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

Posted on by Jani Ruotsalainen, Jos Verbeek and Thais C. Morata


HCstressOccupational 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.



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 .

Posted on by Jani Ruotsalainen, Jos Verbeek and Thais C. Morata

10 comments on “What Works Best to Prevent Stress Among Healthcare Workers: Changing the organization or educating staff?”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Contributing to an organizational blog and to an organization-wide Idea Bank reduce my stress, as well has having a staff that is not too strict, more flexible, less rigid, more understanding rather than fixed, reduces my stress.

    Thank you for your comment. It’s great that you and your employer have identified and implemented measures that you feel have a real tangible stress-reducing effect. It is also interesting that the measures you mention have to do with increasing participation and control neither of which has been thus far formally assessed with intervention studies. Having said that, I do NOT mean to imply that your experience would be any less real or informative without experimental verification. It is just that wide-scale implementation of any good practices usually requires more than anecdotal evidence. Should anyone wish to conduct further studies about various methods for preventing or reducing stress in healthcare, I can only wish they read the advice we give in the review about avoiding major pitfalls in both designing and reporting them. With the ever-increasing demands heaped on you and your colleagues, we need to keep you all physically and mentally healthy. If research, such as our systematic review, can help in that then great!

    This is Great Information post , Wonderful Article I like it , Great Stuff , Thank You Very Much For Sharing me ,


    Stress can make it difficult to fall and stay asleep at night, but good sleep is just what you need during stressful times. Make your sleep space a soothing, tranquil environment. Practice winding down for a little while before heading to bed. If something is weighing on your mind, write it down for tomorrow. If you’re having trouble falling asleep, don’t toss and turn. Get out of bed and do something relaxing, like say reading a book, until you feel ready to drift off. Try to maintain a regular sleep schedule. These are just a few techniques for encouraging good sleep. Find some that work for you because good, restful sleep is an extremely effective stress management tool.

    Thank you for your detailed tips on ways to make sure sleeping problems don’t add to and aggravate stress. What you describe could actually be labelled as cognitive-behavioural techniques (CBT) because here too the idea is to change the way you think and do things. Unfortunately no one has yet studied the effect of improving sleep practices on the experience of stress because we would have found and included these in our systematic review. Therefore we cannot advocate these measures with the same conviction with which we can say other types of CBT really do reduce stress. However, it would be a really good idea to find out and conduct such studies.

    Most effective stress management is probably a good balance of organisational and individual-focused measures. Our systematic review presents the most up-to-date and most reliable evidence on what we can say with a pretty high certainty really works and what doesn’t work to reduce stress in health care workers.

    People who don’t manage stress well can have headaches, stomach pain, sleeping problems, illness, and depression. You can help manage stress by journaling, meditating, exercising, talking to others, or engaging in a hobby.

    Healthcare management depends on our hands, health but also our hearts (thanks, 4H).
    Owners, managers and insurers need to check the stress pulse of HCW staff during the rapid changes occurring in 2015.

    Bed bingo-loading the facilities with readmissions while not emptying beds-is straining resources and the ability of staff to perform thorough cleaning, care, assessments, patient education-and also incapacitating my function of Infection Prevention. It’s stressful when it’s crowded and isolation cannot be performed satisfactorily. Rooms Might not get cleaned, physicians can’t locate patients if moved around- exposures to infectious disease could occur.
    Empty hospital beds are the enemy of a profitable bottom line.
    How do HCW balance the need for a healthy financial environment against safety concerns? That’s stressful !

    I’ve re-lived my entire shift in my sleep when I’m stressed or if I feel I didn’t do my best work. Help us to avoid poor work by not distracting us-violent outbursts occur frequently in several of my settings directed at staff-we now have to worry about potential attacks.
    Help us by cooperating with discharge rules, timely interventions and keeping beds clear in case of isolation (measles,pertussis, flu). Our hearts and hands are extended to the brave Ebola care givers. All mentioned with LOVE

    Thank you for your feedback. We fully appreciate the fact that work overload can be a source of stress in health care. However, it is difficult to provide research-based advice on reducing stress via sorting out issues to do with staffing. This is because it hasn’t been studied. Then again one can imagine insufficient staff numbers having all sorts of detrimental effects even without research showing this.

    Nonetheless, it is interesting that you brought up the issue of workplace violence. NIOSH has workplace violence prevention training for nurses (http://www.cdc.gov/niosh/topics/violence/training_nurses.html). The NIOSH topic page on workplace violence also provides additional information. http://www.cdc.gov/niosh/topics/violence/. The NIOSH document, Violence: Occupational Hazards in Hospitals, identifies three types of interventions (environmental designs, administrative controls and behaviour modification http://www.cdc.gov/niosh/docs/2002-101/).

    The Cochrane Occupational Safety and Health Review group aims to conduct systematic reviews on the effectiveness of these three ways to reduce the incidence of violence in health care. The planned reviews will cover: education and training (i.e. what the healthcare workers themselves can do to e.g. defuse situations etc.), organisational interventions (i.e. what hospitals can do to e.g. schedule shifts so that no HCW is left alone with potentially dangerous patients), and physical structures and devices (i.e. how triage and treatment areas are designed so that potentially violent individuals can be contained).

    You mention being stressed and feeling that you didn’t do your best work. The Cochrane review we discussed in this blog suggests individual stress management might help. The same applies to the brave Ebola caregivers in situations that are extremely stressful. We hope that some of this evidence-based information helps you and them to cope. We also hope it helps your employer and other employers to consider effective stress-prevention and stress-relief policies that will have collective as well as individual benefit for healthcare staff. We do appreciate that this is not a panacea for all stressors that you encounter but it can be a small step forward.

    With Decades of health care experience in different countries, I think: Instead of changing organization of staff education, More time/chances for journaling, meditating, exercising, talking to others, or engaging in a hobby would be better.
    Maxwell Chan

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