Individual‐level interventions for reducing occupational stress in healthcare workers
Information
- DOI:
- https://doi.org/10.1002/14651858.CD002892.pub6Copy DOI
- Database:
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- Cochrane Database of Systematic Reviews
- Version published:
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- 12 May 2023see what's new
- Type:
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- Intervention
- Stage:
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- Review
- Cochrane Editorial Group:
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Cochrane Work Group
- Copyright:
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- Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.
- This is an open access article under the terms of the Creative Commons Attribution Licence , which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
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Authors
Contributions of authors
This update, 2023:
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ST, LE, AL, AT, KN and HM screened the systematic search results for potential new studies to include.
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ST, LE and AL extracted data from included studies.
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ST and JB rebuilt the comparisons and ran the analyses.
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The following review authors wrote parts of the first draft of the updated review text: ST (methods, results), LE (introduction), JB (abstract, plain language summary, summary of findings), RS (discussion ‐ overall completeness and applicability of evidence), KN (discussion ‐ agreements and disagreements with other studies or reviews) and HM (discussion ‐ quality of evidence and potential biases in the review process). All review authors commented on the draft.
2015 version of the review:
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JR, AM, JV and CS screened the systematic search results for potential new studies to include.
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JR, AM, CS and JV extracted data from new included studies and also assessed the risk of bias of the previously included studies.
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JR and JV rebuilt the comparisons and ran the analyses.
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JV and JR wrote the first draft of the updated review text.
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All authors commented on the draft.
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JR is the guarantor of the review.
Sources of support
Internal sources
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Amsterdam UMC location University of Amsterdam, Public and Occupational Health, Meibergdreef 9, Amsterdam, The Netherlands, Netherlands
Personnel
External sources
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National Institute for Health Research (NIHR), UK
An incentive grant to support the production of this review was distributed between the authors and the Cochrane review group.
Declarations of interest
ST: has declared no conflict of interest.
LE: has declared no conflict of interest.
JB: employed as Managing Editor for Cochrane Work up to July 2022. JB was not involved in the editorial process from that moment on.
AL: has declared no conflict of interest.
AT: has declared no conflict of interest.
JR: has declared no conflict of interest.
RS: has declared no conflict of interest.
KN: reports to be involved in a study eligible for inclusion (Gärtner 2013). KN was not involved in assessing this study for eligibility, it's data extraction or bias assessment.
HM: has declared no conflict of interest.
Cochrane Work managed the editorial process for this review. The author team had no influence on how the editorial team managed this review.
Acknowledgements
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This study/project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis Programme (NIHR150837) Incentive Award Scheme 2021. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
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We are grateful for the funding provided for this project by the National Institute for Health Research (NIHR), UK. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care, UK.
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We thank Jos Verbeek, Albert Mariné, and Mariné A, Serra C for their work on the previous version of this review. We thank Vittoria Lutje for updating the searches and running the updated searches.
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We thank J Cohen‐Katz, S Ketelaar/K Nieuwenhuijsen, K Moody, D Oman, P Dunne, J Kline, M Barattucci, T Pehlivan, M Sampson 2019, E Smoktunowicz, C West, A Sawyer, A Errazuriz, Jensen, B Yüceer for providing further information or data from their study.
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We thank our colleagues from Amsterdam UMC location Vrije Universiteit Amsterdam and University of Amsterdam, Public and Occupational health, Michiel Greidanus, Sanne Gommers, Donna Beerda, Donny Kreuger, Elmi Zwaan, Fenna van Ommen, Marije Hagendijk, and Judith Mollet for their help with extracting the outcomes as second data extractor.
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We thank the following students of the faculty of Medicine of the University of Amsterdam for their help with extracting the outcomes as second data extractor: Anniek Nauta, Boris Brojović, Bram Millenaar, Charlie Sent, Chiel Klein, Danny Kroon, Frederique Wekker, Guus Kerkvliet, Ida Blokland, Jens Nijzink, Jesse Warmerdam, Loran Mul, Lotte Bos Mertcan Göç, Mirte Dekkers, Nina Bijl, Nisrine Aynaou, Sabine de Beer, Sam Rozemuller.
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We thank the peer reviewers for their comments: Giuseppe La Torre, Department of Public Health and Infectious Diseases ‐ Sapienza University of Rome; Amit Abraham, Weill Cornell Medicine‐Qatar; and Afroditi Kanellopoulou, Statistician, Cochrane Central.
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We thank the Cochrane Work Review Group for supporting the authors in the development of this review.
The following people conducted the editorial process for this article:
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Sign‐off Editor (final editorial decision): Jan Hoving, Cochrane Work, Amsterdam UMC
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Contact Editor: Jos Verbeek, Cochrane Work, Amsterdam UMC
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Managing Editor (selected peer reviewers, collated peer‐reviewer comments, provided editorial guidance to authors, edited the article): Jessica Thomas, Cochrane Work, Amsterdam UMC
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Information Specialist (searching support): Faridi van Etten, Amsterdam UMC
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Methods and Statistician review: Afriditi Kanellopoulou, Statistician at Cochrane Central
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Copy‐editing (initial copy‐edit and final proofread): Heather Maxwell, Copy‐edit Group at Cochrane Central
Version history
| Published | Title | Stage | Authors | Version |
| 2023 May 12 | Individual‐level interventions for reducing occupational stress in healthcare workers | Review | Sietske J Tamminga, Lima M Emal, Julitta S Boschman, Alice Levasseur, Anilkrishna Thota, Jani H Ruotsalainen, Roosmarijn MC Schelvis, Karen Nieuwenhuijsen, Henk F Molen | |
| 2015 Apr 07 | Preventing occupational stress in healthcare workers | Review | Jani H Ruotsalainen, Jos H Verbeek, Albert Mariné, Consol Serra | |
| 2014 Dec 08 | Preventing occupational stress in healthcare workers | Review | Jani H Ruotsalainen, Jos H Verbeek, Albert Mariné, Consol Serra | |
| 2014 Nov 13 | Preventing occupational stress in healthcare workers | Review | Jani H Ruotsalainen, Jos H Verbeek, Albert Mariné, Consol Serra | |
| 2006 Oct 18 | Preventing occupational stress in healthcare workers | Review | Albert Marine, Jani H Ruotsalainen, Consol Serra, Jos H Verbeek | |
| 2000 Apr 24 | Effectiveness of occupational stress management programmes | Protocol | M arine A, Consol CS Serra, Albert Marine | |
Differences between protocol and review
In the previous version of this review titled "Preventing occupational stress in healthcare workers" (Ruotsalainen 2015) interventions were categorised into cognitive‐behavioural, mental and physical relaxation and organisational‐level interventions. We excluded interventions solely targeting organisational‐level stressors, such as work‐demands, variation at work, because they are covered by the Giga 2018 review. We think the new categorisation into focusing on the experience of stress, focusing away from the experience of stress, focusing on individual work‐related risk factors and any combination of these is more informative.
In the previous version of this review (Ruotsalainen 2015) stressors were pooled with stress symptoms. For example, a stressor such as the reward imbalance questionnaire or the Nursing Stress Scale was pooled with stress symptom questionnaires such as the Perceived Stress Scale (PSS)or the Maslach Burnout Inventory (MBI). We are of the opinion, that stressors and stress symptoms cannot be pooled in one meta‐analysis because these are two different constructs (van der Molen 2020). Stressor questionnaires measure organisational‐level risk factors such as, job demands, jobs control, workplace social support, whereas stress symptoms questionnaires such as the PSS focus on the individual's experience of stress (e.g. have you been angered because of things that were outside your control?) (Cohen 1983). Since we have excluded organisational‐level interventions, stressor questionnaires were also excluded.
In the previous version of this review (Ruotsalainen 2015) the review authors reported secondary outcomes of physiological parameters such as hair cortisol. We excluded these secondary outcomes as we think that these parameters cannot be interpreted, because there is no consensus on the validation of stress‐related physiological parameters (Schaafsma 2021).
In the previous version of this review (Ruotsalainen 2015) subgroup analyses were performed for type of healthcare worker. Since interventions targeting organisational‐level interventions were excluded because they are covered by the Giga 2018 review, we did not perform subgroup analysis by type of healthcare worker. We think that the individual‐level interventions work the same way for various healthcare workers (e.g. physicians, nurses), which makes this type of subgroup analysis redundant. We discussed the proposed subgroup analyses based on the duration and intensity of the intervention as stated in the original protocol (Marine 2000). However, no definitions were formulated a priori, and we discussed what a proper grouping would be. We concluded that dividing the studies in shorter or longer and intense or less intense interventions would be an arbitrary ‐ and possibly data driven ‐ approach. Moreover, such a grouping would ideally be based on a mixture of the duration and intensity of the intervention (e.g. number of sessions, the length of the sessions, homework assignments) and the compliance with the intervention. However, we explored whether the arbitrary cut‐off for duration of the intervention of 12 weeks shows an effect in effect size.
De Wijn (de Wijn 2022) found that stress management interventions for nurses in which the sample was exposed to the majority of the planned sessions reached greater effect sizes compared to interventions in which the compliance to the intervention/attendance to the planned sessions was lower. Although this finding should be interpreted with caution due to a lot of missing data, we explored if the effect sizes based on studies in which participants attended 80% or more of the scheduled sessions would differ from the studies were participants attended less than 80% of the scheduled sessions de Wijn 2022.
In the previous version of this review (Ruotsalainen 2015), the objective was formulated as: 'to evaluate the effectiveness of work‐ and person‐directed interventions compared to no intervention or alternative interventions in preventing stress at work in healthcare workers.' Since, healthcare workers have higher levels of stress compared to the general population we think that 'reduce stress' better describes what we want to study than 'preventing stress at work'. In our opinion, this is not really a difference between protocol and review, rather a semantic difference.
In the previous version of this review (Ruotsalainen 2015), the most intensive intervention was included in the analyses in the case of multiple arms. As recommended by the Cochrane Handbook, we have now combined groups to create a single pair‐wise comparison.
In the previous version of this review (Ruotsalainen 2015), the time frames of the measurement of outcomes were: (i) up to one month (ii) from one month to six months (iii) over six months. We have changed these time frames into short‐term defined as up to and including three months after the intervention has been completed, medium term defined as more than three months up to 12 months, and long term defined as 12 months or longer. The rationale here was to focus more on the long‐term effects.
In the previous version of this review (Ruotsalainen 2015), one missing standard deviation (SD) was imputed. We have now excluded studies from the meta‐analyses if missing SDs could not be provided by study authors or when they could not be calculated from the available data.
Notes
2023 update: this review update was split from the original title (Ruotsalainen 2015) and now only included individual‐level interventions and added a further 89 studies including 11,119 participants. We implemented several improvements and described these in the section "Differences between protocol and review". For example, we excluded stressors as an outcome.
Keywords
MeSH
Medical Subject Headings (MeSH) Keywords
Medical Subject Headings Check Words
Humans;
PICOs
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Funnel plot (1.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)
Funnel plot (1.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention))
Funnel plot (2.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention))
Funnel plot (4.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention))
Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)
Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 3: Any symptoms of stress‐related outcome (follow‐up >12 months)
Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 4: Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)
Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 5: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 1: ‘Focus one’s attention on the experience of stress (thoughts, feelings, behaviour)’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 6: Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)
Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)
Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 3: Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)
Comparison 2: ‘Focus one’s attention away from the experience of stress by means of relaxation, exercise or something else’ vs No intervention/wait list/placebo/no stress‐reduction intervention (SMD), Outcome 4: Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)
Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)
Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 3: Any symptoms of stress‐related outcome (follow‐up >12 months)
Comparison 3: ‘Focus on work‐related risk factors on an individual level such as work demands’ vs No intervention/no stress‐reduction intervention (SMD), Outcome 4: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)
Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 3: Any symptoms of stress‐related outcome (follow‐up > 12 months)
Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 4: Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)
Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 5: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 4: ‘Combination of interventions’ vs No intervention/wait list/no stress‐reduction intervention (SMD), Outcome 6: Psychological symptoms: anxiety and depression (follow‐up > 12 months after the end of the intervention)
Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months)
Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 3: Psychological symptoms: anxiety and depression (follow‐up up to 3 months)
Comparison 5: Focus one’s attention on the experience of stress vs focus one’s attention away from the experience of stress, Outcome 4: Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)
Comparison 6: ‘Combination of interventions’ vs focus one's attention on the experience of stress (SMD), Outcome 1: Any symptoms of stress‐related outcome (follow‐up up to 3 months)
Comparison 6: ‘Combination of interventions’ vs focus one's attention on the experience of stress (SMD), Outcome 2: Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)
| An intervention in which one's attention is on the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers | ||||
| Patient or population: healthcare workers | ||||
| Outcomes | Anticipated absolute effects* (95% CI) | № of participants | Certainty of the evidence | What happens |
|---|---|---|---|---|
| Effect with an intervention in which one's attention is on the experience of stress | ||||
| Stress symptoms (follow‐up up to and including 3 months after end of intervention) | SMD 0.37 lower | 3645 | ⊕⊕⊝⊝ | On the short term, an intervention in which one's attention is on the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 4.6 fewer (6.4 fewer to 2.8 fewer) points on the MBI‐emotional exhaustion scale2. |
| Stress symptoms (follow‐up > 3 to 12 months after end of intervention) | SMD 0.43 lower | 1851 | ⊕⊕⊝⊝ | On the medium term, focus one's attention on the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 5.3 fewer (8.7 fewer to 1.7 fewer) points on the MBI‐emotional exhaustion scale3. |
| Stress symptoms (follow‐up >12 months after end of intervention) | no effect estimate | 68 | ⊕⊝⊝⊝ | The evidence is very uncertain about the long‐term effect on stress symptoms of focusing one's attention on the experience of stress. |
| *The risk in the intervention group (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). | ||||
| GRADE Working Group grades of evidence | ||||
| 1 The certainty of the evidence was downgraded by two levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) in combination with some inconsistency and suspicion of publication bias. 2 The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) and very serious imprecision (small sample size, the confidence interval includes both a benefit and a harm). 3 The MBI‐Emotional exhaustion scale has a total score of 54 and we used the mean score (23.6) and standard deviation (12.2) of the control healthcare workers population in Fiol DeRoque 2021 as reference for interpreting the effect sizes. A score below 18 points is regarded as a low score on emotional exhaustion and a score above 36 as a high score on emotional exhaustion (Maslach 1996). | ||||
| An intervention in which one's attention is away from the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers | ||||
| Patient or population: healthcare workers | ||||
| Outcomes | Anticipated absolute effects* (95% CI) | № of participants | Certainty of the evidence | What happens |
|---|---|---|---|---|
| Risk with an intervention in which one's attention is away from the experience of stress | ||||
| Stress symptoms (follow‐up up to and including 3 months after end of intervention) | SMD 0.55 lower | 2366 | ⊕⊕⊝⊝ | On the short term, an intervention in which one's attention is away from the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 6.8 fewer (8.6 fewer to 4.9 fewer) points on the MBI‐emotional exhaustion scale2. |
| Stress symptoms (follow‐up > 3 to 12 months after end of intervention) | SMD 0.41 lower | 427 | ⊕⊕⊝⊝ | On the medium term, an intervention in which one's attention is away from the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 5.0 fewer (9.7 fewer to 0.4 fewer) points on the MBI‐emotional exhaustion scale2. |
| Stress symptoms (follow‐up >12 months after end of intervention) | ‐ | (0 RCTs) | ‐ | No studies reported the long‐term effect on stress symptoms of focusing one's attention away from the experience of stress. |
| *The risk in the intervention group (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). | ||||
| GRADE Working Group grades of evidence | ||||
| 1 The certainty of the evidence was downgraded by two levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) in combination with some inconsistency and suspicion of publication bias. 3 The MBI‐emotional exhaustion scale has a total score of 54 and we used the mean score (23.6) and standard deviation (12.2) of the control healthcare workers population in Fiol DeRoque 2021 as reference for interpreting the effect sizes. A score below 18 points is regarded as a low score on emotional exhaustion and a score above 36 as a high score on emotional exhaustion (Maslach 1996). | ||||
| An intervention in which the focus is on work‐related risk factors on an individual level compared to no intervention/no stress‐reduction intervention for stress reduction in healthcare workers | ||||
| Patient or population: healthcare workers | ||||
| Outcomes | Anticipated absolute effects* (95% CI) | № of participants | Certainty of the evidence | What happens |
|---|---|---|---|---|
| Effect with an intervention in which the focus is on work‐related risk factors on an individual level | ||||
| Stress symptoms (follow‐up up to and including 3 months after end of intervention) | no effect estimate | 87 | ⊕⊝⊝⊝ | The evidence is very uncertain about the short‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms. |
| Stress symptoms (follow‐up > 3 to 12 months after end of intervention) | no effect estimate | 152 | ⊕⊝⊝⊝ | The evidence is very uncertain about the medium‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms. |
| Stress symptoms (follow‐up >12 months after end of intervention) | no effect estimate | 161 | ⊕⊝⊝⊝ | The evidence is very uncertain about the long‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms. |
| *The risk in the intervention group (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). | ||||
| GRADE Working Group grades of evidence | ||||
| 1 The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias), inconsistency and very serious imprecision (small sample size, the confidence interval includes both a benefit and a harm). 2 The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) and very serious imprecision (small sample size, the confidence interval includes both a benefit and no effect). | ||||
| A combination of individual‐level interventions compared to no intervention/wait list/no stress‐reduction intervention for stress reduction in healthcare workers | ||||
| Patient or population: healthcare workers | ||||
| Outcomes | Anticipated absolute effects* (95% CI) | № of participants | Certainty of the evidence | What happens |
|---|---|---|---|---|
| Effect with a combination of individual‐level interventions | ||||
| Stress symptoms (follow‐up up to and including 3 months after end of intervention) | SMD 0.67 lower | 1003 | ⊕⊕⊝⊝ | On the short term, a combination of individual‐level interventions may result in a reduction in stress symptoms. The standardized mean difference translates back to 8.2 fewer (11.7 fewer to 4.8 fewer) points on the MBI‐Emotional exhaustion scale4. |
| Stress symptoms (follow‐up > 3 to 12 months after end of intervention) | SMD 0.48 lower | 574 | ⊕⊕⊝⊝ | 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. The standardized mean difference translates back to 5.9 fewer points (11.7 fewer to no difference) on the MBI‐Emotional exhaustion scale4. |
| Stress symptoms (follow‐up >12 months after end of intervention) | no effect estimate | 88 | ⊕⊝⊝⊝ | The evidence is very uncertain about the long‐term effect of a combination of individual‐level interventions on stress symptoms. |
| CI: confidence interval; SMD: standardized mean difference | ||||
| GRADE Working Group grades of evidence | ||||
| 1 The certainty of the evidence was downgraded by two levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) in combination with some inconsistency and suspicion of publication bias. 2 The certainty of the evidence was downgraded by two levels for very serious risk of bias (lack of blinding; i.e. performance bias) and inconsistency. We did not downgrade for imprecision, as the wide confidence interval is due to the inconsistency between study results. 3 The certainty of the evidence was downgraded by three levels for very serious risk of bias (bias arising from the randomisation process and lack of blinding; i.e. performance bias) and very serious imprecision (small sample size, the confidence interval includes both a benefit and a harm). 4 The MBI‐emotional exhaustion scale has a total score of 54 and we used the mean score (23.6) and standard deviation (12.2) of the control HCW population in Fiol DeRoque 2021 as reference for interpreting the effect sizes. A score below 18 points is regarded as a low score on emotional exhaustion and a score above 36 as a high score on emotional exhaustion (Maslach 1996). | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot | 41 | 3645 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.37 [‐0.52, ‐0.23] |
| 1.1.1 No intervention | 29 | 2434 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.35 [‐0.53, ‐0.16] |
| 1.1.2 Wait list | 9 | 619 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.52 [‐0.80, ‐0.25] |
| 1.1.3 Placebo | 1 | 436 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.21, 0.16] |
| 1.1.4 No stress‐reduction intervention | 2 | 156 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.33 [‐1.19, 0.53] |
| 1.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 19 | 1851 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.43 [‐0.71, ‐0.14] |
| 1.2.1 No intervention | 11 | 1271 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.46 [‐0.90, ‐0.02] |
| 1.2.2 Wait list | 6 | 480 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.53 [‐0.83, ‐0.24] |
| 1.2.3 No stress reduction intervention | 2 | 100 | Std. Mean Difference (IV, Random, 95% CI) | 0.16 [‐0.23, 0.56] |
| 1.3 Any symptoms of stress‐related outcome (follow‐up >12 months) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 1.4 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention) Show forest plot | 8 | 742 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.27 [‐0.58, 0.03] |
| 1.4.1 No intervention | 7 | 482 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐0.68, 0.11] |
| 1.4.2 Wait list | 1 | 260 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐0.53, ‐0.04] |
| 1.5 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 3 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 1.5.1 No intervention | 3 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 1.6 Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot | 41 | 3645 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.37 [‐0.52, ‐0.23] |
| 1.6.1 Short (< 12weeks) | 29 | 2647 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.32 [‐0.49, ‐0.15] |
| 1.6.2 Long (≥ 12 weeks) | 12 | 998 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.50 [‐0.78, ‐0.22] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot | 35 | 2366 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.55 [‐0.70, ‐0.40] |
| 2.1.1 No intervention | 22 | 1565 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.48 [‐0.61, ‐0.35] |
| 2.1.2 Wait list | 8 | 429 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.88 [‐1.53, ‐0.24] |
| 2.1.3 Placebo | 3 | 168 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.43 [‐0.74, ‐0.12] |
| 2.1.4 No stress‐reduction intervention | 2 | 204 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.27 [‐0.55, 0.00] |
| 2.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 6 | 427 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.41 [‐0.79, ‐0.03] |
| 2.2.1 No intervention | 4 | 312 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.43 [‐0.98, 0.12] |
| 2.2.2 Wait list | 2 | 115 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.40 [‐0.77, ‐0.03] |
| 2.3 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention) Show forest plot | 7 | 378 | Std. Mean Difference (IV, Random, 95% CI) | ‐1.07 [‐1.95, ‐0.19] |
| 2.3.1 No intervention | 2 | 127 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.67 [‐1.60, 0.25] |
| 2.3.2 Wait list | 3 | 173 | Std. Mean Difference (IV, Random, 95% CI) | ‐1.89 [‐4.24, 0.46] |
| 2.3.3 Placebo | 2 | 78 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.34 [‐0.79, 0.11] |
| 2.4 Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot | 35 | 2366 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.55 [‐0.70, ‐0.40] |
| 2.4.1 Short (<12 weeks) | 33 | 2255 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.52 [‐0.68, ‐0.37] |
| 2.4.2 Long (≥ 12 weeks) | 2 | 111 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.96 [‐1.48, ‐0.43] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 3.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot | 3 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 3.1.1 No intervention | 2 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 3.1.2 No stress‐reduction intervention | 1 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 3.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 2 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 3.3 Any symptoms of stress‐related outcome (follow‐up >12 months) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 3.4 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 4.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention) Show forest plot | 15 | 1003 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.67 [‐0.95, ‐0.39] |
| 4.1.1 No intervention | 10 | 666 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.71 [‐1.08, ‐0.34] |
| 4.1.2 Wait list | 4 | 270 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.79 [‐1.21, ‐0.38] |
| 4.1.3 No stress‐reduction intervention | 1 | 67 | Std. Mean Difference (IV, Random, 95% CI) | 0.13 [‐0.35, 0.61] |
| 4.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 6 | 574 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.48 [‐0.95, ‐0.00] |
| 4.2.1 No intervention | 3 | 330 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.70 [‐1.52, 0.12] |
| 4.2.2 Wait list | 2 | 177 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.65, ‐0.06] |
| 4.2.3 No stress‐reduction intervention | 1 | 67 | Std. Mean Difference (IV, Random, 95% CI) | 0.00 [‐0.48, 0.48] |
| 4.3 Any symptoms of stress‐related outcome (follow‐up > 12 months) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 4.4 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention) Show forest plot | 4 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 4.4.1 No intervention | 3 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 4.4.2 Wait list | 1 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 4.5 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 4.6 Psychological symptoms: anxiety and depression (follow‐up > 12 months after the end of the intervention) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 5.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months) Show forest plot | 3 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 5.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 2 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 5.3 Psychological symptoms: anxiety and depression (follow‐up up to 3 months) Show forest plot | 1 | Std. Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 5.4 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 1 | 38 | Std. Mean Difference (IV, Random, 95% CI) | 0.24 [‐0.39, 0.88] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 6.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
| 6.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention) Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Totals not selected | |
