Ruotsalainen Jani H, Verbeek Jos H, Mariné Albert, Serra Consol
Cochrane Occupational Safety and Health Review Group, Finnish Institute of Occupational Health, PO Box 310, Kuopio, Finland, 70101.
Cochrane Database Syst Rev. 2015 Apr 7;2015(4):CD002892. doi: 10.1002/14651858.CD002892.pub5.
Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work. This may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.
To evaluate the effectiveness of work- and person-directed interventions compared to no intervention or alternative interventions in preventing stress at work in healthcare workers.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013.
Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.
Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.
In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health.There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction), and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies (SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to -0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies (SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias, and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.
AUTHORS' CONCLUSIONS: There is low-quality evidence that CBT and mental and physical relaxation reduce stress more than no intervention but not more than alternative interventions. There is also low-quality evidence that changing work schedules may lead to a reduction of stress. Other organisational interventions have no effect on stress levels. More randomised controlled trials are needed with at least 120 participants that compare the intervention to a placebo-like intervention. Organisational interventions need better focus on reduction of specific stressors.
由于缺乏技能、组织因素以及工作中社会支持不足，医护人员可能会遭受职业压力。这可能导致精神困扰、职业倦怠和身心问题，以及生活质量和服务质量的下降。
评估与无干预措施或替代干预措施相比，针对工作和个人的干预措施在预防医护人员工作压力方面的有效性。
我们检索了截至2013年11月的Cochrane对照试验中央注册库（CENTRAL）、MEDLINE、EMBASE、PsycINFO、CINAHL、NIOSHTIC - 2和科学引文索引数据库。
旨在预防医护人员心理压力的干预措施的随机对照试验（RCT）。对于组织干预措施，中断时间序列和前后对照（CBA）研究也符合要求。
两位综述作者独立提取数据并评估试验质量。当试验作者使用不同量表测量压力或职业倦怠时，我们使用标准化均数差（SMD）。我们在荟萃分析中合并了相似的研究。我们使用GRADE系统对证据质量进行评级。
在本次更新中，我们增加了39项研究，共计58项研究（54项RCT和4项CBA研究），7188名参与者。我们将干预措施分为认知行为训练（CBT）（n = 14）、身心放松（n = 21）、CBT与放松相结合（n = 6）以及组织干预措施（n = 20）。24项研究的随访时间少于1个月，22项研究为1至6个月，12项研究超过6个月。我们将结果分为压力、焦虑或总体健康。有低质量证据表明，在6项研究中，随访1个月时，无论是否进行放松训练的CBT在减轻压力症状方面并不比无干预措施更有效（SMD -0.27（95%置信区间（CI）-0.66至0.13；332名参与者）。但在7项研究的1至6个月随访中（SMD -0.38，95% CI -0.59至-0.16；549名参与者，相对风险降低13%），以及在2项研究的超过6个月随访中（SMD -1.04，95% CI -1.37至-0.70；157名参与者），无论是否进行放松训练的CBT比无干预措施更能减轻压力。在3项研究中，CBT干预措施与替代干预措施相比，效果没有显著差异。在4项研究的随访1个月时，身体放松（如按摩）在减轻压力方面比无干预措施更有效（SMD -0.48，95% CI -0.89至-0.08；97名参与者），在6项研究的1至6个月随访中（SMD -0.47；95% CI -0.70至-0.24；316名参与者）也是如此。2项研究未发现按摩与额外休息在压力方面有显著差异。在6项研究的1至6个月随访中，心理放松（如冥想）导致的压力症状水平与无干预措施相似（SMD -0.50，95% CI -1.15至0.15；205名参与者），但在1项超过6个月随访的研究中压力较小。1项研究表明，心理放松比参加理论分析课程更有效地减轻压力，另一项研究表明，心理放松比只是坐在椅子上放松更有效。组织干预措施包括工作条件的改变、组织支持、护理方式的改变、沟通技巧的提高以及工作时间表的改变。改变工作时间表（从连续工作改为有周末休息，从四周工作时间表改为两周工作时间表）可减轻压力，SMD为-0.55（95% CI -0.84至-0.25；2项试验，180名参与者）。其他组织干预措施并不比无干预措施或替代干预措施更有效。除一项比较外，我们将所有证据质量评为低。对于CBT，这是由于存在发表偏倚的可能性，对于其他比较，是由于缺乏精确性和偏倚风险。只有放松与无干预的比较证据质量为中等。
有低质量证据表明，CBT以及身心放松比无干预措施更能减轻压力，但不比替代干预措施更有效。也有低质量证据表明，改变工作时间表可能会减轻压力。其他组织干预措施对压力水平没有影响。需要更多至少有120名参与者的随机对照试验，将干预措施与类似安慰剂的干预措施进行比较。组织干预措施需要更好地聚焦于减少特定的压力源。
