Preventing occupational stress in healthcare workers

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

doi:10.1002/14651858.CD002892.pub2

Preventing occupational stress in healthcare workers

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Referencias

References to studies included in this review

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estudios a la espera de valoración
otras referencias

Bittman B, Bruhn KT, Stevens C, Westengard J, Umbach PO. Recreational music‐making: a cost‐effective group interdisciplinary strategy for reducing burnout and improving mood states in long‐term care workers. Advances in Mind‐Body Medicine 2003;19(3‐4):4‐15.

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References to studies excluded from this review

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estudios a la espera de valoración
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Weir R, Stewart L, Browne G, Roberts J, Gafni A, Easton S, Seymour L. The efficacy and effectiveness of process consultation in improving staff morale and absenteeism. Medical Care 1997;35(4):334‐53.

Young LE, Bruce A, Turner L, Linden W. Evaluation of mindfulness‐based stress reduction intervention. The Canadian Nurse 2001;97(6):23‐6.

Zimber A, Rudolf A, Teufel S. A training program to reduce distress among geriatric caregivers [Arbeitsbelastungen in der Altenpflege reduzieren: Ein Trainingsprogramm für Mitarbeiter und Leitugskräfte]. Zeitschrift fur Gerontologie und Geriatrie 2001;34(5):401‐7.

References to studies awaiting assessment

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otras referencias

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Additional references

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estudios a la espera de valoración

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Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Bittman 2003

Methods	Cross‐over study
Participants	112 randomly selected staff of a retirement community in the USA
Interventions	1) Recreational music making 2) No intervention ‐control
Outcomes	Maslach Burnout Inventory, Profile of Mood States
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Cohen‐Katz 2005

Methods	RCT
Participants	25 nurses, pastoral care, respiratory therapy and social work personnel in the USA
Interventions	1) Mindfulness‐based stress reduction programme 2) No intervention ‐control
Outcomes	Maslach Burnout Inventory, Brief Symptom Inventory
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Delvaux 2004

Methods	RCT
Participants	115 oncology nurses in Belgium
Interventions	1) Psychological Training Program 2) No intervention ‐control
Outcomes	Nursing Stress Scale
Notes	Organisational
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Ewers 2002

Methods	RCT
Participants	20 forensic mental health nurses in the UK
Interventions	1) Psychosocial Intervention Training 2) No intervention ‐control
Outcomes	Maslach Burnout Inventory
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Heaney 1995

Methods	RCT
Participants	1375 direct care staff and home managers in the USA
Interventions	1) Caregiver support program 2) No intervention ‐control
Outcomes	Social support, Organisational climate, SCL‐90‐R, Confidence in coping ability
Notes	Organisational
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Jones 2000

Methods	RCT
Participants	79 student nurses reporting significant levels of affective distress at screen in the UK
Interventions	1) multi‐modal stress management 2) No intervention ‐control
Outcomes	Derogatis Stress profile, B&S Stress Inventory, GHQ, STAI, BDI, ways of coping, absenteeism
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Low risk	A ‐ Adequate

Lee 1994

Methods	RCT
Participants	60 hospital nurses suffering from either: insomnia, headache or gastrointestinal discomfort in Taiwan
Interventions	1) assertiveness training 2) traditional inservice program about computer applications in nursing
Outcomes	Perceived Stress Scale, Rathus Assertiveness Schedule
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Lökk 1997

Methods	Cluster‐randomised trial
Participants	26 health care personnel in a geriatric hospital in Sweden
Interventions	1) support and advice from a psychologist 2) passive attendance by psychologist
Outcomes	Blood pressure and pulse rate, prolactin, cortisol, DHEA, estradiol
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Lökk 2000

Methods	Cluster‐randomised trial
Participants	26 health care personnel in a geriatric hospital in Sweden
Interventions	1) support and advice from a psychologist 2) passive attendance by psychologist
Outcomes	A structured made‐to‐measure stress questionnaire
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

McElligott 2003

Methods	RCT
Participants	20 nurses working at a tertiary care center in the USA
Interventions	1) AMMA therapy 2) a standardised touch therapy protocol
Outcomes	VAS of anxiety, blood pressure, heart rate, pulse oximetry, skin temperature
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Melchior 1996

Methods	RCT
Participants	161 psychiatric nurses in long‐stay settings in the Netherlands
Interventions	1) support and advice given by nurse managers or quality care coordinators 2) No intervention ‐control
Outcomes	Maslach Burnout Inventory
Notes	Organisational
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Norvell 1987

Methods	RCT
Participants	12 respiratory therapists in the USA
Interventions	1) stress management program 2) No intervention ‐control
Outcomes	MBI, C‐H Inventory of Phys Symptoms, The Hassles Scale, The Uplifts Scale
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Proctor 1998

Methods	Cluster‐randomised trial
Participants	98 care staff in residential nursing homes in the UK
Interventions	1) developing knowledge and skills and individual programme planning 2) No intervention ‐control
Outcomes	The Occupational Stress Indicator, GHQ
Notes	Organisational
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Razavi 1993

Methods	RCT
Participants	72 oncology nurses in Belgium and France
Interventions	1) a 24‐h Psychological Training Program 2) No intervention ‐control
Outcomes	The Nursing Stress Scale
Notes	Organisational
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Rowe 1999

Methods	RCT
Participants	126 health‐care professionals from the USA
Interventions	1) Stress management/ adaptive coping training, with refresher sessions 2) No intervention ‐control
Outcomes	Maslach Burnout Inventory
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Schrijnemaekers 2003

Methods	Cluster‐randomised trial
Participants	300 professional caregivers in homes for elderly persons in the Netherlands
Interventions	1) Emotion‐oriented care training, clinical lessons and supervision meetings 2) No intervention ‐control
Outcomes	Maslach Burnout Inventory, Job satisfaction
Notes	Organisational
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Tsai 1993

Methods	RCT
Participants	137 nurses in Taiwan
Interventions	1) Training about stress at work, relaxation, breathing, imagery and meditation 2) traditional in‐service education about theory analysis
Outcomes	Nurse Stress Checklist, Chinese General Health Questionnaire
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

von Baeyer 1983

Methods	Cross‐over study
Participants	14 nurses in a burn treatment unit in Canada
Interventions	1) Cognitive‐behavioural stress management training 2) No intervention ‐control
Outcomes	STAI
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

West 1984

Methods	RCT
Participants	60 acute care hospital nurses in the USA
Interventions	1) Stress Inoculation (SI) training 2) No intervention ‐control
Outcomes	MBI, Job‐related tension, Life satisfaction STAI, RAS, Systolic and diastolic blood pressure
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Yung 2004

Methods	RCT
Participants	65 nurse managers in China
Interventions	1) Cognitive relaxation 2) Stretch‐release relaxation 3) No intervention ‐control
Outcomes	C‐STAI, C‐GHQ
Notes	Person‐directed
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment?	Unclear risk	D ‐ Not used

Characteristics of excluded studies [ordered by study ID]

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estudios incluidos

Study	Reason for exclusion
Beddoe 2004	The study does not employ a control group.
Berg 1994	The study is non‐randomised by design.
Bradley 2002	The study does not employ an intervention. It is an aetiological study.
Bruneau 2004	The study is non‐randomised by design.
Bunce 1996	The study is non‐randomised by design.
Calomeni 1999	The study does not have a stress outcome.
Drain 1991	The participants of the study are not health care personnel or nursing students with clinical duties.
Fernandez 1995	The study does not employ an intervention.
Freedy 1994	The study is non‐randomised by design.
Godbey 1994	The participants are nursing students but do not have clinical duties.
Heaman 1995	The participants are nursing students but do not have clinical duties.
Hughes 2003	The participants are nursing students but do not have clinical duties.
Johansson 1991	The participants are nursing students but do not have clinical duties.
Jones 1998	The study is non‐randomised by design.
Keyes 1988	The study is non‐randomised by design.
Kushnir 1998	The study is non‐randomised by design.
Lloyd 2002	The participants of the study are not health care personnel or nursing students with clinical duties.
Mancini 1983	The participants are nursing students but do not have clinical duties.
McCue 1991	The study is non‐randomised by design.
McPhail 1990	The study does not have a stress outcome.
Murphy 1983	The study is non‐randomised by design.
Nissen 1997	The study does not have a stress outcome.
Pålsson 1996	The study is non‐randomised by design.
Schinke 1977	The study does not intend to prevent or treat stress or burnout.
Sharif 2004	The participants are nursing students but do not have clinical duties.
Taylor 2001	The study does not have a stress outcome.
Teasdale 2001	The study does not employ an intervention.
Toivanen 1993	The participants of the study are not health care personnel or nursing students with clinical duties.
van Dierendonck 1998	The study is non‐randomised by design.
Weir 1997	The study does not have a stress outcome.
Young 2001	The study is non‐randomised by design.
Zimber 2001	The study is non‐randomised by design.

Data and analyses

Open in table viewer

Comparison 1. Person‐directed intervention vs no intervention (Short Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Beck & Srivastava Stress Scale and Perceived Stress Scale Show forest plot	2	130	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.85 [‐1.21, ‐0.49]
Open in figure viewer Analysis 1.1 Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 1 Beck & Srivastava Stress Scale and Perceived Stress Scale.
2 Maslach Burnout Inventory Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.2 Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 2 Maslach Burnout Inventory.
2.1 Emotional Exhaustion	3	129	Mean Difference (IV, Random, 95% CI)	‐5.82 [‐11.02, ‐0.63]
2.2 Depersonalization	3	129	Mean Difference (IV, Random, 95% CI)	‐2.44 [‐5.06, 0.17]
2.3 Personal Accomplishment (lack of)	3	129	Mean Difference (IV, Random, 95% CI)	‐4.89 [‐8.71, ‐1.07]
3 State Trait Anxiety Inventory Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.3 Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 3 State Trait Anxiety Inventory.
3.1 State anxiety	3	135	Mean Difference (IV, Random, 95% CI)	‐9.42 [‐16.92, ‐1.93]
3.2 Trait anxiety	3	135	Mean Difference (IV, Random, 95% CI)	‐6.91 [‐12.80, ‐1.01]
4 General Health Questionnaire Show forest plot	2	127	Mean Difference (IV, Random, 95% CI)	‐11.87 [‐27.24, 3.49]
Open in figure viewer Analysis 1.4 Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 4 General Health Questionnaire.

Open in table viewer

Comparison 2. Person‐directed intervention vs no intervention (Medium and Long Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maslach Burnout Inventory (at 2 years) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.1 Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 1 Maslach Burnout Inventory (at 2 years).
1.1 Emotional Exhaustion	1	84	Mean Difference (IV, Random, 95% CI)	‐6.0 [‐8.16, ‐3.84]
1.2 Depersonalisation	1	84	Mean Difference (IV, Random, 95% CI)	‐0.62 [‐1.89, 0.65]
1.3 Personal Accomplishment (lack of)	1	84	Mean Difference (IV, Random, 95% CI)	‐5.82 [‐7.89, ‐3.75]
2 Stait Trait Anxiety Inventory (Jones at 3 months and Yung at 1 month) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only
Open in figure viewer Analysis 2.2 Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 2 Stait Trait Anxiety Inventory (Jones at 3 months and Yung at 1 month).
2.1 State anxiety	2	121	Mean Difference (IV, Random, 95% CI)	‐8.31 [‐11.49, ‐5.13]
2.2 Trait anxiety	2	121	Mean Difference (IV, Random, 95% CI)	‐4.09 [‐7.60, ‐0.58]
3 Perceived Stress Scale (at 1 month) Show forest plot	1	57	Mean Difference (IV, Fixed, 95% CI)	‐6.10 [‐8.44, ‐3.76]
Open in figure viewer Analysis 2.3 Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 3 Perceived Stress Scale (at 1 month).
4 General Health Questionnaire (at 1 month) Show forest plot	1	48	Mean Difference (IV, Fixed, 95% CI)	‐7.10 [‐10.58, ‐3.62]
Open in figure viewer Analysis 2.4 Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 4 General Health Questionnaire (at 1 month).

Open in table viewer

Comparison 3. Work‐directed intervention vs no intervention (Short Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maslach Burnout Inventory Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only
Open in figure viewer Analysis 3.1 Comparison 3 Work‐directed intervention vs no intervention (Short Term), Outcome 1 Maslach Burnout Inventory.
1.1 Emotional Exhaustion	1	161	Mean Difference (IV, Random, 95% CI)	‐1.52 [‐3.61, 0.57]
1.2 Depersonalisation	1	161	Mean Difference (IV, Random, 95% CI)	‐1.14 [‐2.18, ‐0.10]
1.3 Personal Accomplishment (lack of)	1	161	Mean Difference (IV, Random, 95% CI)	0.07 [‐1.12, 1.26]
2 Nursing Stress Scale Show forest plot	1	115	Mean Difference (IV, Fixed, 95% CI)	‐0.34 [‐0.62, ‐0.06]
Open in figure viewer Analysis 3.2 Comparison 3 Work‐directed intervention vs no intervention (Short Term), Outcome 2 Nursing Stress Scale.
3 General symptoms Show forest plot	1	57	Mean Difference (IV, Fixed, 95% CI)	‐2.90 [‐5.16, ‐0.64]
Open in figure viewer Analysis 3.3 Comparison 3 Work‐directed intervention vs no intervention (Short Term), Outcome 3 General symptoms.

Open in table viewer

Comparison 4. Work‐directed intervention vs no intervention (Medium Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Nursing Stress Scale (at 6 months) Show forest plot	1	111	Mean Difference (IV, Fixed, 95% CI)	‐0.19 [‐0.49, 0.11]
Open in figure viewer Analysis 4.1 Comparison 4 Work‐directed intervention vs no intervention (Medium Term), Outcome 1 Nursing Stress Scale (at 6 months).

Analysis 1.1

Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 1 Beck & Srivastava Stress Scale and Perceived Stress Scale.

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Analysis 1.2

Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 2 Maslach Burnout Inventory.

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Analysis 1.3

Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 3 State Trait Anxiety Inventory.

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Analysis 1.4

Comparison 1 Person‐directed intervention vs no intervention (Short Term), Outcome 4 General Health Questionnaire.

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Analysis 2.1

Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 1 Maslach Burnout Inventory (at 2 years).

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Analysis 2.2

Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 2 Stait Trait Anxiety Inventory (Jones at 3 months and Yung at 1 month).

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Analysis 2.3

Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 3 Perceived Stress Scale (at 1 month).

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Analysis 2.4

Comparison 2 Person‐directed intervention vs no intervention (Medium and Long Term), Outcome 4 General Health Questionnaire (at 1 month).

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Analysis 3.1

Comparison 3 Work‐directed intervention vs no intervention (Short Term), Outcome 1 Maslach Burnout Inventory.

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Analysis 3.2

Comparison 3 Work‐directed intervention vs no intervention (Short Term), Outcome 2 Nursing Stress Scale.

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Analysis 3.3

Comparison 3 Work‐directed intervention vs no intervention (Short Term), Outcome 3 General symptoms.

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Analysis 4.1

Comparison 4 Work‐directed intervention vs no intervention (Medium Term), Outcome 1 Nursing Stress Scale (at 6 months).

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Table 1. Search strategy (MEDLINE)

Search strategy

1 exp Burnout, professional
2 burnout.tw.
3 exp job satisfaction
4 job satisfaction.tw.
5 (mental adj25 health adj25 professional$) .ab,ti.
6 (stress adj25 professional$) .ab,ti.
7 (stress adj25 occupational) .ab,ti.
8 randomised controlled trial.pt.
9 controlled clinical trial.pt.
10 randomised controlled trials
11 random allocation
12 double blind method
13 single blind method
14 or/8‐13
15 clinical trial.pt.
16 exp Clinical trial
17 (clin$ adj25 trial$) .ti,ab.
18 ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind $ or 12010 mask$)) .ti,ab.
19 19 placebos
20 placebos.ti,ab.
21 random.ti,ab.
22 research design
23 or/15‐22
24 comparative study
25 exp "Evaluation and Follow Up"
26 follow up studies
27 prospective studies
28 (control$ or prospectiv$ or volunteer$) .ti,ab.
29 or/24‐28
30 14 or 23 or 29
31 animal
32 human
33 31 and 32
34 31 not 33
35 or/1‐7
36 exp anxiety/ or exp anxiety disorders
37 anxiety.ti.
38 exp Depression
39 depression.ti.
40 or/35‐39
41 exp Health personnel
42 health.mp. and personnel.ti,ab. [mp=title, abstract, registry]
43 Nursing
44 nurse.mp. or nursing.ti,ab. [mp=title, abstract, registry]
45 limit 44 to human
46 or/41‐45
47 40 and 46
48 34
49 limit 48 to human
50 30
51 limit 50 to human
52 47 and 51
53 52 and 8
54 41 or 42
55 54 and 51 and 40
56 health.mp. and personnel.tw. [mp=title, abstract, registry]
57 54 and 56
58 54 or 56
59 58 and 51 and 40
60 (health and related and occupation$) .ab,tw,ti.
61 cleaners.mp. [mp=title, abstract, registry]
62 exp Occupational diseases
63 58 and 62
64 58 or 62
65 from 64 keep 8

Table 1. Search strategy (MEDLINE)

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Table 2. Levels of evidence: legend

HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
High quality positive effect (strong evidence)	Low quality, positive effect (limited evidence)	High quality, negative effect (strong evidence)	Low quality, negative effect (limited evidence)	High quality, inconsistent effect	Low quality, inconsistent effect

Table 2. Levels of evidence: legend

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Table 3. Study quality and intervention type

Study ID	Intervention type	Intervention content	Reporting	External validity	Internal validity	Power
Bittman	Person‐directed		8	2	8	4
Cohen‐Katz	Person‐directed		3	0	8	1
Delvaux	Organisational	communication skills	8	1	10	4
Ewers	Person‐directed		8	1	9	0
Heaney	Organisational	participatory problem solving	5	0	6	5
Jones	Person‐directed		7	0	8	3
Lee	Person‐directed		8	0	8	3
Lökk	Person‐directed		7	1	8	1
McElligott	Person‐directed		5	0	6	0
Melchior	Organisational	primary nursing	7	1	7	4
Norvell	Person‐directed		3	0	6	0
Proctor	Organisational	coping with difficult residents	6	0	7	3
Razavi	Organisational	communication skills	7	0	8	3
Rowe	Person‐directed		8	0	9	3
Schrijnemaekers	Organisational	emotion‐oriented care	7	1	10	5
Tsai	Person‐directed		5	1	6	4
von‐Baeyer	Person‐directed		8	1	9	0
West	Person‐directed		6	0	8	1
Yung	Person‐directed		10	0	9	2

Table 3. Study quality and intervention type

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Table 4. Levels of evidence: Person‐directed interventions: Stress

Stress scale	HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
Beck and Srivastava Stress Inventory		Jones
Perceived Stress Scale		Lee
Stress Assessment Inventory						Rowe 1999
Nursing Stress Checklist		Tsai
Job‐Related Tension Index		West

Table 4. Levels of evidence: Person‐directed interventions: Stress

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Table 5. Levels of evidence: Person‐directed interventions: Maslach Burnout Inventory

MBI subscales	HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
Emotional Exhaustion		Cohen‐Katz Ewers Norvell Rowe West				Bittman
Depersonalisation		Ewers Rowe				Bittman Cohen‐Katz Norvell West
Personal Accomplishment		Cohen‐Katz Ewers Rowe West				Bittman Norvell

Table 5. Levels of evidence: Person‐directed interventions: Maslach Burnout Inventory

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Table 6. Levels of evidence: Person‐directed interventions: State Trait Anxiety Inventory

STAI facets	HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
State		Jones von Baeyer West Yung
Trait		Jones von Baeyer West				Yung

Table 6. Levels of evidence: Person‐directed interventions: State Trait Anxiety Inventory

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Table 7. Levels of evidence: Person‐directed interventions: general symptoms

Scale	HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
Brief Symptom Inventory						Cohen‐Katz
GHQ General Health Questionnaire		Jones
C‐H Inventory of Physical Symptoms						Norvell
Chinese GHQ						Tsai
Chinese GHQ		Yung

Table 7. Levels of evidence: Person‐directed interventions: general symptoms

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Table 8. Levels of evidence: Work‐directed interventions: Stress

Stress scale	HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
Nursing Stress Scale	Delvaux
Occupational Stress Indicator						Proctor

Table 8. Levels of evidence: Work‐directed interventions: Stress

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Table 9. Levels of evidence: Work‐directed interventions: Maslach Burnout Inventory

MBI subscales	HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
Emotional Exhaustion					Schrijnemaekers	Melchior
Depersonalisation					Schrijnemaekers	Melchior
Personal Accomplishment	Schrijnemaekers					Melchior

Table 9. Levels of evidence: Work‐directed interventions: Maslach Burnout Inventory

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Table 10. Levels of evidence: Work‐directed interventions: general symptoms

Scale	HQ+	LQ+	HQ‐	LQ‐	HQinc	LQinc
Symptom Checklist‐90‐Revised						Heaney
GHQ General Health Questionnaire (somatic symptoms)		Proctor

Table 10. Levels of evidence: Work‐directed interventions: general symptoms

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Comparison 1. Person‐directed intervention vs no intervention (Short Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Beck & Srivastava Stress Scale and Perceived Stress Scale Show forest plot	2	130	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.85 [‐1.21, ‐0.49]

2 Maslach Burnout Inventory Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Emotional Exhaustion	3	129	Mean Difference (IV, Random, 95% CI)	‐5.82 [‐11.02, ‐0.63]
2.2 Depersonalization	3	129	Mean Difference (IV, Random, 95% CI)	‐2.44 [‐5.06, 0.17]
2.3 Personal Accomplishment (lack of)	3	129	Mean Difference (IV, Random, 95% CI)	‐4.89 [‐8.71, ‐1.07]
3 State Trait Anxiety Inventory Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 State anxiety	3	135	Mean Difference (IV, Random, 95% CI)	‐9.42 [‐16.92, ‐1.93]
3.2 Trait anxiety	3	135	Mean Difference (IV, Random, 95% CI)	‐6.91 [‐12.80, ‐1.01]
4 General Health Questionnaire Show forest plot	2	127	Mean Difference (IV, Random, 95% CI)	‐11.87 [‐27.24, 3.49]

Comparison 1. Person‐directed intervention vs no intervention (Short Term)

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Comparison 2. Person‐directed intervention vs no intervention (Medium and Long Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maslach Burnout Inventory (at 2 years) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Emotional Exhaustion	1	84	Mean Difference (IV, Random, 95% CI)	‐6.0 [‐8.16, ‐3.84]
1.2 Depersonalisation	1	84	Mean Difference (IV, Random, 95% CI)	‐0.62 [‐1.89, 0.65]
1.3 Personal Accomplishment (lack of)	1	84	Mean Difference (IV, Random, 95% CI)	‐5.82 [‐7.89, ‐3.75]
2 Stait Trait Anxiety Inventory (Jones at 3 months and Yung at 1 month) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 State anxiety	2	121	Mean Difference (IV, Random, 95% CI)	‐8.31 [‐11.49, ‐5.13]
2.2 Trait anxiety	2	121	Mean Difference (IV, Random, 95% CI)	‐4.09 [‐7.60, ‐0.58]
3 Perceived Stress Scale (at 1 month) Show forest plot	1	57	Mean Difference (IV, Fixed, 95% CI)	‐6.10 [‐8.44, ‐3.76]

4 General Health Questionnaire (at 1 month) Show forest plot	1	48	Mean Difference (IV, Fixed, 95% CI)	‐7.10 [‐10.58, ‐3.62]

Comparison 2. Person‐directed intervention vs no intervention (Medium and Long Term)

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Comparison 3. Work‐directed intervention vs no intervention (Short Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maslach Burnout Inventory Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Emotional Exhaustion	1	161	Mean Difference (IV, Random, 95% CI)	‐1.52 [‐3.61, 0.57]
1.2 Depersonalisation	1	161	Mean Difference (IV, Random, 95% CI)	‐1.14 [‐2.18, ‐0.10]
1.3 Personal Accomplishment (lack of)	1	161	Mean Difference (IV, Random, 95% CI)	0.07 [‐1.12, 1.26]
2 Nursing Stress Scale Show forest plot	1	115	Mean Difference (IV, Fixed, 95% CI)	‐0.34 [‐0.62, ‐0.06]

3 General symptoms Show forest plot	1	57	Mean Difference (IV, Fixed, 95% CI)	‐2.90 [‐5.16, ‐0.64]

Comparison 3. Work‐directed intervention vs no intervention (Short Term)

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Comparison 4. Work‐directed intervention vs no intervention (Medium Term)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Nursing Stress Scale (at 6 months) Show forest plot	1	111	Mean Difference (IV, Fixed, 95% CI)	‐0.19 [‐0.49, 0.11]

Comparison 4. Work‐directed intervention vs no intervention (Medium Term)

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Referencias

References to studies included in this review

Bittman 2003 {published data only}

Cohen‐Katz 2005 {unpublished data only}

Delvaux 2004 {published data only}

Ewers 2002 {published data only}

Heaney 1995 {published data only}

Jones 2000 {unpublished data only}

Lee 1994 {published data only}

Lökk 1997 {published data only}

Lökk 2000 {published data only}

McElligott 2003 {unpublished data only}

Melchior 1996 {published data only}

Norvell 1987 {published data only}

Proctor 1998 {published data only}

Razavi 1993 {published data only (unpublished sought but not used)}

Rowe 1999 {published data only}

Schrijnemaekers 2003 {published data only}

Tsai 1993 {published data only}

von Baeyer 1983 {published data only}

West 1984 {published data only}

Yung 2004 {published data only}

References to studies excluded from this review

Beddoe 2004 {published data only}

Berg 1994 {published data only}

Bradley 2002 {published data only}

Bruneau 2004 {published data only}

Bunce 1996 {published data only}

Calomeni 1999 {published data only}

Drain 1991 {published data only}

Fernandez 1995 {published data only}

Freedy 1994 {published data only}

Godbey 1994 {published data only}

Heaman 1995 {published data only}

Hughes 2003 {published data only}

Johansson 1991 {published data only}

Jones 1998 {published data only}

Keyes 1988 {published data only}

Kushnir 1998 {published data only}

Lloyd 2002 {published data only}

Mancini 1983 {published data only}

McCue 1991 {published data only}

McPhail 1990 {published data only}

Murphy 1983 {published data only}

Nissen 1997 {published data only}

Pålsson 1996 {published data only}

Schinke 1977 {published data only}

Sharif 2004 {published data only}

Taylor 2001 {published data only}

Teasdale 2001 {published data only}

Toivanen 1993 {published data only}

van Dierendonck 1998 {published data only}

Weir 1997 {published data only}

Young 2001 {published data only}

Zimber 2001 {published data only}

References to studies awaiting assessment

Carson 1999 {published data only}

Additional references

Beck 1961

Beck 1991

Benoliel 1990

Campbell 2001

Cohen 1982

Cohen 1983

Cooper 1988

Cooper 2001

de Vet 2003

Deckard 1994

Deeks 2003

DeFrank 1987

Derogatis 1976

Derogatis 1983

Downs 1998

Dunnette 1990

EPOC 1998

Firth 1989

Firth‐Cozens 1999

Gilbody 2006