Preventing occupational stress in healthcare workers

Jani H Ruotsalainen; Jos H Verbeek; Albert Mariné; Consol Serra

doi:10.1002/14651858.CD002892.pub4

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Funnel plot of comparison: 1 Cognitive‐behavioural intervention vs no Intervention (SMD), outcome: 1.1 Any Stress‐related Outcome (follow‐up up to 1 month).

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Figure 4

Funnel plot of comparison: 1 Cognitive‐behavioural intervention vs no Intervention (SMD), outcome: 1.2 Any Stress‐related Outcome (follow‐up 1 ‐ 6 months).

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Figure 5

Funnel plot of comparison: 3 Relaxation vs. no intervention (SMD), outcome: 3.2 Any stress outcome (follow‐up 1 ‐ 6 months).

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Analysis 1.1

Comparison 1 Cognitive‐behavioural intervention vs no Intervention (SMD), Outcome 1 Any Stress‐related Outcome (follow‐up up to 1 month).

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Analysis 1.2

Comparison 1 Cognitive‐behavioural intervention vs no Intervention (SMD), Outcome 2 Any Stress‐related Outcome (follow‐up 1 ‐ 6 months).

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Analysis 1.3

Comparison 1 Cognitive‐behavioural intervention vs no Intervention (SMD), Outcome 3 Any Stress‐related Outcome (follow‐up more than 6 months).

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Analysis 1.4

Comparison 1 Cognitive‐behavioural intervention vs no Intervention (SMD), Outcome 4 State‐Trait Anxiety Inventory (follow‐up up to 1 month).

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Analysis 1.5

Comparison 1 Cognitive‐behavioural intervention vs no Intervention (SMD), Outcome 5 State‐Trait Anxiety Inventory (follow‐up 1 ‐ 6 months).

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Analysis 1.6

Comparison 1 Cognitive‐behavioural intervention vs no Intervention (SMD), Outcome 6 General Health Questionnaire (follow‐up up to 1 month).

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Analysis 2.1

Comparison 2 Cognitive‐behavioural intervention vs. non‐stress management intervention (SMD), Outcome 1 Any stress scale (follow‐up 1 ‐ 6 months).

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Analysis 2.2

Comparison 2 Cognitive‐behavioural intervention vs. non‐stress management intervention (SMD), Outcome 2 Any stress scale (follow‐up more than 6 months).

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Analysis 2.3

Comparison 2 Cognitive‐behavioural intervention vs. non‐stress management intervention (SMD), Outcome 3 Anxiety (follow‐up 1 ‐ 6 months).

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Analysis 3.1

Comparison 3 Relaxation vs. no intervention (SMD), Outcome 1 Any stress outcome (follow‐up up to 1 month).

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Analysis 3.2

Comparison 3 Relaxation vs. no intervention (SMD), Outcome 2 Any stress outcome (follow‐up 1 ‐ 6 months).

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Analysis 3.3

Comparison 3 Relaxation vs. no intervention (SMD), Outcome 3 Any stress outcome (follow‐up more than 6 months).

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Analysis 3.4

Comparison 3 Relaxation vs. no intervention (SMD), Outcome 4 State Anxiety (follow‐up 1 ‐ 6 months).

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Analysis 3.5

Comparison 3 Relaxation vs. no intervention (SMD), Outcome 5 Trait Anxiety (follow‐up 1 ‐ 6 months).

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Analysis 3.6

Comparison 3 Relaxation vs. no intervention (SMD), Outcome 6 General Health (follow‐up 1 ‐ 6 months).

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Analysis 4.1

Comparison 4 Relaxation vs. other intervention (SMD), Outcome 1 Any stress outcome.

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Analysis 4.2

Comparison 4 Relaxation vs. other intervention (SMD), Outcome 2 Any anxiety outcome.

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Analysis 4.3

Comparison 4 Relaxation vs. other intervention (SMD), Outcome 3 General Health Questionnaire.

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Analysis 5.1

Comparison 5 Organisational intervention vs. no intervention (SMD), Outcome 1 Any stress‐related outcome (follow‐up up to 1 month).

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Analysis 5.2

Comparison 5 Organisational intervention vs. no intervention (SMD), Outcome 2 Any stress‐related outcome RCTs (follow‐up 1 ‐ 6 months).

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Analysis 5.3

Comparison 5 Organisational intervention vs. no intervention (SMD), Outcome 3 Any stress‐related outcome (follow‐up more than 6 months).

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Analysis 5.4

Comparison 5 Organisational intervention vs. no intervention (SMD), Outcome 4 General Health Questionnaire total score (follow‐up more than 6 months).

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Analysis 6.1

Comparison 6 Organisational intervention vs. other intervention (SMD), Outcome 1 Any stress‐related outcome (follow‐up up to 1 month).

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Analysis 6.2

Comparison 6 Organisational intervention vs. other intervention (SMD), Outcome 2 Any stress‐related outcome (follow‐up 1 ‐ 6 months).

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Analysis 6.3

Comparison 6 Organisational intervention vs. other intervention (SMD), Outcome 3 Any stress‐related outcome (follow‐up more than 6 months).

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Analysis 6.4

Comparison 6 Organisational intervention vs. other intervention (SMD), Outcome 4 General Health Questionnaire (total score).

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Analysis 7.1

Comparison 7 Cognitive‐behavioural intervention vs. no intervention (MD), Outcome 1 Maslach Burnout Inventory (follow‐up up to 1 month).

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Analysis 7.2

Comparison 7 Cognitive‐behavioural intervention vs. no intervention (MD), Outcome 2 Maslach Burnout Inventory (follow‐up 1 to 6 months).

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Analysis 8.1

Comparison 8 Cognitive‐behavioural intervention and relaxation vs. no intervention (MD), Outcome 1 Maslach Burnout Inventory (follow‐up up to 1 month).

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Analysis 9.1

Comparison 9 Cognitive‐behavioural intervention vs. other intervention (MD), Outcome 1 Maslach Burnout Inventory (follow‐up more than 6 months).

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Analysis 10.1

Comparison 10 Relaxation vs. no intervention (MD), Outcome 1 Maslach Burnout Inventory (follow‐up 1 ‐ 6 months).

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Analysis 11.1

Comparison 11 Organisational intervention vs. no intervention (MD), Outcome 1 Maslach Burnout Inventory (follow‐up less than 1 month).

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Analysis 11.2

Comparison 11 Organisational intervention vs. no intervention (MD), Outcome 2 Maslach Burnout Inventory (follow‐up 1 ‐ 6 months).

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Analysis 11.3

Comparison 11 Organisational intervention vs. no intervention (MD), Outcome 3 Maslach Burnout Inventory or Oldenburg Burnout Inventory (follow‐up more than 6 months).

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Analysis 12.1

Comparison 12 Organisational intervention vs. other intervention (MD), Outcome 1 Maslach Burnout Inventory (follow‐up 1 ‐ 6 months).

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Analysis 13.1

Comparison 13 Cognitive‐behavioural intervention vs. no Intervention (SUBGROUPS) (SMD), Outcome 1 Any Stress‐related Outcome (follow‐up up to 1 month).

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Analysis 13.2

Comparison 13 Cognitive‐behavioural intervention vs. no Intervention (SUBGROUPS) (SMD), Outcome 2 Any Stress‐related Outcome (follow‐up 1 ‐ 6 months).

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Analysis 14.1

Comparison 14 Relaxation vs. no intervention (SUBGROUPS) (SMD), Outcome 1 Any stress outcome (follow‐up to 1 month).

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Analysis 14.2

Comparison 14 Relaxation vs. no intervention (SUBGROUPS) (SMD), Outcome 2 Any stress outcome (follow‐up 1 ‐ 6 months).

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Summary of findings for the main comparison. Cognitive‐behavioural intervention compared to no Intervention for reducing stress

Cognitive‐behavioural intervention compared to no Intervention for reducing stress
Patient or population: Healthcare workers Settings: Health Care Intervention: Cognitive‐behavioural intervention Comparison: No Intervention (SMD)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	No Intervention	Cognitive‐behavioural intervention
Stress 1 Month Various Measurement Instruments Follow‐up: 0 ‐ 1 month	The median stress level across all control groups across all follow‐up times was 24.33 points on the Emotional Exhaustion subscale of the Maslach Burnout Inventory¹	The mean stress level at 1 month in the intervention groups was 1.22 points lower (2.98 lower to 0.59 higher).	SMD ‐0.27 (‐0.66 to 0.13)	332 (6 studies)	⊕⊕⊝⊝ low²^,³	This meta‐analysis was back transformed to the EE subscale of the MBI by using the median SD of the EE scale across control groups.
Stress 1 ‐ 6 months Various Instruments. Scale from: 0 to 2. Follow‐up: 1 ‐ 6 months	The median stress level across all control groups across all follow‐up times was 24.33 points on the Emotional Exhaustion subscale of the Maslach Burnout Inventory¹	The mean stress at 1 ‐ 6 months in the intervention groups was 1.83 points lower (0.77 to 2.85 lower).	SMD ‐0.38 (‐0.59 to ‐0.16)	549 (8 studies)	⊕⊕⊝⊝ low²^,³	This meta‐analysis was back transformed to the EE subscale of the MBI by using the median SD of the EE scale across control groups.
Stress > 6 months Various Instruments Follow‐up: > 6 months	The median stress level across all control groups across all follow‐up times was 24.33 points on the Emotional Exhaustion subscale of the Maslach Burnout Inventory¹	The mean stress at more than 6 months in the intervention groups was 11.34 points lower (4.47 to 14.94 lower)	SMD ‐1.04 (‐1.37 to ‐0.70)	157 (2 studies)	⊕⊕⊝⊝ low²^,³	This meta‐analysis was back transformed to the EE subscale of the MBI by using the median SD of the EE scale across control groups.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ This was the median from the control groups of all studies that measured the effect of CBT vs. no intervention on Emotional Exhaustion with the same scale. ² Most studies were at a high risk of bias ³ Publication bias detected with funnel plot

Summary of findings for the main comparison. Cognitive‐behavioural intervention compared to no Intervention for reducing stress

Relaxation compared to no intervention (SMD) for
Patient or population: Healthcare workers Settings: Health care Intervention: Relaxation Comparison: No intervention (SMD)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	no intervention (SMD)	Relaxation
Stress 1 month	The median stress level across all control groups across all follow‐up times was 22.17 points on the Emotional Exhaustion subscale of the Maslach Burnout Inventory¹	The mean stress at 1 month in the intervention groups was 2.14 points lower (0.36 to 3.96 lower).	SMD ‐0.48 (‐0.89 to ‐0.08)	97 (4 studies)	⊕⊕⊝⊝ low	This meta‐analysis was back transformed to the EE subscale of the MBI by using the median SD of the EE scale across control groups.
Stress 1 ‐ 6 months	The median stress level across all control groups across all follow‐up times was 22.17 points on the Emotional Exhaustion subscale of the Maslach Burnout Inventory¹	The mean stress at 1 ‐ 6 months in the intervention groups was 4.84 points lower (2.37 to 6.92 lower).	SMD ‐0.49 (‐0.78 to ‐0.21)	521 (12 studies)	⊕⊕⊕⊝ moderate	This meta‐analysis was back transformed to the EE subscale of the MBI by using the median SD of the EE scale across control groups.
Stress > 6 months	The median stress level across all control groups across all follow‐up times was 22.17 points on the Emotional Exhaustion subscale of the Maslach Burnout Inventory¹	The mean stress at > 6 months in the intervention groups was 5.67 points lower (3.39 to 7.95 lower).	SMD ‐1.89 (‐2.65 to ‐1.13)	40 (1 study)	⊕⊕⊝⊝ low	This result was back transformed to the EE subscale of the MBI by using the median SD of the EE scale across control groups.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ This was the median from the control groups of all studies that measured the effect of relaxation vs. no intervention on Emotional Exhaustion with the same scale.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Any Stress‐related Outcome (follow‐up up to 1 month) Show forest plot	7	332	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.66, 0.13]

1.1 Cognitive‐behavioural intervention only vs. no intervention	4	248	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.60, 0.11]
1.2 Cognitive‐behavioural intervention and relaxation vs. no intervention	3	84	Std. Mean Difference (IV, Random, 95% CI)	‐0.45 [‐1.61, 0.70]
2 Any Stress‐related Outcome (follow‐up 1 ‐ 6 months) Show forest plot	8	549	Std. Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.59, ‐0.16]

2.1 Cognitive‐behavioural intervention only vs. no intervention	6	439	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.47, ‐0.09]
2.2 Cognitive‐behavioural intervention and relaxation vs. no intervention	2	110	Std. Mean Difference (IV, Random, 95% CI)	‐0.78 [‐1.38, ‐0.18]
3 Any Stress‐related Outcome (follow‐up more than 6 months) Show forest plot	2	157	Std. Mean Difference (IV, Fixed, 95% CI)	‐1.04 [‐1.37, ‐0.70]

3.1 Cognitive‐behavioural intervention with or without relaxation vs. no intervention	2	157	Std. Mean Difference (IV, Fixed, 95% CI)	‐1.04 [‐1.37, ‐0.70]
4 State‐Trait Anxiety Inventory (follow‐up up to 1 month) Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

4.1 CBT and relaxation vs. no intervention State Anxiety	3	135	Mean Difference (IV, Random, 95% CI)	‐11.07 [‐18.39, ‐3.75]
4.2 CBT and relaxation vs. no intervention Trait Anxiety	3	135	Mean Difference (IV, Random, 95% CI)	‐8.36 [‐10.02, ‐6.70]
5 State‐Trait Anxiety Inventory (follow‐up 1 ‐ 6 months) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 CBT and relaxation vs. no intervention State Anxiety	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 CBT and relaxation vs. no intervention Trait Anxiety	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 General Health Questionnaire (follow‐up up to 1 month) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 CBT and relaxation vs. no intervention	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

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