions may benefit employee health, as predicted by the demand-control-support model, but may not protect employees from generally poor working conditions. More investigation of the relative impacts of different interventions, implementation and the distribution of effects across the socioeconomic spectrum is required.
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.
