Individual‐level interventions for reducing occupational stress in healthcare workers

Sietske J Tamminga; Lima M Emal; Julitta S Boschman; Alice Levasseur; Anilkrishna Thota; Jani H Ruotsalainen; Roosmarijn MC Schelvis; Karen Nieuwenhuijsen; Henk F Molen

doi:10.1002/14651858.CD002892.pub6

. 2023 May 12;2023(5):CD002892. doi: 10.1002/14651858.CD002892.pub6

Individual‐level interventions for reducing occupational stress in healthcare workers

Sietske J Tamminga ^1,^2,^✉, Lima M Emal ^1,², Julitta S Boschman ^1,², Alice Levasseur ³, Anilkrishna Thota ⁴, Jani H Ruotsalainen ⁵, Roosmarijn MC Schelvis ^1,^2,⁶, Karen Nieuwenhuijsen ^1,², Henk F Molen ^1,²

Editor: Cochrane Work Group

PMCID: PMC10175042 PMID: 37169364

Abstract

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.

Keywords: Humans, Anxiety, Anxiety/diagnosis, Emotions, Health Personnel, Health Personnel/psychology, Occupational Stress, Occupational Stress/prevention & control, Psychotherapy, Psychotherapy/methods

Plain language summary

The effect of individual‐level interventions for reducing stress in healthcare workers

Key messages

‐ Individual‐level interventions in which one’s attention is on the experience of stress (like focusing on thoughts, feelings, behaviour) or away from the experience of stress (like exercising, relaxing) may reduce stress among healthcare workers up to one year after the intervention.

‐ A combination of individual‐level interventions may reduce stress up to a couple of months after the intervention.

‐ We do not know if interventions that focus on work‐related risk factors on an individual level have any effect on stress.

What is stress?

There is currently no clear definition of (work‐related) stress. This review is about healthcare workers with low levels of stress to moderate distress and burnout, which might lead to depression and anxiety but does not have to. People with stress can experience physical symptoms like headaches, muscle tension or pain, but also mental symptoms, like impaired concentration. They can also have behavioural problems (like conflicts with other people) and emotional problems (like emotional instability).

What can be done about stress among healthcare workers?

Stress among healthcare workers can be tackled at an organisational level, but also at an individual level. Stress management interventions at the individual‐level aim to:

‐ focus one’s attention on the experience of stress (thoughts, feelings, behaviour), for example by cognitive‐behavioural therapy or coping skills training;

‐ focus one’s attention away from the experience of stress, for example by yoga, Tai Chi, drawing, or acupuncture;

‐ alter work‐related risk factors on an individual level, such as alterations in work demands.

What did we want to find out?

We wanted to find out if various types of individual‐level stress management interventions are better than no intervention (or another intervention) to reduce stress among healthcare workers currently working as such.

What did we do

We searched for studies that looked at stress management interventions in healthcare workers and reported on stress symptoms. The healthcare workforce comprises a wide variety of professions and occupations who provide some type of healthcare service, including direct care practitioners and allied professionals.

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and study size.

What did we find?

We found a total of 117 studies that involved a total of 11,119 healthcare workers. Most studies followed their participants up to three months and some up to 12 months, but only few longer than a year.

We found that there may be an effect on stress reduction in healthcare workers from stress management 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. The long‐term effects of stress management interventions, longer than a year after the intervention has ended, remain unknown. The same applies for interventions on (individual‐level) work‐related risk factors.

What are the limitations of the evidence?

The estimates of the effects of individual‐level stress management interventions may be biassed because of a lack of blinding of the participants in the included studies. Furthermore, many studies were relatively small. Taken together, our confidence in the effects we found is reduced.

How up to date is this evidence?

The evidence is up‐to‐date to February 2022.

Summary of findings

Summary of findings 1. An intervention in which one's attention is on the experience of stress (feelings, thoughts, behavior) compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers.

An intervention in which one's attention is on the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers
Patient or population: healthcare workers  Setting: various healthcare settings Intervention: an intervention in which one's attention is on the experience of stress  Comparison: no intervention/wait list/placebo/no stress‐reduction intervention
Outcomes	*Anticipated absolute effects^ (95% CI)**	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
	Effect with an intervention in which one's attention is on the experience of stress
Stress symptoms (follow‐up up to and including 3 months after end of intervention)	SMD 0.37 lower (0.52 lower to 0.23 lower)	3645 (41 RCTs)	⊕⊕⊝⊝ Low¹	On the short term, an intervention in which one's attention is on the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 4.6 fewer (6.4 fewer to 2.8 fewer) points on the MBI‐emotional exhaustion scale².
Stress symptoms (follow‐up > 3 to 12 months after end of intervention)	SMD 0.43 lower (0.71 lower to 0.14 lower)	1851 (19 RCTs)	⊕⊕⊝⊝ Low¹	On the medium term, focus one's attention on the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 5.3 fewer (8.7 fewer to 1.7 fewer) points on the MBI‐emotional exhaustion scale³.
Stress symptoms (follow‐up >12 months after end of intervention)	no effect estimate	68 (1 RCT)	⊕⊝⊝⊝ Very low ²	The evidence is very uncertain about the long‐term effect on stress symptoms of focusing one's attention on the experience of stress.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).   CI: confidence interval; SMD: standardized mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

An intervention in which one's attention is away from the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers
Patient or population: healthcare workers  Setting: various healthcare settings Intervention: an intervention in which one's attention is away from the experience of stress  Comparison: no intervention/wait list/placebo/no stress‐reduction intervention
Outcomes	*Anticipated absolute effects^ (95% CI)**	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
	Risk with an intervention in which one's attention is away from the experience of stress
Stress symptoms (follow‐up up to and including 3 months after end of intervention)	SMD 0.55 lower (0.70 lower to 0.40 lower)	2366 (35 RCTs)	⊕⊕⊝⊝ Low ¹	On the short term, an intervention in which one's attention is away from the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 6.8 fewer (8.6 fewer to 4.9 fewer) points on the MBI‐emotional exhaustion scale².
Stress symptoms (follow‐up > 3 to 12 months after end of intervention)	SMD 0.41 lower (0.79 lower to 0.03 lower)	427 (6 RCTs)	⊕⊕⊝⊝ Low ¹	On the medium term, an intervention in which one's attention is away from the experience of stress may result in a reduction in stress symptoms. The standardized mean difference translates back to 5.0 fewer (9.7 fewer to 0.4 fewer) points on the MBI‐emotional exhaustion scale².
Stress symptoms (follow‐up >12 months after end of intervention)	‐	(0 RCTs)	‐	No studies reported the long‐term effect on stress symptoms of focusing one's attention away from the experience of stress.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).   CI: confidence interval; SMD: standardized mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

An intervention in which the focus is on work‐related risk factors on an individual level compared to no intervention/no stress‐reduction intervention for stress reduction in healthcare workers
Patient or population: healthcare workers  Setting: various healthcare settings Intervention: an intervention in which the focus is on work‐related risk factors on an individual level  Comparison: No intervention/no stress‐reduction intervention
Outcomes	*Anticipated absolute effects^ (95% CI)**	№ of participants (studies)	Certainty of the evidence (GRADE)	What happens
	Effect with an intervention in which the focus is on work‐related risk factors on an individual level
Stress symptoms (follow‐up up to and including 3 months after end of intervention)	no effect estimate	87 (3 RCTs)	⊕⊝⊝⊝ Very low ¹	The evidence is very uncertain about the short‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms.
Stress symptoms (follow‐up > 3 to 12 months after end of intervention)	no effect estimate	152 (2 RCTs)	⊕⊝⊝⊝ Very low ²	The evidence is very uncertain about the medium‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms.
Stress symptoms (follow‐up >12 months after end of intervention)	no effect estimate	161 (1 RCT)	⊕⊝⊝⊝ Very low ²	The evidence is very uncertain about the long‐term effect of an intervention in which the focus is on work‐related risk factors on stress symptoms.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).   CI: confidence interval; SMD: standardized mean difference; MD: mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Date	Event	Description
12 May 2023	New search has been performed	This review has been updated to include the results of a new search on February 2022. The previous review (Ruotsalainen 2015) has been split into this review on individual‐level interventions and a review on organization‐level interventions (Giga 2018). We used a replacement approach and used the previous review (Ruotsalainen 2015) as one source of studies.
12 May 2023	New citation required and conclusions have changed	In this update, we added 89 studies on top of the 28 related titles identified from the studies in the previous review making 117 total included studies. For this update, we categorized stress‐interventions and outcomes in another way, resulting in new GRADE assessments that are not one‐to‐one comparable to the previous version

Search ID#	Search Terms	Actions
S9	s7 NOT s8	View Results (1,521) View Details Edit
S8	TI patient*	View Results (727,918) View Details Edit
S7	S3 AND S6	View Results (1,742) View Details Edit
S6	AB ("randomized controlled trial" OR "controlled clinical trial" OR "controlled trial" OR random OR double‐blind OR "double blind") OR TI ("randomized controlled trial" OR "controlled clinical trial" OR "controlled trial" OR random OR double‐blind OR "double blind")	View Results (416,931) View Details Edit
S5	S3 AND S4	View Results (7,386) View Details Edit
S4	TX "randomized controlled trial" OR "controlled clinical trial" OR "controlled trial" OR random OR double‐blind OR "double blind" OR single‐blind OR "single blind" OR "clinical trial" OR ( ( singl OR doubl* OR trebl* OR tripl* ) AND (mask* OR blind* ) )	View Results (1,760,234) View Details Edit
S3	S1 AND S2	View Results (22,854) View Details Edit
S2	AB "health care personnel" OR "healthcare personnel" OR "health care worker" OR "healthcare worker" OR "health worker" OR "health professional" OR "health care professional" OR "healthcare professional" OR "medical care personnel" OR nurse? OR physician? OR anesthetist? OR audiologist? OR "dental staff" OR "dental personnel" OR dentist? OR "medical staff" OR "nursing staff" OR "nursing personnel" OR nutritionist? OR dietitian? OR therapist? OR pharmacist? OR veterinarian? OR "medical perso ...	View Results (1,026,684) View Details Edit
S1	AB stress OR "occupational stress" OR "occupational strain" OR "occupational burden" OR "work stress" OR "work strain?" OR "work burden?" OR "work‐related stress" OR "work‐related strain?" OR "work‐related burden?" OR "psychological load?"	View Results (146,198) View Details Edit

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)	41	3645	Std. Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.52, ‐0.23]
1.1.1 No intervention	29	2434	Std. Mean Difference (IV, Random, 95% CI)	‐0.35 [‐0.53, ‐0.16]
1.1.2 Wait list	9	619	Std. Mean Difference (IV, Random, 95% CI)	‐0.52 [‐0.80, ‐0.25]
1.1.3 Placebo	1	436	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.21, 0.16]
1.1.4 No stress‐reduction intervention	2	156	Std. Mean Difference (IV, Random, 95% CI)	‐0.33 [‐1.19, 0.53]
1.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)	19	1851	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.71, ‐0.14]
1.2.1 No intervention	11	1271	Std. Mean Difference (IV, Random, 95% CI)	‐0.46 [‐0.90, ‐0.02]
1.2.2 Wait list	6	480	Std. Mean Difference (IV, Random, 95% CI)	‐0.53 [‐0.83, ‐0.24]
1.2.3 No stress reduction intervention	2	100	Std. Mean Difference (IV, Random, 95% CI)	0.16 [‐0.23, 0.56]
1.3 Any symptoms of stress‐related outcome (follow‐up >12 months)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
1.4 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)	8	742	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.58, 0.03]
1.4.1 No intervention	7	482	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.68, 0.11]
1.4.2 Wait list	1	260	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.53, ‐0.04]
1.5 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
1.5.1 No intervention	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
1.6 Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)	41	3645	Std. Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.52, ‐0.23]
1.6.1 Short (< 12weeks)	29	2647	Std. Mean Difference (IV, Random, 95% CI)	‐0.32 [‐0.49, ‐0.15]
1.6.2 Long (≥ 12 weeks)	12	998	Std. Mean Difference (IV, Random, 95% CI)	‐0.50 [‐0.78, ‐0.22]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)	35	2366	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐0.70, ‐0.40]
2.1.1 No intervention	22	1565	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐0.61, ‐0.35]
2.1.2 Wait list	8	429	Std. Mean Difference (IV, Random, 95% CI)	‐0.88 [‐1.53, ‐0.24]
2.1.3 Placebo	3	168	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.74, ‐0.12]
2.1.4 No stress‐reduction intervention	2	204	Std. Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.55, 0.00]
2.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)	6	427	Std. Mean Difference (IV, Random, 95% CI)	‐0.41 [‐0.79, ‐0.03]
2.2.1 No intervention	4	312	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.98, 0.12]
2.2.2 Wait list	2	115	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.77, ‐0.03]
2.3 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)	7	378	Std. Mean Difference (IV, Random, 95% CI)	‐1.07 [‐1.95, ‐0.19]
2.3.1 No intervention	2	127	Std. Mean Difference (IV, Random, 95% CI)	‐0.67 [‐1.60, 0.25]
2.3.2 Wait list	3	173	Std. Mean Difference (IV, Random, 95% CI)	‐1.89 [‐4.24, 0.46]
2.3.3 Placebo	2	78	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.79, 0.11]
2.4 Explanatory analysis ‐ subgroup (short vs long duration of intervention): any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)	35	2366	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐0.70, ‐0.40]
2.4.1 Short (<12 weeks)	33	2255	Std. Mean Difference (IV, Random, 95% CI)	‐0.52 [‐0.68, ‐0.37]
2.4.2 Long (≥ 12 weeks)	2	111	Std. Mean Difference (IV, Random, 95% CI)	‐0.96 [‐1.48, ‐0.43]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
3.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)	3	Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.1.1 No intervention	2	Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.1.2 No stress‐reduction intervention	1	Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)	2	Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
3.3 Any symptoms of stress‐related outcome (follow‐up >12 months)	1	Mean Difference (IV, Random, 95% CI)	Totals not selected
3.4 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)	1	Mean Difference (IV, Random, 95% CI)	Totals not selected

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months after the end of the intervention)	15	1003	Std. Mean Difference (IV, Random, 95% CI)	‐0.67 [‐0.95, ‐0.39]
4.1.1 No intervention	10	666	Std. Mean Difference (IV, Random, 95% CI)	‐0.71 [‐1.08, ‐0.34]
4.1.2 Wait list	4	270	Std. Mean Difference (IV, Random, 95% CI)	‐0.79 [‐1.21, ‐0.38]
4.1.3 No stress‐reduction intervention	1	67	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.35, 0.61]
4.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)	6	574	Std. Mean Difference (IV, Random, 95% CI)	‐0.48 [‐0.95, ‐0.00]
4.2.1 No intervention	3	330	Std. Mean Difference (IV, Random, 95% CI)	‐0.70 [‐1.52, 0.12]
4.2.2 Wait list	2	177	Std. Mean Difference (IV, Random, 95% CI)	‐0.36 [‐0.65, ‐0.06]
4.2.3 No stress‐reduction intervention	1	67	Std. Mean Difference (IV, Random, 95% CI)	0.00 [‐0.48, 0.48]
4.3 Any symptoms of stress‐related outcome (follow‐up > 12 months)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
4.4 Psychological symptoms: anxiety and depression (follow‐up up to 3 months after the end of the intervention)	4		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
4.4.1 No intervention	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
4.4.2 Wait list	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
4.5 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
4.6 Psychological symptoms: anxiety and depression (follow‐up > 12 months after the end of the intervention)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months)	3		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
5.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
5.3 Psychological symptoms: anxiety and depression (follow‐up up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected
5.4 Psychological symptoms: anxiety and depression (follow‐up > 3 to 12 months after the end of the intervention)	1	38	Std. Mean Difference (IV, Random, 95% CI)	0.24 [‐0.39, 0.88]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 Any symptoms of stress‐related outcome (follow‐up up to 3 months)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
6.2 Any symptoms of stress‐related outcome (follow‐up > 3 to 12 months after the end of the intervention)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

*Study characteristics*
Methods	Study design: randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics Yoga Age (mean ± SD): NR Sex (N (% female)): NR Sample size: 20 Years of experience (mean ± SD): NR Control (No intervention) Age (mean ± SD): NR Sex (N (% female)): NR Sample size: 20 Years of experience (mean ± SD): NR Overall Age (mean ± SD): 46.38 ± 10.23 Sex (N (% female)): 39 (98%) Sample size: 40 Years of experience (mean ± SD): 14.21 ± 11.02 Included criteria: no prior experience with yoga, willingness to complete eight weekly sessions and homework exercises, and willingness to be randomly assigned to the research or control group. Excluded criteria: serious illness or major orthopaedic diagnoses of the neck, back, pelvis, or lower extremities that could interfere with completion of the yoga intervention protocol. Pretreatment: NR Compliance rate: NR Response rate: NR Type of healthcare worker: exclusively nurses
Interventions	Intervention characteristics Yoga Type of the intervention: Intervention type 2 ‐ to focus one’s attention away from the experience of stress Description of the intervention: In early yoga sessions, participants learned to become conscious of their breathing. Breathing is both a conscious and unconscious process and therefore gives conscious access to the autonomic nervous system. Inhalation stimulates the sympathetic nervous system, while exhalation stimulates the parasympathetic nervous system. When one inhales, heart rate increases and when one exhales, heart rate decreases. Practising mindful breathing allows individuals to calm the body and mind immediately, thereby decreasing stress or energising the nervous system if one feels fatigued or depressed (Burg & Michalak, 2011; Mason et al., 2013). Throughout the intervention, the instructor taught participants the basics of postural alignment, deep breathing, and monitoring the mind with simple meditations. Each session concluded with deep relaxation. Each participant received handouts for each session to provide further information and a visual reminder of the exercises, the basis for cultivating a home practice. As the series progressed, additional exercises, breathing practices, and meditations were added to expose participants to the wide range of movements that can work not only the skeletal muscles but also other body systems such as the internal organs, nervous system, circulation, and emotions. The number of sessions: eight Duration of each session on average: NR Duration of the entire intervention: eight weeks Duration of the entire intervention short vs long: Short Intervention deliverer: Experienced yoga instructor, who is an osteopathic physician in the local community Intervention form: Group Control (no intervention) Type of the intervention: NA Description of the intervention: NA The number of sessions: NA Duration of each session on average: NA Duration of the entire intervention: NA Duration of the entire intervention short vs long: NA Intervention deliverer: NA Intervention form: NA
Outcomes	MBI Outcome type: ContinuousOutcome Health Promoting Lifestyle Profile II (HPLP II) Outcome type: ContinuousOutcome
Identification	Sponsorship source: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Research and Creative Activities Fund of Texas Christian University. Country: USA Setting: Hospital Comments: NR Authors name: Gina K. Alexander Institution: Texas Christian University, Harris College of Nursing and Health Sciences Email: g.alexander@tcu.edu Address: TCU Box 298620, Fort Worth, TX 76129, USA Time period: NR
Notes	MBI‐EE included in analysis 2.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Questionnaire, and core study questionnaires. After individuals completed consent forms and baseline assessments, they were enroled in the study and randomized to the intervention (yoga) or usual care control group. A total of 54 individuals Sequence generation process not mentioned
Allocation concealment (selection bias)	Unclear risk	Insufficient information to understand whether intervention allocations could have been foreseen in advance of, during, enrolment.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Not reported.
Selective reporting (reporting bias)	Unclear risk	No trial registration or study protocol reported in the study and we did not find one online. No indication of selective reporting.
Other bias	Unclear risk	Compliance rate and response rate not reported.

*Study characteristics*
Methods	Study design: randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics Mindfulness training Age in years (mean ± SD): NR Sex (N (% female)): NR Sample size: 21 Years of experience (> 10 years): NR Control (wait list) Age in years (mean ± SD): NR Sex (N (% female)): NR Sample size: 21 Years of experience (> 10 years): NR Overall Age in years (mean ± SD): 47.3 ± 9.4 Sex (N (% female)): 24 (57%) Sample size: 42 Years of experience (> 10 years): 28 (67%) Included criteria: willingness to complete the questionnaires and commitment to adhere to the programmes' attendance and dedication requirements. Excluded criteria: were being in psychiatric or psychological treatment, or not being actively practising at the time of the study. Pretreatment: no initial differences between groups were found for the main variables of our study (mindfulness, F = 2.51, P = 0.12; burnout, F = 1.11, P = 0.30; and emotional exhaustion, F = 2.87, P = 0.10), including demographic or professional characteristics (P > 0.05) Type of healthcare worker: exclusively physicians Response rate: NR Compliance rate: regarding acceptability of the intervention to participants, the attendance rates for the two phases of the program were 88% for weekly sessions and 72% for monthly sessions
Interventions	Intervention characteristics Mindfulness training Type of the intervention: Intervention type 1 ‐ to focus one’s attention on the experience of stress Description of the intervention: The sessions were taught following the standardised MBSR protocol. Twenty‐minute PowerPoint presentation of a particular topic related to the medical profession (e.g. dealing with suffering, interpersonal relationships). A 45‐minute mindfulness exercise (body‐scan, yoga stretches, and meditation—i.e. breathing, observing thoughts, walking meditation). A 60‐minute group reflection about the weekly topic and the experiences with the mindfulness practice. This included Krasner's narrative and appreciative enquiry exercises. Dedicated time to record HR and BP at the beginning and end of each session. Additionally, participants were asked to practice mindfulness exercises every day for a period of 45 minutes by means of a set of CDs distributed to them and containing the same exercises as the ones practised in the class sessions. They were also required to register the number of days practised per week and the length of each of the sessions in minutes by means of a record sheet specially designed for that purpose The number of sessions: 9 Duration of each session on average: 2.5 hours + 45 min homework Duration of the entire intervention: 8 weeks Duration of the entire intervention short vs long: Short Intervention deliverer: MBSR instructor who was trained by Kabat‐Zinn at the Stress Reduction Clinic in the University of Massachusetts (USA) Intervention form: Group + homework Control (wait list) Type of the intervention: wait list Description of the intervention: The wait list control group was told that a similar course would be offered again. The number of sessions: NA Duration of each session on average: NA Duration of the entire intervention: NA Duration of the entire intervention short vs long: NA Intervention deliverer: NA Intervention form: NA
Outcomes	Maslach Burnout Inventory ‐ Emotional Exhaustion Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Depersonalisation Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Personal accomplishment (lack of) Outcome type: ContinuousOutcome
Identification	Sponsorship source: The authors report the University of the Basque Country (UPV/EHU)provided funding for the materials and travel expenses. The Official Medical College of Biscay in Spain provided the physical setting to conduct the sessions. Country: Spain Setting: all participants were actively used in public (42.9%) or private (52.4%) practice. Comments: NR Authors name: Alberto Amutio, PhD; Institution: Department of Social Psychology and Methodology of the BehavioralSciences, Faculty of Psychology, University of the Basque Country (UPV/EHU), Spain Email: Alberto.amutio@ehu.eus Address: Avda Tolosa, 70, Donostia‐San Sebastian, Gipuzko Time period: NR
Notes	MBI‐EE included in analysis 1.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "Participants in the experimental group (n = 21) were randomly selected using the statistical program SPSS 20.0. The remaining subjects were included in the control group (n = 21)."
Allocation concealment (selection bias)	Unclear risk	Judgement Comment: Unable to judge whether participants and/or investigators could possibly foresee assignment
Blinding of participants and personnel (performance bias) All outcomes	High risk	Quote: "Each participant in the experimental group committed to attending the sessions, doing the exercises assigned as home‐work, and answering the evaluation questions at the end of each of the phases of the study. The waitlist control group was told that a similar course would be offered again." Judgement Comment: Participants not blinded
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	not explicitly stated whether participants dropped out.
Selective reporting (reporting bias)	Unclear risk	No trial registration or no study protocol reported, nor did we find one online.
Other bias	Low risk	No indication of other sources of bias

*Study characteristics*
Methods	Study design: randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics Control (no intervention) Age in years (mean ± SD): 49.9 (8.7) Sex (N (% female)): 21 (95.5%) Sample size: 22 Years of experience (mean ± SD): 24.0 (10.8) Mindfulness and self‐compassion program Age in years (mean ± SD): 50.0 (7.9) Sex (N (% female)): 17 (73.9%) Sample size: 23 Years of experience (mean ± SD): 24.0 (8.0) Overall Age in years (mean ± SD): 4.9 (8.2) Sex (N (% female)): 38 (84.4%) Sample size: 45 Years of experience (mean ± SD): 24.0 (9.3) Included criteria: informed consent, committing to completing the pre‐ and post‐intervention questionnaires, attending at least 75% of the sessions and practising mindfulness and self‐compassion for 45 minutes a day. Excluded criteria: having completed a mindfulness and/or compassion program in the previous 6 months; having a psychiatric illness that did not make participation in the study advisable. Pretreatment: they were not significant in any of the characteristics considered. Type of healthcare worker: various healthcare staff but 46.7% nurses and physicians 53.3% Response rate: NR Compliance rate: Intervention group 92% and control group 92%
Interventions	Intervention characteristics Control (no intervention) Type of the intervention: NA Description of the intervention: NA Number of sessions: NA Duration of each session: NA Duration of the entire intervention: NA Duration of the entire intervention short vs long: NA Intervention deliverer: NA Intervention form: NA Mindfulness and self‐compassion program Type of the intervention: Intervention type 2 ‐ to focus one’s attention away from the experience of stress Description of the intervention: Each session dealt with a specific topic and included mindfulness and self‐compassion practices, with time for dialogue and exchange of experiences among the participants. Material was provided for the practices at home (manual of theoretical contents, audios and practice diaries). Learning how to become conscious of one's breathing. Throughout the intervention, the instructor taught participants the basics of postural alignment, deep breathing, and monitoring the mind with simple meditations. Each session concluded with deep relaxation. Number of sessions: 8 sessions Duration of each session: 2.5 hours each Duration of the entire intervention: 8 weeks Duration of the entire intervention short vs long: short Intervention deliverer: It was taught by an instructor with a master's degree in Mindfulness and trained in the MBSR and MSC programs. Intervention form: group
Outcomes	Perceived Stress Questionnaire (PSQ) Outcome type: ContinuousOutcome Reporting: Fully reported Direction: Lower is better Data value: Endpoint
Identification	Sponsorship source: This work has been partially financed by the Department of Health of the Government of Navarra, by obtaining the first prize in the II Contest of Ideas for Health Research in Primary Care. Country: Spain Setting: NR Comments: NR Authors name: Aranda Auserón Institution: Subdirección de Farmacia, Servicio Navarro de Salud‐Osasunbidea (SNS‐O), Pamplona, Spain Email: garandaa@navarra.es Address: NR
Notes	PSS included in analysis 2.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	The randomization of the groups was carried out by assigning correlative numbers to the 48 participants and selecting a total of 25 from a balloon with 48 numbered balls; these numbers were part of the intervention group, with the rest remaining in the control group.
Allocation concealment (selection bias)	Unclear risk	Insufficient information to understand whether intervention allocations could have been foreseen in advance of, during, enrolment.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants not blinded whereas outcomes are self‐reported
Incomplete outcome data (attrition bias) All outcomes	Low risk	3 of the 48 (16%) randomised participants were lost to follow‐up, which is below our pre‐defined cut‐off point.
Selective reporting (reporting bias)	Unclear risk	No trial protocol or registration mentioned in the study nor did we find one online.
Other bias	Unclear risk	Low participation rate in the study (48 of 1281; 3.75%)

*Study characteristics*
Methods	Study design: randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics Evaluation of a well‐being workshop Age 25 to 29 30 to 34 35 to 44: 12 (52) 5 (22) 6 (26) Sex ((N) % female): 16 (70%) Sample size: 23 Years of experience (mean ± SD): NR Control (no intervention) Age 25 tp 29 30 to 34 35 to 44: 16 (70) 4 (17) 3 (13) Sex ((N) % female): 18 (78%) Sample size: 23 Years of experience (mean ± SD): NR Overall Age 25 to 29 30 to 34 35 to 44: 28 (61) 9 (20) 9 (20) Sex ((N) % female): 34 (74%) Sample size: 46 Years of experience (mean ± SD): NR Included criteria: recruitment was restricted to physician trainees completing their RACP basic physician training in New South Wales (NSW) hospitals. Excluded criteria: NR Pretreatment: differences between groups at 3 and 6 months were assessed using linear regression models, with group as a covariate, and adjusted for the participants’ baseline value of the outcome measure. Compliance rate: not explicitly reported "Lack of control over work rosters, difficulty swapping shifts, being on call or studying for the RACP exams, were major factors influencing the intervention group participant attendance at workshops" Response rate: 88% Type of healthcare worker: exclusively physician trainees
Interventions	Intervention characteristics Evaluation of a wellbeing workshop Type of the intervention: Intervention type 1 ‐ to focus one’s attention on the experience of stress Description of the intervention: following review of the international literature, a workshop was developed in consultation with local experts to promote health and wellbeing for physician trainees. The workshop objectives were to outline strategies for wellbeing and stress management and to encourage participants to apply these strategies in their own lives. The workshop incorporated case studies specifically developed for physician trainees, a holistic well‐being framework and group work activities to encourage discussion about approaches to work, life and self‐care. Some topics in the workshop included stressors relating to work–life balance, understanding well‐being and resilience, mindfulness, barriers to looking after well‐being, giving and receiving feedback and stress management strategies. The number of sessions: 1 Duration of each session on average: 4.5 hours including 1‐hour break Duration of the entire intervention: 4.5 hours Duration of the entire intervention short vs long: Short Intervention deliverer: Workshops were facilitated by specialist clinicians who received specific training to facilitate the workshops Intervention form: Group Control (no intervention) Type of the intervention: NA Description of the intervention: NA The number of sessions: NA Duration of each session on average: NA Duration of the entire intervention: NA Duration of the entire intervention short vs long: NA Intervention deliverer: NA Intervention form: NA
Outcomes	ProQOL ‐ Burnout Outcome type: ContinuousOutcome DASS ‐ stress Outcome type: ContinuousOutcome DASS ‐ Anxiety Outcome type: ContinuousOutcome DASS ‐ Depression Outcome type: ContinuousOutcome
Identification	Sponsorship source: The authors received no financial support for the research, authorship, and/or publication of this article Country: Australian Setting: Several hospitals Comments: NR Authors name: Carmen Axisa Institution: University of Technology Sydney, Sydney, NSW, and; PhD Candidate, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia Email: carmen.axisa@uts.edu.au Address: University of Technology Sydney, Building 10, Level 7, 235 Jones St, Ultimo, Sydney, NSW 2007, Australia. Time period: 2014‐105
Notes	DASS‐stress included in analysis 1.1 and 1.2 DASS‐Anxiety included in analysis 1.4 and 1.5
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "Participants were randomly assigned to the intervention or control group using a web‐based True Random Number Generator service."
Allocation concealment (selection bias)	Unclear risk	Unable to judge whether participants and/or investigators could possibly foresee assignment
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported
Incomplete outcome data (attrition bias) All outcomes	High risk	46 of the 59 (78%) randomised participants included in the analyses. Not reported whether lost to follow‐up was at random.
Selective reporting (reporting bias)	Low risk	No trial registration or no study protocol reported. No indication of selective reporting.
Other bias	Unclear risk	Compliance difficult to assess.

*Study characteristics*
Methods	‐Study design: cluster‐randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics Psychoeducational intervention Age in years (mean ± SD): 43.4 ± 10.0 Sex (N (% female)): 27 (100%) Sample size: 27 Years of experience (mean ± SD): 9.84 ± 4.9 Education‐only (active control) Age in years (mean ± SD): 45.9 ± 8.0 Sex (N (% female)): 31 (100%) Sample size: 31 Years of experience (mean ± SD): 9.4 ± 2.5 Overall Age in years (mean ± SD): 44.72 ± 9.0 Sex (N (% female)): 58 (100%) Sample size: 58 Years of experience (mean ± SD): 9.6 ± 3.7 Included criteria: to be included in the study, DCWs had to be employed for at least two months (so adjustments to the residents and facility had been achieved) and provide morning personal care (i.e. period of time between 7AM and 12AM that involved activities related to bathing, grooming, dressing and toileting) to people with a diagnosis of moderate to severe dementia. Excluded criteria: temporary DCWs and trainees were excluded as it was not possible to ensure their participation until the end of the study. Pretreatment: None of the measured socio‐demographic variables were statistically significantly different at baseline. At baseline, there were no significant differences between the groups in perceived stress, burnout, or job satisfaction. Compliance rate: NR Response rate: 100% Type of healthcare worker: Exclusively direct care workers (DCWs)
Interventions	Psychoeducational intervention Type of the intervention: Intervention type 4 ‐ Combination of two or more of the above Description of the intervention: the supportive component aimed to provide DCWs with coping strategies to manage work‐related stress and prevent burnout (e.g. time‐management, assertiveness, and problem‐solving). At the end of each supportive component, relaxation techniques, stretching, and strengthening exercises were practised. The number of sessions: 8 Duration of each session on average: 90 min Duration of the entire intervention: 8 weeks Duration of the entire intervention short vs long: short Intervention deliverer: by a gerontologist and a physical therapist with training and experience in PCC approaches and psycho‐educational groups Intervention form: group Education‐only (active control) Type of the intervention: education‐only Description of the intervention: the control facilities received an education‐only intervention.The coordination, length, order, and content of the sessions were the same as the educational component of the PE intervention. It was the absence of the supportive component that distinguished both interventions. Each participant was assisted during morning care by the same professionals who helped DCWs to deliver a more PCC and clarified doubts that emerged from sessions. The number of sessions: 8 Duration of each session on average: 90 min Duration of the entire intervention: 8 weeks Duration of the entire intervention short vs long: short Intervention deliverer: by a gerontologist and a physical therapist with training and experience in PCC approaches and psycho‐educational groups Intervention form: Group
Outcomes	The Perceived Stress Scale (PSS) Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Emotional exhaustion Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Depersonalisation Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Personal accomplishment Outcome type: ContinuousOutcome
Identification	Sponsorship source: This work was supported by grants (grant numbers SFRH/BD/72460/2010 and RIPD/CIF/109464/2009) from the Foundation for Science and Technology (FCT) Country: Portugal Setting: 4 aged‐care facilities Comments: NR Authors name: Ana Barbosa Institution: Department of Health Sciences, University of Aveiro, Campus Universita ´rio de Santiago, Email: anabarbosa@ua.pt Address: Agra do Crastoedifıcio 30, Aveiro, Portugal. Time period: NR
Notes	PSS included in analysis 7.1 and 7.2
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	All four facilities agreed to participate and were randomly allocated to the experimental group—PE intervention—or control group— education‐only intervention, using a random number generator.
Allocation concealment (selection bias)	Low risk	After recruitment, the facilities within each pair were randomly assigned to the experimental group–PE intervention—or control group— education‐only intervention—using a random number generator. This decision was supported by the fact that education has become the most widely used approach with DCWs. Randomization occurred at the facility level because of possible contamination. No indication of allocation concealment
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Participants were blinded to the experimental or the control group.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Researchers were not blinded to the intervention or assessments, however outcomes were PROs.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Lost to follow‐up not at random (due to sick leave, dismissal, vacation) but relatively small (13%)
Selective reporting (reporting bias)	Unclear risk	No trial registration or study protocol reported, nor did we find one online. No indication of selective reporting.
Other bias	Unclear risk	Unit of analysis error (i.e. when a study ignored the clustering of the data in their analysis). Compliance not reported.

*Study characteristics*
Methods	RCT, USA
Participants	Nurses with at least 6 months full‐time bedside nursing in a hospital setting. Those who regularly receive massage therapy on their own as well as anyone with medical reasons for not being able to have chair massage were excluded.
Interventions	1) Experimental: massage: application to the back, neck, shoulders, arms and hands. Techniques used were effleurage, petrissage, friction, vibration and compression. One 30‐minute session per person over 4 days 2) Control: 10‐minute self‐directed break
Outcomes	The Perceived Stress Scale
Identification
Notes	PSS included in analysis 2.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Not reported.
Allocation concealment (selection bias)	Low risk	"Sample size was 82 participants, randomly assigned to the massage group or the control group per a randomization schedule developed by a biostatistician who worked for the hospital but was not on the study team" (p. 337)
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	"A total of 60 follow‐up surveys were completed, a 73% return rate" (p.339)
Selective reporting (reporting bias)	Low risk	There was only one outcome measured and reported.
Other bias	Unclear risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	RCT, UK
Participants	20 forensic mental health nurses
Interventions	1) Experimental: psychosocial Intervention Training: 20 days of training with the aim to improve nurses' knowledge about serious mental illness and attitude towards patients and thus decrease subjective burnout. Training duration 6 months. The training helps clinicians to conceptualise their patients' problems within a more empathic framework and trains them in the skills to intervene effectively. Thus, self‐efficacy may increase and jobs may be perceived as more rewarding. 2) Control: no intervention
Outcomes	MBI directly after training
Identification
Notes	MBI‐EE included in analysis 3.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"The 20 staff who volunteered for the PSI training were randomly allocated to either the experimental PSI training group (n = 10) or a waiting list control group (n=10). The sample was stratified by ward, sex and day/night duty, thus subjects in each group represented all grades of staff and all wards." (p. 473)
Allocation concealment (selection bias)	Unclear risk	Not reported.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Presumably all participants completed all measurements as no data reported on dropouts.
Selective reporting (reporting bias)	Low risk	All outcomes reported.
Other bias	Unclear risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	RCT, the Netherlands
Participants	99 nursing assistants
Interventions	1) Experimental: Integrated emotion‐oriented care: Basic training course of two days with an intermediary period of two weeks for homework (for all staff members on intervention wards) addressing staff members' own experience, phases of ego‐experience of the demented residents and the application of (non‐)verbal empathic skills. Advanced course of seven days spread out over seven to eight months for five people from each intervention ward and an Adviser course of 10 days over nine months for one person from each intervention ward. 2) Control: Training and support in giving usual care
Outcomes	The Organization and Stress Scale
Identification
Notes	OSS included in analysis 3.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"A pretest‐posttest control group design with matched groups (randomized clinical trial) was used" (p. 331)
Allocation concealment (selection bias)	Unclear risk	Not reported.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	"During the experimental period 25 nursing assistants dropped out due to: illness (11), pregnancy (2), and transfer (9). In three cases questionnaires were missing. Data analysis was carried out on 99 'complete' cases. Drop‐out did not differ between the groups..." (p. 333)
Selective reporting (reporting bias)	High risk	For nursing assistants results consist of covariance analyses that were not prespecified.
Other bias	Low risk	We did not identify any indications of other sources of bias.

*Study characteristics*
Methods	Cluster‐RCT, the Netherlands
Participants	Nurses on wards of an academic hospital were screened for work and health problems: Experimental: 29 wards, 591 participants of which 151 screened positive. Control: 28 wards, 561 participants of which 161 screened positive. Experimental: 17%, Control 22% men, > 45 years age ‐ Experimental 51% Control 46%, > 10 years of experience ‐ Experimental 51% Control 41%
Interventions	1) Experimental 1: all who screened positive were referred to Occupational Health Physician (OHP). Participants who were screened as positive were invited for a face‐to‐face preventive consultation with their occupational physician. The consultation was voluntary, and workers could reschedule or cancel it if they wished. Supervisors were not informed about the screening results or about the invitation for and content of the preventive consultation of any employee. The 7‐step protocol for OHPs closely followed occupational physicians’ care as usual for consultations initiated by the employee in contrast to the compulsory consultation in the context of absenteeism. Occupational physicians received 3 hours of training from the researchers on the use of the protocol. (CBT) 2) Experimental 2: participants received personalised feedback on their screening results immediately after filling out the baseline questionnaire, both onscreen and in an e‐mail. The personalised feedback was followed by an invitation for a tailored offer of self‐help EMH interventions, on the basis of an algorithm based on the specific symptoms and the work‐relatedness of the symptoms. participants were mostly offered a choice of 2 to 3 EMH interventions to leave room for personal preferences. Participants who screened negative on all mental health complaints were invited to follow an EMH intervention aimed at enhancing and retaining their mental fitness. The EMH interventions are self‐help interventions on the Internet aimed at reducing specific mental health complaints or enhancing well‐being. The interventions are mainly based on the principles of cognitive behavioural therapy and combine a variety of aspects, e.g. providing information and advice, weekly assignments, the option of keeping a diary and a forum to get in contact with others who have similar complaints. The EMH interventions were developed as stand‐alone interventions by the Trimbos Institute (CBT). 2) Control: waiting list: In the control arm. Participants filled out the baseline questionnaire; however, results of the screening‐questionnaires were not to be reported back to participants, and no further interventions were advised at baseline. As compensation, participants in the control arm received their personal screening results together with a tailored choice for a self‐help EMH intervention six months after baseline.
Outcomes	Gartner 2013: the study's primary outcome was help‐seeking behaviour; we used secondary outcomes: distress from the Dutch 4DKL, anxiety and depression from Brief Symptom Inventory Ketelaar 2013: the study used work‐functioning as the primary outcome: we used the distress part of the Dutch 4DKL as stress outcome; anxiety and depression were also measured but not reported Bolier 2014: Brief Symptom Inventory (BSI) ‐ Anxiety and Brief Symptom Inventory (BSI) ‐ depression Noben 2014: cost‐effectiveness
Identification
Notes	We got the following data for the distress scale of the 4DKL at 6 months follow‐up for the group who screened positive from author K Nieuwenhuijsen: Experimental: N = 86 6.24 ± 6.52 Control: N = 116 6.82 ± 6.57 We got the following data from author S. Ketelaar: Distress measure with 4DKL at 6 months follow‐up for the group who screened positive: Experimental: N = 52 6.06 ± 6.54; Control: N = 116 6.82 ± 6.5.7 4DKL included in analysis 1.2 Intervention groups combined to create a single pair‐wise comparison. BSI‐depression included in analysis 1.4 Experimental 2 vs control 4DKL included in analysis 5.2 Experimental 1 vs Experimental 2
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	" Randomization was performed at the ward level (n = 86). Randomization sequences with a block size of three were generated with Nquery Advisor (Statistical Solutions, Ltd, Cork, Ireland) by one researcher (K.N.) who was not involved in the recruitment"
Allocation concealment (selection bias)	Unclear risk	Not blinded
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	At 3 months lost to follow‐up: Experimental 37% / Control 30%; at 6 months Experimental 46% / Control 34%
Selective reporting (reporting bias)	Low risk	Gartner 2013: All outcomes reported that were announced in protocol Ketelaar 2013: Anxiety and Depression were not reported in Ketelaar 2013 but in Bolier 2014
Other bias	Unclear risk	Compliance very low: 34% of those invited visited their OHP

*Study characteristics*
Methods	RCT, Turkey
Participants	Quote: "All of the nurses (n = 227) were invited to complete the Maslach Burnout Inventory (MBI) developed by Maslach & Jackson (1981). Those who completed the questionnaire and received a score on emotional exhaustion higher than the median score for all nurses were invited to participate in the burnout reduction intervention." (p. 487) 108 nurses were randomised to one of three conditions.
Interventions	1) Coping training (N = 36) Quote: "The group that received coping training consisted of two groups, each group consisting of 18 people. In the first week, the concept of stress was explained to the nurses, and coping methods used by the nurses in stressful conditions were discussed. In the second session, basic communication skills on the stress level were discussed. In the third session, cognitive coping methods were presented theoretically. In the fourth session, cognitive distortions found among nurses and methods for coping with these distortions were discussed. In the fifth session, the problem‐solving method was theoretically explained to the nurses. In the sixth session, stressful situations that the nurses encountered were discussed and resolved by means of the problem‐solving method. In the seventh session, problems that the nurses had difficulty coping with were discussed by utilizing the skills learnt during the course of the programme." (p. 488) 2) Support group (N = 36) "...the support group consisted of three groups, each group consisting of 12 people. The nurses talked about the most frequently encountered stressors in the workplace and expressed their feelings towards their jobs. At the beginning of each session, the nurses expressed their feelings related to difficult situations at the workplace. Then, a problem chosen by the nurses was attempted to be solved by using reflective cycle steps. Researchers provided information when needed. Possible solution methods were discussed in the groups, and the nurses were advised to use these methods in their daily lives. The nurses shared their difficult and favourable times and also exchanged recommendations with each other." (p. 488) 3) Control: No intervention (N = 36)
Outcomes	MBI
Identification
Notes	MBI‐EE included in analysis 1.1 and 1.2. Intervention groups combined to create a single pair‐wise comparison.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Random allocation was concealed by using a system of sequentially numbered, opaque, sealed envelopes containing the computer‐generated random allocation, which had been drawn up by a statistician. During the randomization, the researchers and the participants did not know the groups to which they would be allocated." (p. 487)
Allocation concealment (selection bias)	Low risk	See above
Blinding of participants and personnel (performance bias) All outcomes	High risk	"No blinding was applied to the participants and the researchers." (p. 487)
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	"Intention‐to‐treat analysis was used because of sample loss." (p. 487)
Selective reporting (reporting bias)	Low risk	The authors only measured and adequately reported results of the MBI.
Other bias	Unclear risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	Cluster‐RCT, Denmark
Participants	210 eldercare workers
Interventions	1) Experimental 1: Stress Management Intervention: The SMI was developed to address the work stress in health care with particular attention to prevention of burnout and development of strategies for stress management. Training occurred over 20 weeks, with group sessions every 2 weeks, and each session lasting 2 hours. Between sessions, the participants were given assignments concerning implementation of the programme in daily practice. 2) Experimental 2: Transfer Technique Intervention: The TTI was based on the Stockholm training concept, which aims to reduce the biomechanical load on the back, minimise work in asymmetric postures, and prevent sudden unexpected loads. Training in the TTI arm was a combination of practical classroom education (24 hours for each worker) and instruction at the work site. There were 11 instructors who belonged to the 7 groups in the TTI arm, with 1 to 2 persons in each group who received 30 hours of education during the initial phase of the study. 3) Control: Reference Programme consisting of lessons of the participants' own choice in matters unrelated to the intervention programmes but of the same duration as the active intervention lessons (e.g. on skin care, proper treatment of a person with diabetes, etc.)
Outcomes	MBI (results not reported in article but obtained directly from author)
Identification	MBI‐EE included in analysis 1.2
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Randomization was performed at group level because the intervention programs were meant to involve the employee as a group during education and implementation. The assignment to the different intervention programs was balanced to secure representation of all 3 programs in each of the wards." (p.1762)
Allocation concealment (selection bias)	Unclear risk	Not reported.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	Quote: "Altogether, 163 members of the source population (79%) participated in both baseline and follow‐up investigation, and completed at least 2 sets of diaries during the study period. The proportion of dropouts from baseline to follow‐up did not differ significantly across intervention groups. We observed no differences in age and number of years occupied in health care and mean intensity of LBP during the past year between participants who remained in the study and participants who dropped out." (p.1762).
Selective reporting (reporting bias)	High risk	Results data for the MBI, Setterlind's Stress Scores and rating of social support were not reported because they were not statistically significantly different between groups. "...[N]o significant changes were found in either of the intervention arms in ... the Maslach Burnout Inventory, the Setterlind stress scores, or the rating of social support (data not shown)" (p. 1765)
Other bias	Low risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	Study design: cluster‐randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics Novel training (intervention group) Age (N (%)) 26‐30, 31‐35, 36‐40, 41‐50: 17 (29%), 38 (64%), 4 (7%), 0 Sex (N (% female)): 45 (76%) Sample size: 59 Years of experience (mean ± SD): NR Usual training (control group) Age (N (%)) 26‐30, 31‐35, 36‐40, 41‐50: 12 (29%), 27 (66%), 1 (2%), 1 (2%) Sex (N (% female)): 31 (76%) Sample size: 41 Years of experience (mean ± SD): NR Overall Age (N (%)) 26‐30, 31‐35, 36‐40, 41‐50: NR Sex (N (% female)): NR Sample size: 100 Years of experience (mean ± SD): NR Included criteria: NR Excluded criteria: NR Pretreatment: there were no significant differences between the UT and intervention arms with respect to age, gender, or additional professional degrees. At baseline, pretest data reveal that UT and intervention groups did not differ significantly in their scores on the PHOSAH, MBI, PPOS, or Empowerment at Work Scale (Table 2). Mean scores on the PHOSAH, the primary outcome measure, were 7.4 (SD 4.2) for fellows in the UT group and 8.2 (SD 3.3) for the intervention group (P = 0.35). However, baseline performance on the PHOSAH was somewhat lower than previously published, with mean score of 9 (SD 3.4) .15 Fellows in both groups had similar levels of satisfaction with their fellowship training in several domains of humanism and professionalism (Table 3). Compliance rate: NR Response rate: NR Type of healthcare worker: paediatric haematology‐oncology fellows
Interventions	Intervention characteristics Novel training (intervention group) Type of the intervention: Intervention type 1 ‐ to focus one’s attention on the experience of stress Description of the intervention: The intervention arm of this study futilises a novel, 4‐module, case‐based curriculum which aims to foster PHO fellows’ reflection on the feelings, challenges, and conflicts arising in the care of children and families affected by cancer or blood disorders. The number of sessions: NR Duration of each session on average: NR Duration of the entire intervention: NR Duration of the entire intervention short vs long: short Intervention deliverer: faculty facilitator Intervention form: group Usual training (control group) Type of the intervention: NR Description of the intervention: NR The number of sessions: NR Duration of each session on average: NR Duration of the entire intervention: NR Duration of the entire intervention short vs long: NR Intervention deliverer: NR Intervention form: NR
Outcomes	Maslach Burnout Inventory ‐ Emotional Exhaustion Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Depersonalisation Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Personal accomplishment (lack of) Outcome type: ContinuousOutcome
Identification	Sponsorship source: NR Country: USA Setting: Hospital Comments: NR Authors name: Jennifer Kesselheim Institution: Department of Pediatric Oncology, Dana‐Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusettes Email: Jennifer_kesselheim@dfci.harvard.edu Address: Jennifer Kesselheim, Dana‐Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusettes 450 Brookline Avenue, D1107, Boston, MA02215 Time period: 2016‐2017
Notes	MBI‐EE included in analysis 1.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: Program directors committed to study participation sought local approval from their Institutional Review Board after which their program was randomized to either the intervention or UT arm of the study. Sequence generation process insufficiently described.
Allocation concealment (selection bias)	Unclear risk	Unable to judge whether participants and/or investigators could possible foresee assignment.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	89 of the 100 randomised participants included in the analysis (89%). Reasons not described nor whether missing was at random. However loss to follow‐up is below our pre‐defined cut‐off point.
Selective reporting (reporting bias)	Unclear risk	No trial registration or no study protocol reported, nor did we fine one online
Other bias	Unclear risk	Unit of analysis error (i.e. when a study ignored the clustering of the data in their analysis). Compliance not reported.

*Study characteristics*
Methods	RCT, Brazil
Participants	75 nurses at the Teaching Hospital of the University of São Paulo. Quote: "In order to define the sample of participants, the authors used the Stress Inventory or Stress Symptoms List – SSL. This instrument was applied to all subjects who agreed to participate in the study (N = 109); however, only subjects who achieved mean (29 to 60 points), high (61 to 120 points) or very high (>120 points) scores were included in the sample; 75 of them completed the study. As for the distribution of the participants, 22 subjects were placed in the Control Group, 27 in the Needles Group and 26 in the Seeds Group." (p. 88) Quote: "The inclusion criteria were: belonging to the nursing team; voluntary participation in the study with availability to attend the sessions; obtaining a minimum SSL score at mean, high and very high stress level; not being pregnant. The authors excluded from the sample all the subjects who went on vacation or medical leave after the beginning of the study; did not show up to the session or gave up due to adverse effects, and those who had low SSL score." (p. 88)
Interventions	1) Experimental 1: Auriculotherapy (form of acupuncture performed on the ears) with needles (n = 27) 2) Experimental 2: Auriculotherapy with seeds (n = 26) 3) Control: No intervention(n = 22) "The intervention groups received eight sessions (one session a week), with duration of 5 to 10 minutes each session, on the Shenmen, Kidney and Brainstem points. The first two points have calmative properties and the kidney point has energetic function. After the location of the reactive points with a point locator, the ear auricle was hygienized with cotton and ethyl alcohol 70% and, then, semi‐permanent needles were applied or seeds were fixed with adhesive plaster, according to the intervention group. In the group of auriculo therapy with seeds, mustard seeds were used, and the participants were instructed to stimulate them three times a day, for 15 times, with moderate pressure. The volunteers were instructed to remove the needles or seeds 24 hours before the session and, in case there was any discomfort, itching or signs of allergy, they should remove them before that." (p. 88)
Outcomes	Stress Symptoms List
Identification
Notes	SSl included in analysis 2.1. Intervention groups combined to create a single pair‐wise comparison.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"This randomized controlled clinical experiment was performed with three groups..." (p. 88)
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	"...there was a loss of 34 subjects during the study. Seven professionals went on vacation after the beginning of the study and two on medical leave; 12 missed the session because they had forgotten it, due to traffic problems or the difficulty to reschedule it and seven did not show up for the first session. One participant gave up due to adverse effects, in this case, nightmares, and five exclusions were due to low score (1), not belonging to the nursing team (3), and not filling out properly the questionnaires (1)." (p. 89) The authors do not report how the dropouts were distributed among the study groups.
Selective reporting (reporting bias)	High risk	The authors present data separately for participants who had high SSL scores to begin with in table 2 but not at all for participants with a moderate SSL score.
Other bias	Low risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	Randomised controlled trial, Taiwan
Participants	60 hospital nurses suffering from either: insomnia, headache or gastrointestinal discomfort.
Interventions	1) Experimental: assertiveness training: six 2‐hour sessions on Monday, Wednesday and Friday at 2pm to 4pm on two consecutive weeks. The contents of sessions included the concept of beliefs and negative self‐statements, building a positive belief system, applying assertion to clinical settings and developing group and self‐reinforcement support systems. 2) Control: Traditional in‐service programme about computer applications in nursing.
Outcomes	Perceived Stress Scale, Rathus Assertiveness Schedule
Identification
Notes	PSS included in analysis 1.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Subjects were randomly assigned to one of two treatments: assertiveness training (AT) or alternate treatment control (ATC), which served as a control and contained updated knowledge of new computer technology for in patient settings." (p. 419)
Allocation concealment (selection bias)	Unclear risk	"Subjects admitted to the study agreed to random treatment assignment and a 2‐month commitment to the study. However, the subjects did not know whether they would receive treatment or control procedures during that time." (p. 425) Difficult to judge whether participants and/or investigators could possibly foresee assignment.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	"Of the respondents who initially chose to participate, three did not complete the study and were not included in the data analysis due to their failure to attend all sessions, failure to complete the questionnaire, or decision to leave hospital employment." (p. 425) Loss to follow‐up is below our review pre‐defined cut‐off point (three of the 60 (0.05%))
Selective reporting (reporting bias)	Low risk	All outcomes reported.
Other bias	Low risk	We did not find any indications of other sources of bias.

PERMALINK

Individual‐level interventions for reducing occupational stress in healthcare workers

Sietske J Tamminga

Lima M Emal

Julitta S Boschman

Alice Levasseur

Anilkrishna Thota

Jani H Ruotsalainen

Roosmarijn MC Schelvis

Karen Nieuwenhuijsen

Henk F Molen

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Summary of findings 1. An intervention in which one's attention is on the experience of stress (feelings, thoughts, behavior) compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers.

Summary of findings 2. An intervention in which one's attention is away from the experience of stress compared to no intervention/wait list/placebo/no stress‐reduction intervention for stress reduction in healthcare workers.

Summary of findings 3. An intervention in which the focus is on work‐related risk factors on an individual level compared to no intervention/no stress‐reduction interventionfor stress reduction in healthcare workers.

Summary of findings 4. A combination of individual‐level interventions compared to no intervention/wait list/no stress‐reduction intervention for stress reduction in healthcare workers.

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Type of healthcare worker

Duration and intensity of the intervention

Compliance

Sensitivity analysis

Summary of findings and assessment of the certainty of the evidence

Results

Description of studies

Results of the search

1.

Included studies

Study designs

Country and time period

Type of settings and participants

Sample sizes

Interventions

Type of control group

Multiple intervention arms

Multiple control arms

Outcomes

Follow‐up

(i) Short term

(ii) Medium term

(iii) Long term

Excluded studies

Risk of bias in included studies

2.

Allocation

*Study characteristics*
Methods	Randomised controlled trial, Canada
Participants	30 nurses and nurse aides working in a large urban geriatric teaching hospital
Interventions	1) Experimental: mindfulness‐based stress reduction programme: four 30‐minute group sessions including didactic section and experiential exercises. Participants also received a CD or audiocassette of guided exercises and a manual with the help of which they were instructed to practise for at least 10 minutes per day five days per week. 2) Control: no intervention
Outcomes	MBI, Smith Relaxation Dispositions Inventory
Identification
Notes	MBI‐EE included in analysis 1.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	"Nurses and nurse aides were recruited from long‐term and complex continuing care units in a large urban geriatric teaching hospital and randomly assigned to intervention or wait‐list control groups. Because the study was conducted during the summer, however, several exceptions were made to accommodate participants' vacation schedules and additional control participants were recruited." (p. 106)
Allocation concealment (selection bias)	Unclear risk	Not reported.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	It is unclear if any participants dropped out.
Selective reporting (reporting bias)	Low risk	All outcomes reported
Other bias	Low risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	Randomised controlled trial, Argentina
Participants	74 hospital paediatric resident physicians. " A total of 81% were female; the mean age was 27.3 ± 1.4 years; 57% were working in inpatient areas, 35% in the outpatient clinic, and 8% in the intensive care unit." " A comparison of the characteristics of both groups (experimental and control) revealed no significant differences." (p. 494)
Interventions	1) Experimental: self‐care workshop intervention (n = 37). quote: "The experimental group received a brief intervention consisting of two 2.5‐hour workshops directed by mental health professionals, which covered repercussions of burnout syndrome on professional activity, recognition of risk indicators for burnout syndrome, and tools to cope (identification of strengths, coping behaviors, preventive and self‐care behaviors)." (p. 494) 2) Control: (n = 37) No intervention
Outcomes	MBI
Identification
Notes	It is unclear why 43 (37%) out of the available 117 resident physicians did not participate in the study. Not able to include in analysis due to missing data.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"After administration of the questionnaire, subjects were randomly assigned to one of the two study groups." (p. 494)
Allocation concealment (selection bias)	Unclear risk	Not reported.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Apparently no participants were lost to follow‐up
Selective reporting (reporting bias)	Unclear risk	The authors do not report standard deviations with the mean MBI subscale scores.
Other bias	Unclear risk	It is unclear if these 74 were all the participants or only those that could be followed up.

*Study characteristics*
Methods	Study design: randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics Acceptance and Commitment Therapy (ACT) Age (mean ± SD): 40.5 ± 12.8 Sex (N (% female)): 49 (96%) Sample size: 51 Years of experience (mean ± SD): NR Control (wait list) Age (mean ± SD): 41.8 ± 12.3 Sex (N (% female)): 49 (91%) Sample size: 54 Years of experience (mean ± SD): NR Overall Age (mean ± SD): NR Sex (N (% female)): 98 (93%) Sample size: 105 Years of experience (mean ± SD): NR Included criteria: the inclusion criteria were to be over 18 years old and have at least 6 months of experience in the ce Excluded criteria: NR Pretreatment: no significant group differences were found at baseline for demographics, neither for outcome measures. Compliance rate: 86% Response rate: 43% Type of healthcare worker: various
Interventions	Intervention characteristics Acceptance and Commitment Therapy (ACT) Type of the intervention: Intervention type 4 ‐ Combination of two or more of the above Description of the intervention: The intervention was specifically designed for workers providing services in the dementia context. Implement each of the hexaflex components of ACT (Contact with the Present Moment, Acceptance, Self as Context, Cognitive Defusion, Values and Committed Action) in different sessions (including meditation exercise). The number of sessions: 6 sessions Duration of each session on average: 90 minutes Duration of the entire intervention: NR Duration of the entire intervention short vs long: Short Intervention deliverer :neuropsychologist of the Social and Health Centre widely trained and experienced in dementia care and ACT Intervention form: conducted in the work setting Control (wait list) Type of the intervention: NA Description of the intervention: NA The number of sessions: NA Duration of each session on average: NA Duration of the entire intervention: NA Duration of the entire intervention short vs long: NA Intervention deliverer: NA Intervention form: NA
Outcomes	Maslach Burnout Inventory ‐ Emotional Exhaustion Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Depersonalisation Outcome type: ContinuousOutcome Maslach Burnout Inventory ‐ Personal accomplishment Outcome type: ContinuousOutcome State‐Trait Anxiety Inventory (STAI) ‐ Anxiety‐Trait Outcome type: ContinuousOutcome
Identification	Sponsorship source: Country: NR Setting: CSSV Ricard Fortuny Hospital: a center made up of 6 long‐term hospitalization units, two nursing home units, a day center and a palliative unit. Comments: NR Authors name: Xavier Montaner Institution: Consorci Sociosanitari Ricard Fortuny Email: xavier.casino@gmail.com Address: Avinguda Garraf 3, 08720, Vilafranca del Penedés (Barcelona), Spain Time period: The study was carried out between May 2017 and September 2018
Notes	MBI‐EE included in analysis 4.1 and 4.2 STAI included in analysis 4.4 and 4.5
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: "randomly assigned"
Allocation concealment (selection bias)	Unclear risk	Not described
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Quote: "The drop‐out rate at the end of the intervention in the sample as a whole was 15.5%, 17.3% at 3 months of follow‐up, and 20% at 12 months of follow‐up. Although the attrition effect was higher in the IG, there were no statistically significant differences between groups drop‐out rates (Table 2)."
Selective reporting (reporting bias)	Unclear risk	No trial registration, nor did we find one online.
Other bias	Low risk	No indication of other bias.

*Study characteristics*
Methods	RCT with individual participants, USA
Participants	Paediatric oncology staff (50% nurses, 20% physicians); Experimental 23 Control 24; Men: Experimental 30% Control 8%; Age: not reported; stated to be equal; Experience > 10 years: Experimental 48% Control 46%
Interventions	1) Experimental: 8 weeks of didactic and experiential mindfulness education via a structured, skills‐training course delivered in a group setting at their hospital. The course included 1 initial 6‐hour session; 6 weekly 1‐hour follow‐up sessions; and a final 3‐hour wrap‐up session (15 hours total class time) 2) Control: No intervention
Outcomes	MBI; Perceived Stress Scale
Identification
Notes	Authors provided additional data: SDs of MBI at follow‐up: Experimental: EE: 7.67; DP: 3.54; PA 3.69 Control: EE: 6.39; DP: 4.59; PA: 5.27 MBI‐EE included in analysis 1.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Using a computer‐generated random numbers schema in blocks of ten
Allocation concealment (selection bias)	Unclear risk	Participants were stratified according to their respective professions and randomised to a mindfulness‐based course (intervention) or no intervention (control)
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	All participants reported outcomes
Selective reporting (reporting bias)	Low risk	All outcomes stated in the 'Methods' section reported.
Other bias	Low risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	RCT, Sweden
Participants	131 healthcare workers who scored above the 75th percentile on the exhaustion dimension of the Oldenburg Burnout Inventory
Interventions	1) Experimental: reflecting peer‐support group: Ten 2‐hour weekly sessions where participants discussed and reflected with colleagues about work‐related stress and burnout, provided mutual support for each other, compared experiences and set individual goals to find out alternative ways to handle perceived stressful situations. The sessions started with a short 10‐minute guided relaxation. 2) Control: no intervention
Outcomes	The General Nordic Questionnaire for Psychological and Social Factors at Work (QPS Nordic), Oldenburg Burnout Inventory, The Hospital Anxiety and Depression Scale, The Short Form Health Survey (SF‐36)
Identification
Notes	OBI included in analysis 3.2 and the HADS in analysis 3.4
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "The randomization procedure was performed by a statistician using the Statistical Analysis Software, version 8.2." (p. 508)
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	High risk	Altogether 27% of participants dropped out during follow‐up and the reasons for the control group participants leaving were not known
Selective reporting (reporting bias)	Low risk	All outcomes reported.
Other bias	Low risk	We did not find any indications of other sources of bias.

*Study characteristics*
Methods	RCT with individual participants, Portugal
Participants	Physiotherapists scoring more than 26 on Emotional Exhaustion subscale of MBI out of 106 screened with MBI, and not familiar with Qigong; Experimental n = 8 Control n = 8
Interventions	1) Experimental: Qigong exercise: posture, breathing and mind focus; classes 20 min/day 1 week; self‐treatment 2X / day 2 weeks, total 3 weeks 2) Control: waiting list for 3 weeks; after that they got the treatment as well
Outcomes	MBI
Identification
Notes	MBI‐EE included in analysis 2.1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: "the design was a prospective randomized controlled study"
Allocation concealment (selection bias)	Unclear risk	Quote: "the design was a prospective randomized controlled study"
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Outcomes for all participants reported
Selective reporting (reporting bias)	Unclear risk	Baseline data not reported for the RCT group only
Other bias	Low risk	We did not find any indications of other sources of bias

*Study characteristics*
Methods	Study design:‐cluster randomised controlled trial Study grouping: parallel group
Participants	Baseline characteristics MINDBODYSTRONG Age (mean ± SD): NR Sex (N (% female)): 41 (87%) Sample size: 49 Years of experience (mean ± SD): < 1 Control (no intervention) Age (mean ± SD): NR Sex (N (% female)): 35 (83%) Sample size: 44 Years of experience (mean ± SD): < 1 Overall Age (mean ± SD): 24.5 ± NR Sex (N (% female)): 76 (84%) Sample size: 90 Years of experience (mean ± SD): < 1 Included criteria: inclusion criteria included all NLRNs hired during the study period who signed consent for the study. Excluded criteria: exclusion criteria included any NLRN who did not consent to participate in the study. Pretreatment: A MANOVA was used to determine group differences at baseline. No significant differences were noted in mean variable scores between the control group and the intervention group for any of the study variables Compliance rate: 96% Response rate: 85% (89 out of 105) Type of healthcare worker: exclusively newly licenced nurses
Interventions	Intervention characteristics MINDBODYSTRONG Type of the intervention: Intervention type 1 ‐ to focus one’s attention on the experience of stress Description of the intervention: The MINDBODYSTRONG Program is a novel adaptation of an evidence‐based cognitive behavioural skills–building intervention that provides a theory‐based approach to improve the mental health, healthy lifestyle beliefs and behaviours, and job satisfaction ofNLRNs. The curriculum is manualized into a workbook to ensure consistency of information, allow participants to interact during all skills building/practice activities, and provide a guide for accomplishing goals. The MINDBODYSTRONG Program was adapted from the evidence‐based Creating Opportunities for Personal Empowerment Program by Melnyk, which has been shown to decrease depressive, anxiety, and stress symptoms and increase healthy lifestyle behaviours in children, adolescents, and college‐age youth in numerous studies. 23‐27 Each of the 8 MINDBODYSTRONG sessions (Table 1) focus' on three areas: caring for the mind, caring for the body, and skills building. Participants learn CBT concepts, establish weekly goals, and complete skills‐building activities weekly. Each session begins with a review of previously learnt concepts and a review of skills‐building activities. The number of sessions: 8 Duration of each session on average: 45‐minute Duration of the entire intervention: 8 weeks Duration of the entire intervention short vs long: short Intervention deliverer: Author Intervention form: Group Control (no intervention) Type of the intervention: Usual care Description of the intervention: The attention control group received the usual nurse residency curriculum that included a 30‐ to 45‐minute debriefing session each week where they discussed successes and challenges experienced the prior week while also receiving peer support from other cohort members. Members of the control group were given information on the Employee Assistance Program and other resources available to employees of the organization. The number of sessions: 8 Duration of each session on average: 30‐ to 45‐minute Duration of the entire intervention: 8 weeks Duration of the entire intervention short vs long: short Intervention deliverer: Author Intervention form: Group
Outcomes	Perceived Stress Scale (PSS) Outcome type: ContinuousOutcome Generalized Anxiety Disorder Scale (GAD‐7) Outcome type: ContinuousOutcome Personal Health Questionnaire Outcome type: ContinuousOutcome
Identification	Sponsorship source: NR Country: USA Setting: a large, Midwestern academic medical center with an accredited nurse residency program. Comments: NR Authors name: Dr Sampson Institution: The Ohio State University Wexner Medical Center Email: marlene.sampson@osumc.edu Address: 600 Ackerman Rd, Suite 2017E, Columbus, OH 43202 Time period: 2018‐2019
Notes	We kindly received the mean and SD of the PSS for both groups from author M. Sampson PSS included in analysis 1.1 and 1.2.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: "Participants were NLRNs hired between July 1, 2018, and September 30, 2018, and placed in 1 of 4 cohorts based on hire date. Two cohorts were randomly assigned to the control group, and 2 cohorts were randomly assigned to the MINDBODYSTRONG intervention group." Sequence generation process insufficiently described
Allocation concealment (selection bias)	Unclear risk	Difficult to judge whether participants and/or investigators could possibly foresee assignment. However, it is assumed that randomization was performed in one go and that participants and/or investigators could not foresee assignment.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants were not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	89 of the 93 (96%) randomised participants included in the analyses. Not reported whether loss to follow‐up was at random.
Selective reporting (reporting bias)	Unclear risk	No trial registration or no study protocol reported, nor did we find one online
Other bias	Low risk	No indication of other sources of bias

*Study characteristics*
Methods	Cluster‐randomised trial, the Netherlands
Participants	300 professional caregivers in homes for elderly persons
Interventions	1) Experimental: emotion‐oriented care training, clinical lessons and supervision meetings: 1‐hour clinical lesson, 6‐day training programme with 4 days at a 2‐week interval and last 2 days at a 4‐week interval. The participants were taught about the dementia syndrome and various care models for communicating with elderly people with dementia (e.g. reality orientation, validation and reminiscence), inequality of the resident‐caregiver relation, understanding the residents' perception of the environment and the attitude and (non‐)verbal communication of staff towards the resident. Intervention homes also received 3 half‐day supervision meetings to support the implementation of emotion‐oriented care. 2) Control: no intervention
Outcomes	MBI, Job satisfaction
Identification	Not able to include in analysis due to missing data.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: "Randomization was performed on the level of homes. ...within each pair, one home was randomly assigned to the intervention or control group, and the home was assigned to the alternate state." (p. S51)
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Quote: "Missing values on items that were part of a scale or subscale were replaced according to the "mean value of valid subtests" principle (i.e. replacement by the mean value calculated from the valid item scores of the [sub‐] scale obtained for the same subject at the same time point). This replacement strategy was only used if less than 25% of the items of a scale or subscale had missing values." (p. S52)
Selective reporting (reporting bias)	Low risk	All outcomes reported
Other bias	Low risk	We did not find any indications of other sources of bias

*Study characteristics*
Methods	RCT, Australia
Participants	40 trained hospital nurses who complained being overstressed
Interventions	1) Experimental: Ego‐enhancement training: One 50‐minute session and three 20‐minute sessions 1 week as part of training in the techniques of: physical relaxation, mental calmness, disposing of "rubbish", removal of a barrier and enjoyment of a special place. 2) Control: no intervention
Outcomes	Stress Profile
Identification
Notes	Stress profile included in analysis 2.2.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote:"In the first stage of the experiment the nurses were matched on their Profile scores, one member of each pair being allocated at random to either a non‐treatment control group or an experimental group experiencing four treatment sessions" (p. 318)
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	It is unclear if any participants dropped out
Selective reporting (reporting bias)	Low risk	Only 1 outcome measure used and reported
Other bias	Low risk	We did not find any indications of other sources of bias

*Study characteristics*
Methods	RCT, Taiwan
Participants	137 nurses
Interventions	1) Experimental: Training about stress at work, relaxation, breathing, imagery and meditation: One 90‐minute session in each of 2 weeks and 1 follow‐up session in the 5th week. Training covered: sources of stress at work, relaxation as a coping method and meditation including breathing exercise and imagery that emphasised the underlying cognitive process of meditation. 2) Control: traditional in‐service education about theory analysis
Outcomes	Nurse Stress Checklist, Chinese General Health Questionnaire
Identification
Notes	GHQ included in analysis 2.1.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "For each unit, a coin was thrown to select which nurse from this unit would be assigned to either the experimental or control group." (p. 56)
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias) All outcomes	High risk	Participants not blinded.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Participants were not blinded whereas outcomes are self‐reported.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	It is unclear if any participants dropped out
Selective reporting (reporting bias)	Low risk	All outcomes reported
Other bias	Low risk	We did not find any indications of other sources of bias