Relaxation training methods for nurse managers in Hong Kong: a controlled study

Addressing Health Care Workers' Mental Health: A Systematic Review of Evidence-Based Interventions and Current Resources

Background. Mental health is declining in health care workers. Objectives. To provide a comprehensive assessment of intervention literature focused on the support and treatment of mental health within the health care workforce. Search Methods. We searched online databases (e.g., Medline, PsycINFO). Selection Criteria. We selected manuscripts published before March 2022 that evaluated the target population (e.g., nurses), mental health outcomes (e.g., burnout, depression), and intervention category (e.g., mindfulness). Data Collection and Analysis. Of 5158 publications screened, 118 interventions were included. We extracted relevant statistics and information. Main Results. Twenty (17%) earned study quality ratings indicating design, analysis, and implementation strengths. Randomized controlled trials were used by 52 studies (44%). Thirty-eight percent were conducted in the United States (n = 45). Ninety (76%) reported significant changes, and 46 (39%) reported measurable effect sizes. Multiple interventions significantly reduced stress (n = 29; 24%), anxiety (n = 20; 17%), emotional exhaustion or compassion fatigue (n = 16; 14%), burnout (n = 15; 13%), and depression (n = 15; 13%). Authors' Conclusions. Targeted, well-designed mental health interventions can improve outcomes among health care workers. Public Health Implications. Targeted health care‒focused interventions to address workers' mental health could improve outcomes within this important and vulnerable workforce. (Am J Public Health. 2024;114(S2):S213-S226. https://doi.org/10.2105/AJPH.2023.307556).

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.

Effect of stress management based on cognitive-behavioural therapy on nurses as a universal prevention in the workplace: a systematic review and meta-analysis protocol

INTRODUCTION

The mental health status of nurses affects not only their well-being but also the organisational outcomes and the quality of patient care. Hence, stress management strategies are critical as a universal prevention measure that address an entire population and are not directed at a specific risk group to maintain nurses' mental health in the workplace. No systematic review or meta-analysis has been conducted to evaluate the effect of cognitive-behavioural therapy (CBT) that specifically focuses on universal prevention. Therefore, the aim of this study is to examine the effectiveness that is reported in published randomised controlled trial (RCT) studies.

METHODS AND ANALYSIS

This systematic review and meta-analysis will analyse published studies selected from electronic databases (ie, Cochrane Central Register of Controlled Trials, PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, PsycARTICLES, Web of Science and the Japan Medical Abstracts Society). The inclusion criteria for studies are that they (1) were conducted to assess the effect of CBT on the mental health of nurses as a universal prevention, (2) used an RCT design and (3) provided sufficient results (sample sizes, means and SD) to estimate the pooled effect sizes with 95% CIs. Studies will be excluded if they only targeted nurses who had been screened as being at high risk in terms of their mental health and indicated that they required the prevention. The methodological quality of the included studies will be assessed using the Cochrane Collaboration's risk of bias tool.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is based on information obtained from previous studies. The results and findings of this study will be submitted for publication in a peer-reviewed international scientific journal. Results from this study will be helpful when implementing CBT strategies for nurses as a universal preventative measure in the workplace and for managing stress-related outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020152837.

Interventions to reduce the risk of mental health problems in health and social care workplaces: A scoping review

Work in the health and social care sector is stressful, and work-related stress increases the risk of depression, anxiety, burnout, and sleep disorders. Although interventions to reduce stress and burnout at workplaces have been developed and studied, most studies have lacked the effectiveness to improve the situation. Thus, more knowledge on interventions and analysis of their mechanisms is needed to reduce the risk of more adverse mental health problems (MHP). We conducted a scoping review to identify the relevant literature on individual and organizational interventions to improve mental health in health and social care workplaces. Data were gathered on target groups, intervention types and their effectiveness, and the outcomes of the interventions. We summarized this data thematically. The final review consisted of 76 studies. Mental health interventions primarily focused on health care workers rather than social care professionals. The interventions were mostly directed at individual workers, ignoring organizational-level interventions. They used a great variety of outcomes and questionnaires, and the questionnaires that measured the outcomes were used ambiguously. In most cases, the reported effectiveness of the studied interventions was incoherent, and many of the interventions had both statistically significant and non-significant effects. Evidence that interventions reduce the risk of work-related MHP is scarce. High-quality randomized controlled trials of interventions to promote mental health with more coherently formed outcomes are needed, especially on the organizational level. More interventions to improve social care professionals' mental health are also needed.

Improving Healthcare Worker Resilience and Well-Being During COVID-19 Using a Self-Directed E-Learning Intervention

Introduction: High rates of burnout, depression, anxiety, and insomnia in healthcare workers responding to the COVID-19 pandemic have been reported globally. Methods: Responding to the crisis, the Foundation for Professional Development (FPD) developed an e-learning course to support healthcare worker well-being and resilience. A self-paced, asynchronous learning model was used as the training intervention. Each module included practical, skill-building activities. An outcome evaluation was conducted to determine if completing the course improved healthcare worker knowledge of and confidence in the learning outcomes of the course, their use of resilience-building behaviours, their resilience, and their well-being. A secondary objective was to explore if there were any associations between behaviours, resilience, and well-being. Participants completed pre- and post-course questionnaires to measure knowledge of and confidence in the learning outcomes, y, frequency of self-reported resilience-building behaviours, and levels of resilience (CD-RISC) and well-being (WHO-5). Results were analysed in STATA using paired T-tests, univariate and multivariate linear regression models. Results: Participants (n = 474; 77.6% female; 55.7% primary care) exhibited significant increases in knowledge, confidence, resilience-building behaviour, resilience, and well-being scores. Statistically significant improvements in the frequency of resilience-building behaviours led to significant improvements in resilience (0.25 points; 95% CI: 0.06, 0.43) and well-being (0.21 points; 95% CI: 0.05, 0.36). Increasing changes in well-being scores had a positive effect on change in resilience scores (β = 0.20; 95% CI: 0.11, 0.29), and vice versa (β = 0.28; 95% CI: 0.14, 0.41). Conclusion: A healthcare worker e-learning course can build knowledge and skills that may prompt changes in resilience-building behaviours and improvements in well-being and resilience scores. The findings suggest that e-learning courses may improve more than competency-based outcomes alone but further research is warranted to further explore these relationships.

The Effectiveness and Safety of Mind-Body Modalities for Mental Health of Nurses in Hospital Setting: A Systematic Review

The mental health of nurses including burnout is an important issue. The purpose of this systematic review was to evaluate whether mind-body modalities improve burnout and other mental health aspects of nurses. A comprehensive search was conducted using six electronic databases. Randomized controlled trials using mind-body modalities on the mental health of nurses, up to January 2021, were included. The methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool. Seventeen studies were included in the review. Data on mindfulness-based interventions (MBIs) and yoga were available for burnout, and there was no evidence that multimodal resilience programs including MBIs statistically significantly improved burnout levels compared to no intervention or active control groups. However, one study reported that yoga could significantly improve emotional exhaustion and depersonalization, which are subscales of burnout, compared to usual care. In addition, the effects of MBIs, relaxation, yoga, and music on various mental health outcomes and stress-related symptoms have been reported. In conclusion, there was some evidence that yoga was helpful for improvement in burnout of nurses. However, due to the heterogeneity of interventions and outcomes of the studies included, further high-quality clinical trials are needed on this topic in the future.

The effect of progressive muscle relaxation exercises on compassion satisfaction, burnout, and compassion fatigue of nurse managers

PURPOSE

To investigate the effect of progressive muscle relaxation exercises on compassion satisfaction, burnout, and compassion fatigue of nurse managers.

DESIGN AND METHODS

A pretest, posttest, one-group quasi-experimental study was carried out with 30 nurse managers and they were received "Jacobson: Progressive Muscle Relaxation Exercises" in a group once in a week for 8 weeks.

FINDINGS

After the second month, the mean compassion fatigue (p < 0.01) and the mean burnout scores (p = 0.01) were decreased.

PRACTICE IMPLICATIONS

It is recommended to expand progressive muscle relaxation exercises and to conduct studies in different groups to increase the professional quality of life.

How we assess the perioperative anxiety of surgical patients with pulmonary nodules: the revision of state-trait anxiety inventory

PURPOSE

The aim of the study was to develop a short form of State-Trait Anxiety Inventory (STAI) and calculate the norms for the assessment of anxiety in surgical patients in mainland China.

METHODS

Patients who were scheduled to carry out pulmonary surgery in our department were included. The sinicized 40-item STAI Form-Y was used to assess the anxiety on the surgery eve. Then the coefficient of variation, coefficient of correlation, stepwise regression analysis, principal component analysis, and structural equation model were successively to filter the items. The reliability and validity of the revised STAI was estimated and the norms were computed.

RESULTS

445 intact replies were collected. A 13-item STAI with 6 items in state subscale and 7 items in trait subscale produced similar scores with the full version of STAI. The Cronbach alpha coefficients for the state and trait subscales were 0.924 and 0.936, respectively. The determinant coefficients were 0.781 and 0.822, respectively. Moreover, the norms of both state subscale and trait subscale are provided according to the age and gender.

CONCLUSIONS

The revised short form of STAI has good reliability and validity. It is likely to be more acceptable by reducing the fatigue effects, and is suitable for follow-up study on the assessment and intervention of perioperative anxiety of surgical patients with pulmonary nodules.

The effects of "Workplace Health Promotion Program" in nurses: A randomized controlled trial and one-year follow-up

In this study, the authors examined the effects of the "Workplace Health Promotion Program" (WHPP) on pain, fatigue, stress, professional quality of life (Pro-QoL), and coping skills for nurses. The authors conducted a randomized control trial in 30 nurses who agreed to participate in this study. Progressive relaxation training, posture and breath exercises, and ergonomic suggestions as a WHPP were applied to the intervention group (n = 15) during the five weeks. The intervention group showed decrease in pain (p = .001), fatigue (p = .001), and stress levels (p = .003) and increase in coping skills and Pro-QoL (p < .05). In contrast, the authors observed no improvement in the control group. The authors concluded at the end of the study that WHPP remains effective in nurses.

Correlation Between Subjective Happiness and Pleasant Activities at Workplace in Nursing Staff for Older Individuals in Japan

The purpose of this study was to investigate the correlations between nursing staff's mental health, number of years worked, night shifts performed, and pleasant activities at the workplace. One hundred forty-three subjects who had no missing data were analyzed. Questions consisted of basic attributes, subjective happiness scale (SHS), and pleasant activities conducted at the workplace. Denouements of SHS indicated a significant trend for the main effect, with more pleasant activities in the high SHS group than the low SHS group. The interaction was significant, with fewer pleasant activities in participants in the low SHS group who worked the night shift compared with those who worked the night shift regardless of work experience. The outcomes of this study suggest that it is essential to expand the repertoire of pleasant activities at the workplace to increase the subjective happiness of nursing staff for older individuals.

Effects of an internet-based cognitive behavioral therapy (iCBT) intervention on improving depressive symptoms and work-related outcomes among nurses in Japan: a protocol for a randomized controlled trial

BACKGROUND

Depression is a major problem among nurses; hence, it is important to develop a primary prevention strategy to manage depression among nurses. This randomized controlled trial (RCT) study aims to investigate the effects of a newly developed internet-based cognitive behavioral therapy (iCBT) program on depressive symptoms, measured at baseline and three- and six-month follow-ups, among nurses in Japan.

METHODS

Nurses working at three university hospitals, one public hospital, and twelve private hospitals who meet inclusion criteria will be recruited and randomized either to the intervention group or the control group (planned N = 525 for each group). The newly developed iCBT program for nurses consists of six modules, which cover different components of cognitive behavioral therapy (CBT); transactional stress model (in module 1), self-monitoring skills (in module 2), behavioral activation skills (in module 3), cognitive restructuring skills (in modules 4 and 5), relaxation skills (in module 5), and problem-solving skills (in module 6). Participants in the intervention group will be asked to read these modules within 9 weeks. The primary outcome will be depressive symptoms as assessed by the Beck Depression Inventory-II (BDI-II) at baseline, three-, and six-month follow-ups.

DISCUSSION

The greatest strength of this study is that it is the first RCT to test the effectiveness of the iCBT program in improving depressive symptoms among nurses. A major limitation is that all measurements, including major depressive episodes, are self-reported and may be affected by situational factors at work and participants' perceptions.

TRIAL REGISTRATION

This trial was registered at the University Hospital Medical Information Network clinical trials registry (UMIN-CTR; ID =  UMIN000033521 ) (Date of registration: August 1, 2018).

The effects of a relaxation intervention on nurses' psychological and physiological stress indicators: A pilot study

The present pilot study was designed to examine the feasibility and the effects of a psychomotor relaxation program on nurses' psychological (burnout symptoms, affective states) and physiological stress indicators (salivary cortisol). Fifteen nurses engaged in an 8-week psychomotor relaxation program (two 20-min sessions per week) and 15 maintained their usual activities. The current study showed that the psychomotor relaxation program was feasible and well tolerated by the participants. Compared to the control group, the relaxation group showed a decrease in their levels of emotional exhaustion, depression and salivary cortisol. In the fifteenth session, salivary cortisol concentrations significantly decreased from pre-session to post-session. These results provide preliminary evidence that relaxation interventions are effective strategies for reducing the usual stress experienced by nurses, and demonstrate that a psychomotor relaxation program might be an important occupational stress-management tool for healthcare professionals.

Effectiveness of progressive muscle relaxation therapy as a worksite health promotion program in the automobile assembly line

The aim of this study was to examine the effectiveness of Progressive Muscle Relaxation (PMR) as part of a Worksite Health Promotion Program on self-perceived stress, anxiety and depression among male automotive assembly-line workers through a quasi-experimental trial. Two assembly plants were chosen with one receiving PMR therapy and the other Pamphlets. Intention-to-treat analysis was conducted to test the effectiveness of the relaxation therapy. Stress, Depression and Anxiety levels were measured using the shortened DASS-21 questionnaire. Data were analyzed using Chi-square, Independent sample t test and Repeated-measures analysis of variance to test the significance of the effects of intervention (time * group) for the measures of Stress, Depression and Anxiety. Significant favourable intervention effects on stress were found in the PMR group (Effect size=0.6) as compared to the Pamphlet group (Effect size=0.2). There was a significant group *time interaction effect (p<0.001) on Stress levels. Depression and Anxiety levels were minimal at baseline in both the groups with mild or no reduction in levels. The improvement in stress levels showed the potential of PMR therapy as a coping strategy at the workplace. Further research in this field is necessary to examine the beneficial effects of coping strategies in the workplace.

The dimensions and effects of excessive change

Purpose

– Change excessiveness is argued as a critical contextual aspect of change management. The purpose of this paper is to identify three major dimensions to change excessiveness: change frequency, extent, and impact. A three-factor structure is proposed to broaden the emerging study on the contextual aspects of change. Its pertinence is proposed in addressing healthcare employees’ exhaustion, change-related uncertainty, and support for change.

Design/methodology/approach

– Using questionnaires, a first pilot sample (n=131) was recruited to test the psychometric properties and validity of the three-factor structure, while controlling for affectivity. Structural equation modeling techniques following a two-step approach were used on a second sample (n=363). First a confirmatory assessment of the three-factor structure of excessive change is tested. Second, a full mediation effect of excessive change, as a second-order latent factor, regrouping change frequency, impact and extent as first-order factors, was modeled to predict a tripartite conception of change-related reactions: exhaustion, uncertainty, and support for change.

Findings

– The excessive change three-factor structure is validated, while showing its superiority over alternative models. The fully mediated model is confirmed. Therefore, the significant added effects of change frequency, impact, and extent are positively related to emotional exhaustion and cognitive uncertainty, while negatively related with behavioral support for change.

Originality/value

– This study contributes by proposing a three-factor structure to excessive change assessment based on previous and independent findings in the literature. It also contributes in modeling the added effect of change frequency, extent, and impact in the full mediation relationship of change excessiveness on a tripartite reactions to change in healthcare management settings.

Nurse comfort…more than helpful hands

Nurses first focus on patients and often forget about caring for themselves. This article examines the issue of burnout and describes how nurse comfort can combat it.

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.

Preventing the development of depression at work: a systematic review and meta-analysis of universal interventions in the workplace

BACKGROUND

Depression is a major public health problem among working-age adults. The workplace is potentially an important location for interventions aimed at preventing the development of depression, but to date, the mental health impact of universal interventions in the workplace has been unclear.

METHOD

A systematic search was conducted in relevant databases to identify randomized controlled trials of workplace interventions aimed at universal prevention of depression. The quality of studies was assessed using the Downs and Black checklist. A meta-analysis was performed using results from studies of adequate methodological quality, with pooled effect size estimates obtained from a random effects model.

RESULTS

Nine workplace-based randomized controlled trials (RCT) were identified. The majority of the included studies utilized cognitive behavioral therapy (CBT) techniques. The overall standardized mean difference (SMD) between the intervention and control groups was 0.16 (95% confidence interval (CI): 0.07, 0.24, P = 0.0002), indicating a small positive effect. A separate analysis using only CBT-based interventions yielded a SMD of 0.12 (95% CI: -0.01, 0.24, P = 0.07). [corrected].

CONCLUSIONS

There is good quality evidence that universally delivered workplace mental health interventions can reduce the level of depression symptoms among workers. There is more evidence for the effectiveness of CBT-based programs than other interventions. Evidence-based workplace interventions should be a key component of efforts to prevent the development of depression among adults.

The art of mental health practice: the role of drama in developing empathy

PURPOSE

This paper explores concepts central to acting, and details how these concepts can be related to mental health nursing practice.

DESIGN AND METHODS

The work of the acting theorists Constantin Stanislavski and Lee Strasberg is examined and recontextualized to illustrate how their work is relevant in modern mental health practice, and the development of empathy.

FINDINGS

While these concepts are still utilized in drama, they have not been fully explored in their original context. Their use could combat stress and burnout, heighten awareness, and enhance the projection of emotions.

PRACTICE IMPLICATIONS

These concepts can be linked with reflective practice in mental health, and a stronger emphasis on the values of this approach could allow the nurse to strengthen the level of empathy they demonstrate.

Application of guided imagery to facilitate the transition of new graduate registered nurses

Traditionally, the new graduate registered nurse (RN) transition has included a didactic and skills-based orientation accompanied by a period of preceptored practice. However, these methods do not ensure that new RNs are in a state of reduced anxiety to fully interact with their new environment. Transition to practice may cause anxiety, and the new graduate RN may perceive moderate to severe stress. One method of stress reduction is the use of guided imagery, which has shown strong potential with a variety of populations undergoing stressful events. Today, new graduate RNs expect institutions to facilitate orientation to their new employment settings and assist in the transition to their role as a professional nurse. This article proposes a model that incorporates guided imagery for refining the new graduate RN transition process. The model can be adapted for use in the context of orienting other adult learners to unfamiliar practice situations.

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.

The efficacy of preopoerative instruction in reducing anxiety following gyneoncological surgery: a case control study

Background

This is a quasi-experimental case control research focusing on the impact of systematic preoperative instruction on the level of postoperative anxiety in gyneoncologic patients. The population studied consists of the gyneoncologic surgery patients admitted to the Gynecologic Oncology Service at Zekai Tahir Burak Gynecology Training and Research Hospital from May to September 2010.

Patients and methods

Through a random sampling, 60 patients were recruited in each group. The study group was given a systematic preoperative instruction while the control group was given routine nursing care. Patients were interviewed in the postoperative period and anxiety was measured. The data-collecting tool consisted of the Individual Information Form and the State-Trait Anxiety Inventory. The collected data were analyzed by using the SPSS Program to find the frequency, the percentage, the mean and the standard variables, and the hypothesis was tested with Chi-square, variance, and t-independent test.

Results

It was found that the incidence rates from the post-operative anxiety score of the study group were lower than those of the control group (p < .05). The results of this research demonstrated that gyneoncologic surgery patients who were given systematic preoperative instruction felt less anxious than the ones who were given merely a routine nursing care.

Conclusions

Results of this study suggest that preoperative instruction programs aiming at informing gyneoncologic surgery patients at the preoperative stage should be organized in hospitals and have an essential role.

Effects of short duration stress management training on self-perceived depression, anxiety and stress in male automotive assembly workers: a quasi-experimental study

To examine the effects of short duration stress management training (SMT) on self-perceived depression, anxiety and stress in male automotive assembly workers, 118 male automotive workers from Pekan, Pahang (n = 60, mean age = 40.0 years, SD = 6.67) and Kota Bharu, Kelantan (n = 58, mean age = 38.1 years, SD = 5.86) were assigned to experimental and control group, respectively. A SMT program consisting of aerobic exercise, stress management manual, video session, lecture, question and answer session, and pamphlet and poster session were conducted in the experimental group. A validated short-form Malay version of the Depression Anxiety Stress Scales (DASS-21) were self-administered before and after the intervention program in the experimental and control group and their time and group interaction effects were examined using the repeated measure ANOVA test. Results indicated that the mean (SD) scores for DASS-Depression (p = 0.036) and DASS-Anxiety (p = 0.011) were significantly decreased, respectively, after the intervention program in the experimental group as compared to the control group (significant time-group interaction effects). No similar effect was observed for the mean (SD) scores for DASS-Stress (p = 0.104). However, the mean (SD) scores for subscales of DASS-Depression (Dysphoria, p = 0.01), DASS-Anxiety (Subjective Anxiety, p = 0.007, Situational Anxiety, p = 0.048), and DASS-Stress (Nervous Arousal, p = 0.018, Easily Upset, p = 0.047) showed significant time and group interaction effects. These findings suggest that short duration SMT is effective in reducing some aspects of self-perceived depression, anxiety and stress in male automotive workers.

Stress management during pregnancy: designing and evaluating a mind-body intervention

The objective of this 12-week study was to determine whether a relaxation-guided imagery (R-GI) intervention designed as a primary prevention strategy for stress management was perceived as beneficial to African American women during the second trimester of pregnancy. All participants documented perceived benefits of the R-GI intervention that included the following: (1) improved breathing; (2) ability to relax, clear one's mind, and become calm; (3) ability to channel and decrease stress; (4) release of anxiety; (5) use of R-GI throughout the day helped control anger and state of mind, leading to a smoother day; and (6) improved ability to fall and stay asleep.

Relaxation training for anxiety: a ten-years systematic review with meta-analysis

BACKGROUND

Relaxation training is a common treatment for anxiety problems. Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after relaxation treatment.

METHODS

All studies (1997-2007), both RCT, observational and without control group, evaluating the efficacy of relaxation training (Jacobson's progressive relaxation, autogenic training, applied relaxation and meditation) for anxiety problems and disorders were identified by comprehensive electronic searches with Pubmed, Psychinfo and Cochrane Registers, by checking references of relevant studies and of other reviews. Our primary outcome was anxiety measured with psychometric questionnaires. Meta-analysis was undertaken synthesizing the data from all trials, distinguishing within and between effect sizes.

RESULTS

27 studies qualified for the inclusion in the meta-analysis. As hypothesized, relaxation training showed a medium-large effect size in the treatment of anxiety. Cohen's d was .57 (95% CI: .52 to .68) in the within analysis and .51 (95% CI: .46 to .634) in the between group analysis. Efficacy was higher for meditation, among volunteers and for longer treatments. Implications and limitations are discussed.

CONCLUSION

The results show consistent and significant efficacy of relaxation training in reducing anxiety. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation training.

Relaxation training for anxiety: a ten-years systematic review with meta-analysis

BACKGROUND

Relaxation training is a common treatment for anxiety problems. Lacking is a recent quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after relaxation treatment.

METHODS

All studies (1997-2007), both RCT, observational and without control group, evaluating the efficacy of relaxation training (Jacobson's progressive relaxation, autogenic training, applied relaxation and meditation) for anxiety problems and disorders were identified by comprehensive electronic searches with Pubmed, Psychinfo and Cochrane Registers, by checking references of relevant studies and of other reviews. Our primary outcome was anxiety measured with psychometric questionnaires. Meta-analysis was undertaken synthesizing the data from all trials, distinguishing within and between effect sizes.

RESULTS

27 studies qualified for the inclusion in the meta-analysis. As hypothesized, relaxation training showed a medium-large effect size in the treatment of anxiety. Cohen's d was .57 (95% CI: .52 to .68) in the within analysis and .51 (95% CI: .46 to .634) in the between group analysis. Efficacy was higher for meditation, among volunteers and for longer treatments. Implications and limitations are discussed.

CONCLUSION

The results show consistent and significant efficacy of relaxation training in reducing anxiety. This meta-analysis extends the existing literature through facilitation of a better understanding of the variability and clinical significance of anxiety improvement subsequent to relaxation training.

Dealing with stress: patterns of self-comfort among healthcare students

Stress among healthcare students is a growing problem. As self-comfort is assumed to be a way of coping with stressful emotions, the aim of this study was to describe the patterns of self-comforting actions that healthcare students usually use in distress. One hundred and sixty-eight healthcare students volunteered to write down accounts of what they do when they comfort themselves. Their accounts were analysed using qualitative content analysis. The findings reveal two themes: Ingressing and Transcending. Ingressing comprises the sub-themes Unloading, Distracting, Nurturing oneself, Withdrawing and Reassuring. Transcending comprises the sub-themes Opening up and Finding new perspectives. These findings are in line with some stress-reducing strategies described in the literature on stress management. Winnicott's theory about the phenomenon of transition is used to interpret the findings. In the light of Winnicott's theory, self-comforting measures can be comprehended as the ability to transfer early childhood experiences of being nurtured and comforted into well-adapted strategies to effect relaxation and gain strength.

Personal and professional impact of a course on contemplative practices in health and illness

A nursing graduate course focused on the impact of alternative healing modalities, particularly those that are contemplative in nature, on their professional and personal lives demonstrated that up to 4 years later students found the content to be of value. Suggestions for incorporation of CAM in mainstream nursing courses are shared.

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.