Evaluating the impact of a worksite stress management programme for distressed student nurses: A randomised controlled trial

Effectiveness of stress management interventions for nursing students: A systematic review and meta-analysis

Elevated stress levels are related to diminished mental health, potentially leading to decreased well-being and performance of nursing students. While researchers have focused on developing stress management interventions, there is a need to synthesize the evidence. A systematic review with meta-analysis was conducted to assess the evidence for the effectiveness of stress management interventions in nursing students. A systematic literature search identified controlled stress management interventions employing a validated psychological or physiological stress measure. Forty-one studies were included, with 36 forming a pool of 2715 participants in the meta-analysis. The overall effect on psychological stress was positive. Intervention type, delivery modality, intervention duration in weeks, and number of sessions were moderators of intervention effectiveness, with more significant effects for mind-body programs, on-site delivery methods, durations of 9-12 weeks, and 15-30 sessions. For physiological stress, the biomarkers of blood pressure, heart rate, and cortisol levels decreased significantly. Future research is necessary for promising outcomes related to currently underrepresented indicators and to investigate the long-term effects of interventions.

Individual-level interventions for reducing occupational stress in healthcare workers

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 after the intervention ended), and long term follow-up (> 12 months after 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.

Effectiveness of interventions for academic burnout among nursing students: A systematic review

BACKGROUND

Nursing students experience higher stress and burnout compared to students in other health professions, with a prevalence rate of as high as 20%. More recently, they have been affected by changes in nursing education due to the COVID-19 pandemic, such as requirements for social isolation and distance learning. Although there are existing studies on interventions that address academic burnout among nursing students, there is no synthesis of randomized trials on this topic.

AIM

This study aimed to systematically synthesize studies of interventions for academic burnout among nursing students.

METHODS

A systematic search for randomized controlled trials was performed in PubMed, CINAHL, CENTRAL, Web of Science, and Scopus. Eligibility criteria were based on study directness in relation to the Patient, Intervention, Comparison, and Outcome (PICO) question. Two review authors independently screened articles for inclusion, collected data from the included studies, and performed risk of bias assessments using the Cochrane Risk of Bias Tool 2.0. A narrative synthesis was performed. This review was registered a priori in PROSPERO (CRD42022350196).

RESULTS

Six papers were included in this review. Various interventions were studied: Qigong exercises, progressive muscle relaxation, autogenic therapy and laughter therapy, didactic behavioral sessions focusing on personal and professional development, and coping skills enhancement. The effects of these interventions on academic burnout, depression, and stress among nursing students were short term and their benefits over time remain uncertain.

LINKING EVIDENCE TO ACTION

Progressive muscle relaxation and cognitive behavioral interventions demonstrated short-term positive effects on academic burnout, depression, and stress among nursing students. These findings may support the development of individual-level and organizational-level initiatives for nursing students aimed to lessen or prevent academic burnout. Large-scale, high-quality studies on the effect of interventions on academic burden in various settings and cultures are needed.

The effectiveness of interventions and behaviour change techniques to reduce stress in student nurses: A systematic review

BACKGROUND

Student nurses experience stress leading to poor health and course attrition (Lovegrove, 2018).

OBJECTIVES AND DESIGN

This systematic review aimed to evaluate the effectiveness of interventions and 'behaviour change techniques' (BCTs) to reduce student nurse stress. BCTs are active components of interventions that are observable, replicable, irreducible and designed to change behaviour (Michie et al., 2013).

DATA SOURCES

Thirteen databases were searched from inception to May 2020.

REVIEW METHODS

The interventions were classified according to their target: 'stressors', 'coping', 'cognitive reappraisal' or a combination of these (Lazarus and Folkman, 1984). BCTs were coded using the BCT taxonomy: a hierarchical framework of BCTs (Michie et al., 2013).

RESULTS

28 interventions reported in 23 articles were included in the review. A positive effect was identified in 22 interventions. There were no studies addressing the stressors in isolation and the interventions targeting stressors in combination with coping (n = 1) or cognitive reappraisal (n = 1) found no significant effects. In contrast, 74% of those targeting coping alone (n = 14/19), 100% of those addressing coping and cognitive reappraisal together (n = 4/4) and 66% addressing all three targets together (n = 2/3) were successful. The most common BCTs provided students with information and skills relating to stress management, with 18/21 being successful >50% of the time.

CONCLUSIONS

Overall, most interventions aimed to teach students skills to cope with stress, with the majority having a short-term effect. However, as some interventions and BCTs were infrequently used or poorly described and all studies had a medium-high risk of bias, there is a need for longitudinal high-quality studies.

Improving mental health of student and novice nurses to prevent dropout: A systematic review

Aims

To provide: (a) an overview of interventions aimed at improving mental health of student or novice nurses; and (b) an evaluation of their effectiveness on dropout‐related outcomes.

Design

Systematic review.

Data sources

Research papers published between January 1971–February 2019 were identified from the following databases: Embase, Medline, PsycInfo, CINAHL, ERIC, the Cochrane Library, Web of Science, and Google Scholar.

Review methods

We followed the procedures recommended by the Editorial Board of the Cochrane Collaboration Back Review Group. We included peer‐reviewed articles with a quantitative research design, examining interventions aimed at improving mental health of student and novice nurses and their effect on dropout‐related outcomes. The large variation in studies prohibited statistical pooling and a synthesis without meta‐analysis of studies was performed.

Results

We identified 21 studies with three areas of focus: managing stress or stressors (N = 4); facilitating the transition to nursing practice (N = 14); and a combined approach (N = 3). Five studies showed a statistically significant effect on dropout‐related outcomes. The overall risk of bias was high.

Conclusion

A wide range of interventions are available, but the evidence for their effectiveness is limited. There is a need for high‐quality studies in this field, preferably with a randomized controlled design.

A systematic review of prevention programs targeting depression, anxiety, and stress in university students

BACKGROUND

Given the prevalence of anxiety, depression, and stress among university students, it is important to assess the effectiveness of prevention programs for these problems. Beyond examining effect sizes, applying a common elements approach can enhance our understanding of which practice elements are most frequently included in symptom-reducing programs.

METHOD

This review examined effective (i.e., outcome-producing) prevention programs targeting depression, anxiety, and/or stress in university students. Programs could be delivered in a group-based, online/computer-delivered, or self-administered format and at the universal, selective, or indicated prevention level.

RESULTS

The resulting sample of 62 articles covered 68 prevention programs for college, graduate, or professional students across 15 countries. Average effect sizes for programs were moderate (overall g = 0.65), regardless of delivery format or prevention level. The most common practice elements (overall and for programs producing large effects) were: psychoeducation (72%), relaxation (69%), and cognitive monitoring/restructuring (47%). Many programs were limited by: (a) symptom target-outcome mismatches, (b) disproportionately female samples, and (c) inconsistently reported adherence data.

LIMITATIONS

Commonness of practice elements across outcome-producing interventions does not imply their extensiveness nor unique contribution to effectiveness. Coding was based on information in articles rather than manuals, and inter-rater reliability was moderate for some practice elements.

CONCLUSION

The outcome-producing prevention programs in our sample had common practice elements and produced moderate reduction in symptoms overall. Future research of depression, anxiety, and stress prevention programs for university students can investigate practice elements' unique and combined impact on outcomes, further explore under-tested practice elements, and use findings to inform intervention design.

Group interventions to promote mental health in health professional education: a systematic review and meta-analysis of randomised controlled trials

Effects of interventions for improving mental health of health professional students has not been established. This review analysed interventions to support mental health of health professional students and their effects. The full holdings of Medline, PsycINFO, EBM Reviews, Cinahl Plus, ERIC and EMBASE were searched until 15th April 2016. Inclusion criteria were randomised controlled trials of undergraduate and post graduate health professional students, group interventions to support mental health compared to alternative education, usual curriculum or no intervention; and post-intervention measurements for intervention and control participants of mindfulness, anxiety, depression, stress/distress or burnout. Studies were limited to English and short term effects. Studies were appraised using the PEDro scale. Data were synthesised using meta-analysis. Four comparisons were identified: psychoeducation or cognitive-behavioural interventions compared to alternative education, and mindfulness or relaxation compared to control conditions. Cognitive-behavioural interventions reduced anxiety (-0.26; -0.5 to -0.02), depression (-0.29; -0.52 to -0.05) and stress (0.37; -0.61 to -0.13). Mindfulness strategies reduced stress (-0.60; -0.97 to -0.22) but not anxiety (95% CI -0.21 to 0.18), depression (95% CI -0.36 to 0.03) or burnout (95% CI -0.36 to 0.10). Relaxation strategies reduced anxiety (SMD -0.80; 95% CI -1.03 to -0.58), depression (-0.49; -0.88 to -0.11) and stress (-0.34; -0.67 to -0.01). Method quality was generally poor. Evidence suggests that cognitive-behavioural, relaxation and mindfulness interventions may support health professional student mental health. Further high quality research is warranted.

Effects of mental health interventions for students in higher education are sustainable over time: a systematic review and meta-analysis of randomized controlled trials

Background

Symptoms of depression, anxiety, and distress are more common in undergraduates compared to age-matched peers. Mental ill health among students is associated with impaired academic achievement, worse occupational preparedness, and lower future occupational performance. Research on mental health promoting and mental ill health preventing interventions has shown promising short-term effects, though the sustainability of intervention benefits deserve closer attention. We aimed to identify, appraise and summarize existing data from randomized control trials (RCTs) reporting on whether the effects of mental health promoting and mental ill health preventing interventions were sustained at least three months post-intervention, and to analyze how the effects vary for different outcomes in relation to follow-up length. Further, we aimed to assess whether the effect sustainability varied by intervention type, study-level determinants and of participant characteristics.

Material and Methods

A systematic search in MEDLINE, PsycInfo, ERIC, and Scopus was performed for RCTs published in 1995-2015 reporting an assessment of mental ill health and positive mental health outcomes for, at least, three months of post-intervention follow-up. Random-effect modeling was utilized for quantitative synthesis of the existing evidence with standardized mean difference (Hedges' g) used to estimate an aggregated effect size. Sustainability of the effects of interventions was analyzed separately for 3-6 months, 7-12 months, and 13-18 months of post-intervention follow-up.

Results

About 26 studies were eligible after reviewing 6,571 citations. The pooled effects were mainly small, but significant for several categories of outcomes. Thus, for the combined mental ill health outcomes, symptom-reduction sustained up to 7-12 months post-intervention (standardized mean difference (Hedges' g) effect size (ES) = -0.28 (95% CI [-0.49, -0.08])). Further, sustainability of symptom-reductions were evident for depression with intervention effect lasting up to 13-18 months (ES = -0.30 (95% CI [-0.51, -0.08])), for anxiety up to 7-12 months (ES = -0.27 (95% CI [-0.54, -0.01])), and for stress up to 3-6 months (ES = -0.30 (95% CI [-0.58, -0.03])). The effects of interventions to enhance positive mental health were sustained up to 3-6 months for the combined positive mental health outcomes (ES = 0.32 (95% CI [0.05, 0.59])). For enhanced active coping, sustainability up to 3-6 months was observed with a medium and significant effect (ES = 0.75 (95% CI [0.19, 1.30])).

Discussion

The evidence suggests long-term effect sustainability for mental ill health preventive interventions, especially for interventions to reduce the symptoms of depression and symptoms of anxiety. Interventions to promote positive mental health offer promising, but shorter-lasting effects. Future research should focus on mental health organizational interventions to examine their potential for students in tertiary education.

Healthy ageing at work- Efficacy of group interventions on the mental health of nurses aged 45 and older: Results of a randomised, controlled trial

Objective

This multicentre, randomised controlled trial (RCT) aimed to evaluate the efficacy of a small-group intervention promoting successful ageing at work in older nurses (aged ≥45).

Method

A sample of 115 nurses aged ≥45 from 4 trial sites in Germany were randomly assigned to either the intervention group (IG), that received a small-group intervention of seven weekly sessions of 120 min with a booster session after six weeks or to a wait-list control condition (WLC). Outcomes were measured via validated self-report questionnaires at baseline (T1) and at post-treatment (T2).

Primary outcomes were mental health-related well-being and mental health-related quality of life (QOL). The secondary outcomes included mental health-related and work-related measures.

Results

The intention to treat (ITT) analysis showed significant positive effects of the intervention on mental health. A significant small effect (d = 0.3) in favour of the IG was found for psychological health-related quality of life. Positive small effects (d = 0.24 to d = 0.31) were also found for work related mental strain.

Conclusions

Our small-group intervention based on a theory of successful ageing for nurses aged ≥45 was found to be effective with regard to improvements of psychological health related quality of life and other mental health-related outcomes. Thus, our study shows that the ageing workforce can be reached through specifically designed preventive interventions. The components of our intervention could be easily adapted to the belongings of other professions. Our results suggest that these components should be evaluated in various settings outside the healthcare sector.

Addressing Burnout in Oncology: Why Cancer Care Clinicians Are At Risk, What Individuals Can Do, and How Organizations Can Respond

Despite their benevolent care of others, today, more than ever, the cancer care professional who experiences overwhelming feelings of exhaustion, cynicism, and inefficacy is in grave jeopardy of developing burnout. Clinicians are repeatedly physically and emotionally exposed to exceedingly long hours in direct care with seriously ill patients/families, limited autonomy over daily responsibilities, endless electronic documentation, and a shifting medical landscape. The physical and emotional well-being of the cancer care clinician is critical to the impact on quality care, patient satisfaction, and overall success of their organizations. The prevention of burnout as well as targeting established burnout need to be proactively addressed at the individual level and organizational level. In fact, confronting burnout and promoting wellness are the shared responsibility of both oncology clinicians and their organizations. From an individual perspective, oncology clinicians must be empowered to play a crucial role in enhancing their own wellness by identification of burnout symptoms in both themselves and their colleagues, learning resilience strategies (e.g., mindful self-compassion), and cultivating positive relationships with fellow clinician colleagues. At the organizational level, leadership must recognize the importance of oncology clinician well-being; engage leaders and physicians in collaborative action planning, improve overall practice environment, and provide institutional wellness resources to physicians. These effective individual and organizational interventions are crucial for the prevention and improvement of overall clinician wellness and must be widely and systematically integrated into oncology care.

Process Evaluation in Occupational Stress Management Programs: A Systematic Review

Objective.

To conduct a systematic review of workplace stress management intervention studies that have incorporated process evaluation.

Data Source.

Electronic databases such as PsycINFO and MEDline were searched.

Study Inclusion Criteria.

The inclusion criteria included interventions published in the English language that were focused on either individual- or organizational-level stress management interventions at the workplace, with an outcome evaluation.

Data Extraction.

Each article was coded on key process-relevant variables, including context, recruitment, reach, dose delivered, dose received, fidelity, implementation, and participant's attitudes toward the intervention. Studies that reported on at least one of these process variables were also coded on the following study characteristics: Participants, setting, evaluation design, intervention content, intervention format, and study outcomes.

Data Synthesis.

Statistical Package for the Social Science was used to analyze the data with descriptive statistics.

Results.

Of the 84 studies identified that met the study inclusion criteria, 52 (61.9%) reported findings on at least one of the key relevant process-relevant variables. Variables most frequently included were recruitment (30%), intervention dose received (22%), participants' attitudes toward intervention (19%), and program reach (13%). Fewer than half of the studies presented any findings linking process evaluation and outcome evaluation.

Conclusions.

The incomplete reporting of information relevant to process evaluation makes it difficult to identify reliable determinants of effective intervention implementation or outcomes.

The effect of emotional freedom technique on stress and anxiety in nursing students: A pilot study

BACKGROUND

Stress and anxiety have been identified as significant issues experienced by student nurses during their education. Some studies have suggested that the stress experienced by nursing students is greater than that experienced by medical students, other non-nursing healthcare students, degreed nurses, and the female population in general. A recently introduced energy type therapy, emotional freedom technique (EFT), has shown some success in reducing symptoms of anxiety, stress, and fear in a variety of settings.

OBJECTIVE

The purpose of this study was to determine the efficacy of EFT in decreasing anxiety and stress as a potential intervention to assist students in stress management.

DESIGN

The study used a mixed method design of both qualitative and quantitative measures. Quantitatively, in a one group pretest-posttest design, participants received group instruction in the technique and were encouraged to repeat it daily. Self-reported anxiety was measured at baseline, and then weekly for four weeks using the Perceived Stress Scale (PSS) and the State-Trait Anxiety Inventory (STAI). The qualitative survey was completed by participants at the end of the study in order to capture a more subjective experience.

SETTING

The pilot study was conducted in a two-year college in the southeastern region of the United States.

PARTICIPANTS

All enrolled nursing students in an associate degree nursing program were invited to participate. Participation was voluntary, resulting in an original convenience sample of thirty-nine nursing students (N=39).

METHODS

Data collection instruments included a demographic questionnaire, pretest State-Trait Anxiety Inventory (STAI) and Perceived Stress Scale (PSS). A qualitative questionnaire was also administered at the end of the four weeks. STAI and PSS were administered weekly. Data analysis using RMANOVA was performed at the second, third and the fourth week.

RESULTS

Decreases in anxiety as measured on both the STAI and PSS were statistically significant (p=.05). For PSS, STAI state and trait data, the reduction in self-reported stress was statistically significant with a mean difference baseline to week 4. Qualitative data suggested that nursing students experienced a decrease in feelings of stress and anxiety including a decrease in somatic symptoms.

CONCLUSIONS

Overall, findings suggested that EFT can be an effective tool for stress management and anxiety relief in nursing students.

Preventing occupational stress in healthcare workers

BACKGROUND

Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work. This may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.

OBJECTIVES

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.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.

MAIN RESULTS

In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health.There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction), and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies (SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to -0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies (SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias, and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.

AUTHORS' CONCLUSIONS

There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions. There is also low-quality evidence that changing work schedules may lead to a reduction of stress. Other organisational interventions have no effect on stress levels. More randomised controlled trials are needed with at least 120 participants that compare the intervention to a placebo-like intervention. Organisational interventions need better focus on reduction of specific stressors.

Preventing occupational stress in healthcare workers

BACKGROUND

Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work. which may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.

OBJECTIVES

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.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.

MAIN RESULTS

In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health.There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction), and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies (SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to -0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies (SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias, and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.

AUTHORS' CONCLUSIONS

There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions. There is also low-quality evidence that changing work schedules may lead to a reduction of stress. Other organisational interventions have no effect on stress levels. More randomised controlled trials are needed with at least 120 participants that compare the intervention to a placebo-like intervention. Organisational interventions need better focus on reduction of specific stressors.

Preventing occupational stress in healthcare workers

Background Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work.which may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.Objectives 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.Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL,NIOSHTIC-2 and Web of Science up to November 2013.Selection criteria Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.Data collection and analysis Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.Main results In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health. There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction),and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies(SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to-0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies(SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias,and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.Authors' conclusions There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions. There is also low-quality evidence that changing work schedules may lead to a reduction of stress. Other organisational interventions have no effect on stress levels.More randomised controlled trials are needed with at least 120 participants that compare the intervention to a placebo-like intervention. Organisational interventions need better focus on reduction of specific stressors.

Interventions to reduce stress in university students: a review and meta-analysis

BACKGROUND

Recent research has revealed concerning rates of anxiety and depression among university students. Nevertheless, only a small percentage of these students receive treatment from university health services. Universities are thus challenged with instituting preventative programs that address student stress and reduce resultant anxiety and depression.

METHOD

A systematic review of the literature and meta-analysis was conducted to examine the effectiveness of interventions aimed at reducing stress in university students. Studies were eligible for inclusion if the assignment of study participants to experimental or control groups was by random allocation or parallel cohort design.

RESULTS

Retrieved studies represented a variety of intervention approaches with students in a broad range of programs and disciplines. Twenty-four studies, involving 1431 students were included in the meta-analysis. Cognitive, behavioral and mindfulness interventions were associated with decreased symptoms of anxiety. Secondary outcomes included lower levels of depression and cortisol.

LIMITATIONS

Included studies were limited to those published in peer reviewed journals. These studies over-represent interventions with female students in Western countries. Studies on some types of interventions such as psycho-educational and arts based interventions did not have sufficient data for inclusion in the meta-analysis.

CONCLUSION

This review provides evidence that cognitive, behavioral, and mindfulness interventions are effective in reducing stress in university students. Universities are encouraged to make such programs widely available to students. In addition however, future work should focus on developing stress reduction programs that attract male students and address their needs.

Biofeedback Intervention for Stress and Anxiety among Nursing Students: A Randomized Controlled Trial

Purpose. It has been well documented that nursing students across the world experience stress and anxiety throughout their education and training. The purpose of this randomized controlled study is to investigate the impact of biofeedback intervention program on nursing students' levels of stress and anxiety during their first clinical training. Methods. Participants consisted of 60 second-year baccalaureate nursing students. The 30 participants in the biofeedback group received training on how to use the biofeedback device to assist in stress and anxiety management for 5 weeks while the 30 in the control group did not receive any training. Findings. Results indicated that the biofeedback group was able to maintain the stress level while the control group had a significant increase in the stress level over the 5-week period of clinical training. Additionally, the biofeedback group had a significant reduction in anxiety, while the control group had a moderate increase in anxiety. Conclusions. The better the nursing students can manage their stress and anxiety, the more successful they can be in their clinical training. Ultimately, the more psychologically healthy the nursing students are, the more likely they will flourish and graduate to become productive and contributing members of the nursing profession.

Physical activity and mental well-being in student nurses

There is strong evidence that suggests physical activity can enhance mental well-being. However, this relationship has not been widely investigated in student nurses. A cross-sectional study was conducted to examine the relationship between physical activity and mental well-being in undergraduate student nurses (n=215). Physical activity was measured using the International Physical Activity Questionnaire. Other outcomes included self-esteem, anxiety, depression, life satisfaction, outcome expectations and self-efficacy. Almost, a quarter (23.8%) of the total sample, were meeting the Department of Health's physical activity guideline. Mean body mass index (BMI) was 25.0 with 40% being in the overweight to morbidly obese category. Self-esteem was significantly positively correlated with total physical activity (r=0.16, p=0.038) and moderate intensity activity (r=0.17, p=0.021). No other significant relationships were found between anxiety, depression and satisfaction with life and physical activity. Outcome expectations for exercise and self-efficacy were significantly positively correlated with moderate (r=0.17, p=0.019) and vigorous (r=0.28, p=0.000) intensity activity and total physical activity (r=0.29, p=0.000). BMI was significantly positively correlated with age (r=0.242, p=0.001), significantly negatively correlated with self-efficacy for exercise (r=0.257, p=0.000) and satisfaction with life (r=-0.144, p=0.041). Regression analysis showed that low self efficacy for exercise and increasing age were significant predictors of BMI with a small effect size r(2)=0.126, adjusted r(2)=0.112. BMI and physical activity variables collectively explained only 2% of the variance for anxiety, 4% for depression, 5% for self esteem and 6% for satisfaction with life. BMI was a significant predictor of satisfaction with life (Beta=-0.171, p=0.027). Participation in physical activity may be influential in improving mental well-being in student nurses. Promoting physical activity in student nurses has the potential to increase self-esteem and life satisfaction and decrease the risk of anxiety and depression. Further research is needed to establish whether this relationship is causal and exists in other student nurse populations.

Stress reduction through psychoeducation: a meta- analytic review

The aim of this meta-analysis was to evaluate the effectiveness of psychoeducational interventions in reducing stress and to gain more insight in determining features moderating the magnitude of effects. Relevant studies were selected from 1990 to 2010 and were included according to predetermined criteria. For each study, the standardized mean difference was calculated for the outcome measure primarily related to stress. Nineteen studies met the inclusion criteria; for 16 studies, a standardized mean difference could be calculated. The average effect size was .27 (95% confidence interval = [.14, .40]) at posttest and .20 (95% confidence interval = [-.04, .43]) at follow-up. To determine possible moderators of intervention effects, all 19 studies were included. Only interventions that were shorter in duration provided better results. When a model with multiple moderators was considered, a model combining both intervention duration and the number of women in an intervention was significant and accounted for 42% of the variability found in the data set. Specifically, interventions with more women that were shorter in duration obtained better results.

Developing a web-based stress management intervention for occupational support workers

BACKGROUND

Occupational support workers in the mental healthcare sector are exposed to considerable occupational stress and have little access to stress management facilities.

AIMS

This article describes the process behind creating a web-based stress management intervention (SMI) for occupational support workers in the mental healthcare sector.

METHOD

Mixed methods were used to inform the content of the web-based SMI, following MRC strategy for designing interventions and PRIMA-EF guidelines for best practice in SMI design. We conducted a literature review to ascertain the content of interventions that had been shown to be successful in reducing stress in mental healthcare populations. In addition, we conducted focus groups in order to assess specific stressors that individuals in the occupational support sector deemed to be important.

RESULTS

The literature review showed that a variety of methods had been successful for reducing occupational stress in the mental healthcare sector including: Relaxation and Cognitive Behavioural Therapy techniques, and skills training in; time management, problem-solving and communication. Individuals in the focus groups identified both personal and organisational stressors to be addressed in the intervention.

CONCLUSIONS

This intervention was developed with reference to a design strategy, using input from the target population.

Assessing intervention effectiveness for reducing stress in student nurses: quantitative systematic review

AIMS

To identify the types of interventions that are effective in reducing stress in student nurses, and to make recommendations for future research.

BACKGROUND

Student nurses experience significant stress during their training and this may contribute to sickness, absence and attrition. Given the global shortage of nurses and high dropout rates amongst trainees, the importance for developing stress management programmes for student nurses is becoming more evident. To date, only one review has examined the effectiveness of stress interventions for student nurses, but the emergence of recent literature warrants a new review.

DATA SOURCES

Research papers published between April 1981 and April 2008 were identified from the following databases: Medline, CINAHL, Behavioral Sciences Collection, IBSS and Psychinfo.

REVIEW METHODS

A quantitative systematic review with narrative synthesis was conducted. Key terms included 'nurses OR nursing OR nurse', 'student OR students', 'intervention', 'stress OR burnout'. In addition to database searches, reference lists of selected papers were scanned, key authors were contacted and manual searches of key journals were conducted.

RESULTS

The most effective interventions provided skills for coping with stressful situations (typically relaxation) and skills for changing maladaptive cognitions. Interventions which promoted skills to reduce the intensity or number of stressors were also successful. In most cases, stress interventions did not improve academic performance.

CONCLUSION

The design of stress interventions should be driven by theory. Future studies should focus on interface and organizational factors and the long-term benefits of interventions for student nurses are yet to be demonstrated.

Mental health nursing students differ from other nursing students: Some observations from a study on stress and coping

The study reported here is taken from a wider investigation into stress among preregistration nursing students, undertaken in the nursing department of a large university in northern England. British nursing is divided into four specialties or 'branches': adult, mental health, children's, and learning disability nursing, and the aim of the study was to explore interbranch differences among the students in terms of the sources of stress they identify, the levels of stress they experience, and the ways in which they cope. A cross-sectional survey of all nursing students on the department's roll (n = 1362), using a range of self-report measures bound together in a 'questionnaire pack', was undertaken. The questionnaire pack contained formal measures of sources of stress (Student Nurse Stress Index), stress (specifically, psychological distress) (General Health Questionnaire) and coping (Coping Inventory for Stressful Situations), as well as a set of questions that enabled data on a range of pertinent variables, including the nursing branch being pursued, to be collected. The findings revealed that mental health nurses were notably different from the other three branches in terms of the quantity and characteristics of the sources of stress they faced, the levels of stress they experienced, and the ways in which they coped. These differences were largely advantageous to the students' well-being and speculations are made as to whether the concept of 'hardiness'- especially its focus on a sense of being in control - plays a role in explaining the findings.

Comparison of a Healing Touch, Coaching, and a Combined Intervention on Comfort and Stress in Younger College Students

Three nursing interventions to increase total comfort and reduce stress-related events in young college students experiencing stress were compared. Healing Touch, coaching, and a combination of both, were compared to a waitlist. On comfort and stress, Healing Touch had better immediate results, while coaching had better carryover effects.

Barriers to use of mental health services by Japanese university students

The present cross-sectional study assessed the attitude of Japanese undergraduates towards mental health services and investigated whether mental distress is associated with reluctance to use, and a decreased perceived need for, mental health services. A convenience sample of 194 students (98 men and 96 women) completed the 28-item Japanese version of the General Health Questionnaire and questions regarding reluctance to use and perceived need for mental health services. Participants were in the second to fourth years of undergraduate work and their majors were psychology and technology. Analyses showed that approximately 70% of students were reluctant to use mental health services and this reluctance was less in the group scoring high on anxiety and insomnia than the group scoring lower. Also, perceived need for mental health services was higher for those scoring high on depression. There were some discrepancies in the results and previous studies. Implications of these findings for clinical and preventive practice and for direction for research are discussed.

Essential elements of questionnaire design and development

AIMS

The aims of this paper were (1) to raise awareness of the issues in questionnaire development and subsequent psychometric evaluation, and (2) to provide strategies to enable nurse researchers to design and develop their own measure and evaluate the quality of existing nursing measures.

BACKGROUND

The number of questionnaires developed by nurses has increased in recent years. While the rigour applied to the questionnaire development process may be improving, we know that nurses are still not generally adept at the psychometric evaluation of new measures. This paper explores the process by which a reliable and valid questionnaire can be developed.

METHODS

We critically evaluate the theoretical and methodological issues associated with questionnaire design and development and present a series of heuristic decision-making strategies at each stage of such development. The range of available scales is presented and we discuss strategies to enable item generation and development. The importance of stating a priori the number of factors expected in a prototypic measure is emphasized. Issues of reliability and validity are explored using item analysis and exploratory factor analysis and illustrated using examples from recent nursing research literature.

CONCLUSION

Questionnaire design and development must be supported by a logical, systematic and structured approach. To aid this process we present a framework that supports this and suggest strategies to demonstrate the reliability and validity of the new and developing measure.

RELEVANCE TO CLINICAL PRACTICE

In developing the evidence base of nursing practice using this method of data collection, it is vital that questionnaire design incorporates preplanned methods to establish reliability and validity. Failure to develop a questionnaire sufficiently may lead to difficulty interpreting results, and this may impact upon clinical or educational practice. This paper presents a critical evaluation of the questionnaire design and development process and demonstrates good practice at each stage of this process.

Is the introduction of a student-centred, problem-based curriculum associated with improvements in student nurse well-being and performance? An observational study of effect

AIMS

To explore the impact of curriculum redesign and innovation on student well-being and performance, including essay and examination marks and sickness absence.

BACKGROUND

While the emotional impact of preparing to be a health professional can be reduced by helping students to adapt, the positive effect of curriculum innovation and redesign is rarely evaluated. DESIGN, SAMPLE AND METHODS: Student nurse well-being and performance was compared at weeks 24/25 and 40/50 following course entry between comparable independent cohorts of students undertaking a traditional programme (N=406, 83% return rate) with those on an innovative, student-centred, problem-based educational programme (N=447, 79% return rate). The setting was a School of Nursing and Midwifery in the North-East of Scotland. Measures included stress and mental health outcomes and measures of performance including academic marks and sickness absence.

RESULTS

At week 25 into the course students on the innovative course had fewer academic, clinical and personal worries than students in the previous more traditional programme and were more likely to report using adaptive direct, problem-solving coping at week 50. While students on the innovative course reported less distress in their first year of the course, they scored less well on comparable essay assignments and had reliably greater sickness absence totals than those educated by traditional methods.

CONCLUSION

In this setting, curriculum innovation was associated with positive changes in student well-being but not on performance.

Preventing occupational stress in healthcare workers

BACKGROUND

Healthcare workers can suffer from occupational stress which may lead to serious mental and physical health problems.

OBJECTIVES

To evaluate the effectiveness of work and person-directed interventions in preventing stress at work in healthcare workers.

SEARCH STRATEGY

We searched the Cochrane Depression Anxiety and Neurosis Group trials Specialised Register, MEDLINE, PsychInfo and Cochrane Occupational Health Field database.

SELECTION CRITERIA

Randomised controlled clinical trials (RCT) of interventions aimed at preventing psychological stress in healthcare workers. For work-directed interventions interrupted time series and prospective cohort were also eligible.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. Meta-analysis and qualitative synthesis were performed where appropriate.

MAIN RESULTS

We identified 14 RCTs, three cluster-randomised trials and two crossover trials, including a total of 1,564 participants in intervention groups and 1,248 controls. Two trials were of high quality. Interventions were grouped into 1) person-directed: cognitive-behavioural, relaxation, music-making, therapeutic massage and multicomponent; and 2) work-directed: attitude change and communication, support from colleagues and participatory problem solving and decision-making, and changes in work organisation. There is limited evidence that person-directed interventions can reduce stress (standardised mean difference or SMD -0.85; 95% CI -1.21, -0.49); burnout: Emotional Exhaustion (weighted mean difference or WMD -5.82; 95% CI -11.02, -0.63) and lack of Personal Accomplishment (WMD -3.61; 95% CI -4.65, -2.58); and anxiety: state anxiety (WMD -9.42; 95% CI -16.92, -1.93) and trait anxiety (WMD -6.91; 95% CI -12.80, -1.01). One trial showed that stress remained low a month after intervention (WMD -6.10; 95% CI -8.44, -3.76). Another trial showed a reduction in Emotional Exhaustion (Mean Difference or MD -2.69; 95% CI -4.20, -1.17) and in lack of Personal Accomplishment (MD -2.41; 95% CI -3.83, -0.99) maintained up to two years when the intervention was boosted with refresher sessions. Two studies showed a reduction that was maintained up to a month in state anxiety (WMD -8.31; 95% CI -11.49, -5.13) and trait anxiety (WMD -4.09; 95% CI -7.60, -0.58). There is limited evidence that work-directed interventions can reduce stress symptoms (Mean Difference or MD -0.34; 95% CI -0.62, -0.06); Depersonalization (MD -1.14; 95% CI -2.18, -0.10), and general symptoms (MD -2.90; 95% CI -5.16, -0.64). One study showed that the difference in stress symptom level was nonsignificant at six months (MD -0.19; 95% CI -0.49, 0.11).

AUTHORS' CONCLUSIONS

Limited evidence is available for the effectiveness of interventions to reduce stress levels in healthcare workers. Larger and better quality trials are needed.