What Works Best to Prevent Stress Among Healthcare Workers: Changing the organization or educating staff?

Occupational Safety and Health (OSH) professionals have to make many decisions on a daily basis. These decisions can involve risk assessment methods, preventive workplace measures, workers’ health surveillance or even rehabilitation or return-to-work practices. According to the principles of evidence based practice, such decisions should be guided by high-quality scientific knowledge (van Dijk et al., 2010) such as provided by systematic reviews of the literature. The Cochrane Collaboration is internationally recognized as the leader in producing high quality systematic reviews about the effectiveness of health interventions. The Cochrane Collaboration is a not-for-profit organization with collaborators from over 120 countries working to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Cochrane systematic reviews try to help with the decision-making process by synthesizing the results of multiple studies and finding out, for example, what are the best ways to protect workers against health risks and dangers that exist in the workplace. Cochrane systematic reviews seek answers to the most basic question: “does this intervention work?”

At this point it is worth noting that NIOSH holds a seat on the advisory and editorial boards of the Cochrane Occupational Safety and Health Review Group. This group is one of the many entities that make up the Cochrane Collaboration. For more information on OSH Reviews in particular, subscribe to the group’s bi-monthly Newsletter or follow their individual Twitter feeds (@OSHdoc and @jhruotsalainen) or group (@CochraneOSH). The Review group welcomes your input, whether it be by suggesting topics or authors for a review, using the reviews to guide various health and safety decisions, or by championing evidence-based occupational safety and health practice in general.

Today we would like to highlight a recently updated Cochrane Review on preventing occupational stress in healthcare workers (Ruotsalainen et al., 2014). This review evaluated how well person-directed or organizational interventions prevent stress or burnout in healthcare workers. The authors included 58 studies with altogether 7188 participants. The person-directed interventions included cognitive-behavioral training and mental and physical relaxation that varied from music-making to massage. The organizational changes aimed at increasing social support or changing stressful work-methods or work schedules.

The person-directed interventions, in general, decreased stress and burnout levels. Teaching healthcare workers cognitive-behavioral methods of stress management was 13 % better than no intervention in seven studies. Unfortunately, it is unclear if this reduction is large enough to be experienced as a significant improvement by an individual healthcare worker suffering from work-related stress. The results were similar when cognitive-behavioral training was combined with relaxation. However, when a cognitive-behavioral training course was compared to other training unrelated to stress, the stress levels were similar after both conditions. This could mean that the effect of the stress management course is not very specific. Also mental and physical relaxation led to a moderate reduction in stress levels compared to no intervention in 17 studies.

Unfortunately, there were many fewer studies on organizational interventions and these studies evaluated a range of different interventions. The introduction of social support in the organization did not lead to a considerable reduction of stress levels in workers at less than 6 months follow-up in 4 studies with 2476 participants. However, one study with a longer follow-up did show an effect of organizing social support. It may be that, in the other studies, follow-up time was too short for an effect to show up. Three studies tried to improve psychosocial working conditions with worker participation but none found a considerable effect on stress levels. Only shorter or interrupted work schedules reduced stress levels in two studies in physicians. Even though organizational interventions are considered preferable, there is little evidence to support most of these. The review authors recommend conducting evaluations of organizational interventions that better focus on improving specific working conditions associated with stress. They conclude that cognitive-behavioral training as well as mental and physical relaxation all moderately reduce stress. Changing work schedules can also reduce stress, but at this point there is no clear evidence that other organizational interventions are effective in reducing stress.

NIOSH recognizes the need for more research on the effectiveness of organizational interventions. The NORA Healthcare and Social Assistance (HCSA) Sector has identified the promotion of safe and healthy workplaces and the optimization of safety culture in healthcare organizations as priority goals for funding decisions for both intra and extramural funding. Regarding stress, in a recent webinar our stress experts suggested that we first try to improve organizational issues and only as a last resort try to fix the human response to stressors. They point out that stress does not stop at the doorstep. Especially nowadays, when the home and work spheres get more and more mixed, abating stressors overall becomes more important. This could also be a reason to value personal stress management skills more highly.

Now, we invite you to present your interpretations of the scientific evidence in the light of your own experience. You can participate of the discussion by submitting a comment to the blog or by submitting feedback on the published Cochrane review via the “Submit Comments” button adjacent to the review’s abstract in the Cochrane Library. Jump in and join the discussion! Could that help with our stress level? Can’t hurt to try!

Jani Ruotsalainen is the Managing Editor of the Cochrane Occupational Safety and Health Review Group, based at the Finnish Institute of Occupational Health, in Kuopio, Finland.

Jos Verbeek is the Coordinating Editor of the Cochrane Occupational Safety and Health Review Group, based at the Finnish Institute of Occupational Health, in Kuopio, Finland.

Thais C. Morata is the NIOSH Coordinator of the National Occupational Research Agenda (NORA) Manufacturing Sector Council and member of the Editorial Board of the Cochrane Occupational Safety and Health Review Group.

References

van Dijk FJ, Verbeek JH, Hoving JL, Hulshof CT. A knowledge infrastructure for occupational safety and health. J Occup Environ Med. 2010 Dec;52(12):1262-8. doi: 10.1097/JOM.0b013e318202f2c5.

Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews 2014 , Issue 11 . Art. No.: CD002892. DOI: 10.1002/14651858.CD002892.pub3 .