medicina

Systematic Review
Organizational and Individual Interventions for Managing
Work-Related Stress in Healthcare Professionals:
A Systematic Review
Pierluigi Catapano † , Salvatore Cipolla † , Gaia Sampogna *, Francesco Perris , Mario Luciano ,
Francesco Catapano and Andrea Fiorillo

Department of Psychiatry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy

* Correspondence: [email protected]
† These authors contributed equally to this work.

Abstract: The workplace represents a relevant source of stress for workers, being a risk factor for
many mental disorders and psychological difficulties, including burn-out syndrome. Healthcare
workers and other help-professions are particularly susceptible to work-related stress. The present
systematic review aims to (1) identify available interventions for managing workplace-related stress
symptoms; (2) assess their efficacy; and (3) discuss the current limitations of available interven-
tions. A systematic review has been conducted, searching on PubMed, APA PsycInfo, and Scopus
databases. Eighteen papers have been identified, which included different interventions for the
management of work-related stress in healthcare professionals. These approaches can be grouped
as follows: (1) interventions focusing on the individual level using cognitive-behavioral therapy
(CBT) approaches; (2) interventions focusing on the individual level using relaxation techniques;
and (3) interventions focusing on the organizational level. As regards interventions targeting the
individual level using CBT approaches, mindfulness-based interventions were effective in reducing
levels of burn-out, stress, and anxiety and in improving quality of life. As regards intervention
using relaxation techniques, including art therapy, Emotional Freedom Techniques (ECT) and brief
resilience retreats had a positive effect on the levels of anxiety, stress, and burnout. As regards inter-
Citation: Catapano, P.; Cipolla, S.;
ventions at the organizational level, we found no evidence for supporting its effectiveness in reducing
Sampogna, G.; Perris, F.; Luciano, M.;
the levels of burnout. Furthermore, available studies are heterogeneous in terms of assessment tools,
Catapano, F.; Fiorillo, A.
target populations, and type of interventions, which limits the generalizability of findings.
Organizational and Individual
Interventions for Managing
Work-Related Stress in Healthcare
Keywords: stress; workplace; burnout; physician; healthcare workers; intervention
Professionals: A Systematic Review.
Medicina 2023, 59, 1866. https://
doi.org/10.3390/medicina59101866
1. Introduction
Academic Editor: Woojae Myung
Work-related stress is a complex phenomenon, which has been defined by the World
Received: 3 September 2023 Health Organization as “the response people may have when presented with work de-
Revised: 5 October 2023 mands and pressures that are not matched to their knowledge and abilities and which
Accepted: 18 October 2023 challenge their ability to cope” [1]. Stress can affect workers in many different situations,
Published: 20 October 2023
and it is due to a lack of support from supervisors and other colleagues or to having little
control over work processes [2]. The relationship between levels of stress and working
performance is bidirectional: perceived pressure can be useful to keep the individual alert,
Copyright: © 2023 by the authors.
motivated, able to work, and learn, but, when it exceeds a certain threshold—which varies
Licensee MDPI, Basel, Switzerland. among individuals—becomes excessive or unmanageable, causing stress. Stress can nega-
This article is an open access article tively influence employees’ health and their work performance. The workplace represents
distributed under the terms and a relevant source of stress for workers due to excessive workloads, moral violence, work
conditions of the Creative Commons processes, interactions with patients’ families, professional and administrative demands,
Attribution (CC BY) license (https:// resource constraints, and lack of management support [3]. Therefore, workplaces can play
creativecommons.org/licenses/by/ a central role in the development of mental health problems—such as burn-out syndrome
4.0/). or full-blown mental disorders, mainly anxiety or depressive disorders. Burnout syndrome

Medicina 2023, 59, 1866. https://doi.org/10.3390/medicina59101866 https://www.mdpi.com/journal/medicina

Medicina 2023, 59, 1866 2 of 17

is composed of three dimensions of burnout: emotional exhaustion, depersonalization,

and personal accomplishment [4]. The term “burnout” describes a physical and emotional
strain specifically occurring in the work environment. Burnout syndrome is also known as
chronic work-related stress syndrome [4–10].
As with other helping professions, healthcare workers are particularly susceptible
to work-related stress due to the demands of their everyday clinical practice and the
continuous exposure to patients’ suffering [11,12]. In particular, stress among healthcare
workers ranges from 27 to 87.4% and it significantly affects their physical and mental
health, risk of substance use, work-related delays, absenteeism, and presenteeism, as well
as emigration rate [13]. Additionally, it can lead to patient safety concerns and poor quality
of care. The mismatch between job requirements and available resources, work overload,
working environment, work experience, workplace conflicts, gender discrimination, marital
status, educational status, job satisfaction, and not being rewarded properly are some of
the factors significantly associated with occupational stress among healthcare professionals.
Moreover, an important element which can mediate the impact of job-related stress on
the mental health of healthcare professionals is represented by the sense of coherence
(SOC). This construct is defined as the general orientation of seeing life as understandable,
manageable, and meaningful, and having the ability to cope with stressful situations.
A recent systematic review by Pablo González-Siles (2022) has pointed out that stress,
depression, burnout, and posttraumatic stress disorder (PTSD) negatively correlate with
SOC; in contrast, job satisfaction, well-being, and quality of life positively correlate with
SOC [14].
The coronavirus disease 2019 (COVID-19) pandemic introduced additional stressors,
such as staff redeployment and fear of infection [15]. During the pandemic, increased
levels of work-related stress and of burn-out symptoms have been reported by healthcare
professionals [16], due to the need to manage an unexpected public health emergency
without adequate knowledge and safety means [17–23]. According to EU-OSHA’s workers’
survey OSH Pulse—occupational safety and health in post-pandemic workplaces---almost
half of healthcare workers (44%) reported that their work stress had increased in particular
during the first wave of the pandemic [24–29].
In the initial phase of the pandemic, levels of stress, anxiety symptoms, and sleep
difficulties increased in first-line professionals [30–32]. Also, suicidal risk and suicidal
ideation initially increased [33], with a further worsening of the burden associated with
workplace stress [34–37]. Therefore, the need to develop supportive interventions for
promoting the mental health of healthcare workers has been advocated, and, actually,
many hospitals dealing with COVID-19 patients have established helplines or promoted
psychological help for all healthcare professionals in need of some support [38–40].
Work-related stress on mental health has been recognized as one of the most power-
ful stressful events for mental health by the World Health Organization and by several
international scientific associations, such as the World Psychiatric Association and the
European Psychiatric Association, who are committed to implement and disseminate strate-
gies and multilevel interventions for the prevention, early detection, and management of
work-related stress symptoms.
Interventions for work-related stress symptoms can be grouped into those focusing on
the individual level, using cognitive-behavioural techniques or relaxation approaches, and
those focusing on the organizational level [41].
The present systematic review aims to (1) identify available individual or organization-
level interventions for the management of workplace-related stress symptoms; (2) assess
their efficacy; and (3) discuss the eventual limitations of the available interventions.
Medicina 2023, 59, 1866 3 of 17

2. Methods
2.1. Search Strategy
An extensive literature search for relevant articles has been performed on PubMed,
APA PsycInfo, and Scopus databases entering the following terms: “Occupational Stress”
[Mesh] AND (“Anxiety” [Mesh] OR “Depression” [Mesh] OR “Stress, Physiological”
[Mesh]) AND (“Health Personnel” [Mesh] OR “Health Care Facilities, Manpower, and Ser-
vices” [Mesh]) AND (“prevention and control” [Subheading] OR prevention [Text Word]),
using “Abstract”, “Humans”, “English” as filters on Pubmed; (TITLE-ABS-KEY (occu-
pational AND stress AND (anxiety AND depression AND stress)) AND ((health AND
personnel) OR (health AND care AND facilities AND manpower AND services)) AND
(prevention) AND PUBYEAR > 2014 AND PUBYEAR < 2024AND (LIMIT-TO (DOCTYPE,
“ar”)) AND (LIMIT-TO (LANGUAGE, “English”))), on Scopus; (abstract(occupational
stress) AND noft (anxiety) AND noft (depression) AND noft (stress) AND abstract (health
personnel) OR abstract(health care facility) OR abstract (health care facilities) AND noft
(prevention)) on APA PsycInfo.
The search method has been conducted according to the Preferred Reporting Items for
Systematic Review and Meta-Analysis (PRISMA) statement, as applicable [42].

2.2. Selection Criteria

The literature search was limited to the period from 2015 up to May 2023, since studies
previously published are already covered in the review by Ruotsalainen et al. [41]. Only
papers written in English were included. The reference lists of included articles were
screened to identify additional relevant studies. The following inclusion criteria were used:
(1) studies involving medical doctors, nurses, health personnel or medical students, student
nurses or physicians in training; (2) studies describing interventions aiming to prevent or
reduce work-related stress; and (3) studies reporting occupational and work-related stress
or burnout levels as outcomes. Only studies reporting work-related stress evaluated at the
individual/personal level were included.

2.3. Selection Process

A total of 580 papers were identified, 14 papers were duplicates and were removed,
while the remaining (N = 548) were excluded because they were not relevant. Therefore,
N = 18 papers were evaluated in detail and included in the analysis (Figure 1).
SC and PC extracted the relevant data and synthetized them in a tabular format; GS
and FP triple-checked the extracted data for accuracy.
Inter-rater reliability, referring to the degree of agreement between researchers, has
been calculated, with a Cohen’s kappa score of 0.9.

2.4. Risk-of-Bias Assessment

Two authors (SC and PC) independently evaluated each selected study for the risk
of bias, using the criteria recommended for Randomized Clinical Trials (RCTs) in the
Cochrane Handbook for Systematic Reviews of Interventions [43] and the recommended
tool for assessing risk of bias in non-randomized studies of intervention (NRSI) called
ROBINS-I [44], p. 25.
The overall risk of bias was rated as moderate to high in all non-randomized studies
included in the review; Supplementary Table S1 shows the considered domains and sub-
domains. Two authors resolved disagreements through discussion or by involving a third
author (GS). Results of risk of bias assessment for the RCTs are reported in Supplementary
Table S2. One study was considered to be at a low risk of bias.
Medicina 2023, 59, 1866 Medicina 2023, 59, x FOR PEER REVIEW
4 of 17 4 of 19

Identification of studies via databases and registers

Records identified from:

Records removed before screening:

Identification
PubMed (n = 101)
Duplicate records removed
Scopus (n = 245)
(n = 14)
APA PsycInfo (n = 234)

Reports excluded:

Records screened (n = 566) Review (n = 41)

Commentary/protocol (n = 9)

Reports sought for retrieval Reports not retrieved

Screening

(n = 516) (n = 0)

Reports assessed for eligibility Reports excluded:

(n = 516) Off-topic (n = 435)
Wrong population (n = 63)
Included

Studies included in review

(n = 18)

Figure 1. Flowchart of the included studies.of the included studies.

Figure 1. Flowchart

3. Results Inter-rater reliability, referring to the degree of agreement between researchers, has
been calculated, with a Cohen’s kappa score of 0.9.
Based on Ruotsalainen et al.’s seminal work [41], included studies have been grouped
in three categories: (1) studies focusing
2.4. Risk-of-Bias on the individual level using cognitive-behavioural
Assessment
therapy approaches (Table 1); (2) studies
Two authors (SC focusing
and PC) on the individual
independently leveleach
evaluated using relaxation
selected study for the risk
techniques (Table 2); andof(3) studies
bias, using focusing
the criteriaon the organizational
recommended level (Table
for Randomized Clinical3).
Trials (RCTs) in the
The most frequentlyCochrane
used tools to assess
Handbook burnout,Reviews
for Systematic work-related stress,[43]
of Interventions its and
impact on
the recommended
tool for assessing risk
quality of life, and psychopathological andofpsychological
bias in non-randomized
symptoms studies of intervention
were the Maslach (NRSI) called
ROBINS-I [44], p. 25.
Burnout Inventory (MBI) for burnout (6 out of 18 studies) [45–50]; the Professional Qual-
The overall risk of bias was rated as moderate to high in all non-randomized studies
ity of Life Scale (Pro-QOL) [51,52]
included and
in the the Satisfaction
review; SupplementaryWith
Table Life Scale
S1 shows the(SWS) [46,49]
considered for and sub-
domains
quality of life; the Perceived Stress
domains. TwoScale
authors(PSS) [46–48,53,54];
resolved disagreementsthe Statediscussion
through and Trait or Anxiety
by involving a third
Inventory (STAI) [46,48,49,55,56]; the Cognitive and Affective Mindfulness Scale—Revised
(CAMS-R) [47,48]; and the Patient-Reported Outcomes Measurement Information System
(PROMIS) [50,53] for the assessment of stress and clinical symptoms. The tools used in
each study, grouped by category, are reported in Table 4.

3.1. Studies Focusing on the Individual Level Using Cognitive-Behavioural Therapy or Other
Psychotherapeutic Approaches
A total of 11 studies (out of 18) were focused on reducing the individual levels of stress
and burn-out using CBT or other psychotherapeutic approaches (Table 1). Studies were
carried out mainly in the USA and Spain, with sample sizes ranging from 13 participants
Medicina 2023, 59, 1866 5 of 17

in the study by dos Santos et al. [46] to 105 healthcare workers in Montaner et al. [49].
Included participants were mainly nurses (N = 8 studies) [44,45,48,51,53,56–58], other
healthcare workers (N = 4 studies) [49,57,59,60], physicians (N = 3 studies) [49,54,57],
and trainees in healthcare professions (N = 2 studies) [48,51]. Interventions provided to
participants included a cognitive-behavioural component, ranging from mindfulness-based
programmes [45,46,54,59,60] to informative interventions [48,51].
Many different assessment tools have been adopted for evaluating the levels of
burn-out and stress reported by professionals, including the Maslach Burnout Inventory
(MBI) [45,46,48,49], Perceived Stress Scale (PSS) [46,48,54], Depression, anxiety, and stress
scale (DASS-21) [51,60], Copenhagen Burnout Inventory (CBI) [60], Distress Thermometer
Assessment (DTA) [45], The World Health Organization Health and Work Performance
Questionnaire (HPQ) [45], and Work Stress Scale (WSS) [46]. Tools for assessing quality of
life included the Professional Quality of Life Scale (ProQOL) [51,52], Satisfaction With Life
Scale (SWLS) [46,49], EuroQol (EQ-5D) [45], General Health Questionnaire (GHQ) [57], and
WHO Quality of Life-BREF (WHOQOL-BREF) [46] (Table 4). Studies [46,54,59,60] confirm
that mindfulness-based interventions are effective in the short-term in reducing levels
of burn-out, stress, and anxiety and in improving quality of life. However, longitudinal
studies—such as those by dos Santos et al. and by Haghighinejad et al. [46,60]—showed
that the effect was not sustained at two/three months of follow-up. Furthermore, in two
RCTs [45,51] group stress management programs were not effective in reducing the levels of
burnout and work-related stress compared to the control group. No significant differences
were found in other secondary outcomes, such as risk of depression and alcohol abuse.
In the study by Tarquinio et al. [58], carried out during the COVID-19 pandemic,
at-a-distance EMDR intervention provided to healthcare professionals previously treated
with the same in-person technique was effective in reducing the levels of stress, although
data on the long-term effectiveness are not available. Encouraging results were obtained
from clinical trials using humor-based training sessions, stress-resilience courses, and
Acceptance and Commitment Therapy (ACT) [48,49,57]. On the other hand, the reduction
in secondary traumatic stress obtained by Sullivan throughout self-care practices was not
confirmed at the 6-month follow-up [52].

3.2. Studies Focusing on the Reduction in the Levels of Stress and Burn-Out Using Relaxation
Techniques
Five studies, mainly from the US, were included, with sample sizes ranging from
34 to 106 participants [53,61], who were mainly nurses (N = 4 studies) [53,55,56,61],
trainees in healthcare professions (N = 3 studies) [53,61,62], and other healthcare workers
(N = 3 studies) [53,61,62] (Table 2). Only the study by Kaimal et al. [53] included family
caregivers. The interventions provided to participants shared relaxation techniques, such
as breathing sessions [55], art therapy [53], acupressure points stimulation [56], group
retreats [61], and nature and forest therapy [62].
Studies using art therapy, Emotional Freedom Tecniques (ECT), and brief resilience
retreats [53,56,61] had a positive effect on the levels of anxiety, stress, and burnout (Table 4).
However, these positive effects were not confirmed by biological markers, such as the
salivary levels of IL-6, cortisol, and CRP [53]. Other relaxation practices, such as Shinrin-
Yoku [62] and Relaxation Response [55], did not yield any significant effect.

3.3. Studies Focused on Organizational Level

Two studies, both carried out in the US, were included, with a total of 221 participants,
mainly physicians [50], residents, and clinical fellows [47], not all engaged in clinical ac-
tivities (Table 3). Lebares et al., who used a mixed-intervention program including the
application of mindfulness in association with organizational initiatives, found that the in-
tegrated intervention reduced negative emotions and improved workplace satisfaction [47].
However, the only RCT involving an organizational intervention found no evidence for
supporting its effectiveness in reducing levels of burnout [50].
Medicina 2023, 59, 1866 6 of 17

Table 1. Studies focused on individual level using CBT or other psychotherapeutic approaches.

First Author Type of Study Outcome Measures

(Publication Treatment Arms Intervention of Effectiveness Results
Year) (Country)

Results suggest that a SRP involving mindfulness may be a potentially

effective approach to improve stress, depression, and QoL in a hospital
setting. Comparison between pre- and post-intervention revealed a
Stress Reduction Program PSS; MBI; BDI; STAI; significant reduction in scores for perceived stress-PSS (p = 0.001),
dos Santos T.M. Clinical Trial (SRP), based on the SWLS; SCS; burnout-MBI (p = 0.02), depression-BDI (p = 0.007), and anxiety trait-STAI
13 nurses WHOQOL-BREF;
(2015) [46] (Brazil) Mindfulness-Based Stress (p = 0.049), and a significant increase in scores for physical (p = 0.002) and
Reduction program WSS psychological (p = 0.007) domains of the quality-of-life scale. These values
remained stable six weeks after the intervention, except for the physical
and psychological domains of the QoL scale, which showed a significant
decline at follow-up (p < 0.05).
There was a small but not statistically significant reduction in alcohol use
Randomized 46 physician trainees Workshop to outline
Axisa C. AUDIT; DASS-21; (p = 0.23), depression (p = 0.49), and burnout (p = 0.83) in the intervention
(2019) [51] Controlled Trial (23 intervention group; strategies for wellbeing ProQOL
(Australia) group compared to the control group, measured at the primary endpoint at
23 control group) and stress management
6 months.
Integration of mindfulness-based interventions as part of staff meetings
Pediatric Respiratory
Luzarraga J. Mindfulness-based decreased members’ physical and emotional stress-related symptoms and
Clinical Trial Therapists intervention as part DTA; breath rate
(2019) [59] (USA) increased members’ sense of calm. The distress scores were noted to
(40 first session, of staff meeting decrease in session 1 (p = 0.001) and in session 2 (p = 0.39). Breathing rate
24 second session)
also decreased during both sessions (p = 0.001).
Rinaldi A. Clinical Trial 7 physicians Mindfulness intervention There was a significant reduction in perceived stress (p = 0.019) from
PSS-10
(2019) [54] (Italy) and 13 nurses called Focus baseline to the end of the course.
A statistically significant reduction in secondary traumatic stress (p = 0.029)
37 nurses in a pediatric Organizational and was found comparing pre-intervention and 4-month post-intervention
Sullivan C.E. Clinical Trial ProQOL; Brief COPE;
(2019) [52] (USA) oncology unit individual self-care CD-RISC2 scores; these data were not confirmed after the 6-month follow-up period,
practices
probably due to concomitant holidays (recognized as stress factor).
Group brief
Randomized 80 junior nurses mindfulness-based stress HADS; PRIME-MD;
Watanabe N. management program (the No significant differences between the program and leaflet groups were
Controlled Trial (40 intervention group; GAD-7; MBI; ISI;
(2019) [45] (Japan) HPQ; EQ-5D observed in all the outcomes.
40 control group) control group received a
psychological brochure)
After-training scores were higher in positive attitudes toward humor
58 medical and (p = 0.001) and cheerfulness (p = 0.001) and lower in seriousness (p = 0.001)
13 humor-based training and psychological distress in almost all its dimensions (p < 0.05). After
León-Pérez J.M. Clinical Trial non-medical staff in an MSHS; STCI-S;
(2021) [57] (Spain) emergency ambulance session (like social skills GHQ-28 training, it was observed a reduction of 10-5% of potential cases of minor
service training procedures)
psychiatric disorder (from 62.1% to 51.7% using a 6-point cut-off in GHQ;
from 55.2% to 50% using a 7-point cut-off).
Medicina 2023, 59, 1866 7 of 17

Table 1. Cont.

First Author
Type of Study Outcome Measures
(Publication Treatment Arms Intervention Results
(Country) of Effectiveness
Year)
38 core surgical trainees Data analysis compared results between intervention group and those
(14 completed the 5 weeks enhanced who declined to participate in the course. No significant differences
Luton O.W. Clinical Trial MBI; PSS-10; PHQ-2,
course; 10 discontinued stress-resilience training were found between groups except for the levels of perceived stress: the
(2021) [48] (UK) CAMS-R; STAI
the intervention; (ESRT) course median score at PSS-10 was lower (range 8–33) in the intervention group
14 declined to participate) than in the non-intervention group (11–34) (p < 0.01).
105 healthcare workers
ACT intervention was effective in reducing anxiety (p < 0.001) and
with patients affected by
Randomized Acceptance and emotional exhaustion (p < 0.01) and in increasing the life satisfaction
Montaner X. cognitive impairment AAQ-II; MBI; STAI;
Controlled Trial Commitment Therapy (p < 0.001) and personal accomplishment (p < 0.001) of workers,
(2021) [49] and/or dementia SWLS
(Spain) (ACT) maintained at the 3 and 12-month follow-up. There were no differences
(51 intervention group;
in psychological flexibility between the intervention and control group.
54 control group)
17 nurses facing Remote Eye Movement
There was a significant (p < 0.001) decrease in the anxiety score, the
Tarquinio C. Clinical Trial patients with COVID-19, Desensitization and
HADS; SUD depression score, as well as in the SUD. The scores then appear to be
(2021) [58] (France) who was already in Reprocessing (EMDR)
stable over time between the post-test after 24 h and 1 week later.
EMDR therapy therapy treatment
Immediately after the training, the results showed that the reduction in
Modified burnout in dimensions of “work-characteristic-related”, “client-related”
Randomized 50 non-medical hospital
Haghighinejad mindfulness-based stress and “work-distaste-related” and decreased anxiety and stress scores in
Controlled Trial staff (25 intervention CBI; DASS-21
H. (2022) [60] reduction (MBSR) the intervention group were significantly more than in the control group
(Iran) group; 25 control group)
program (p < 0.05). After 3 months this effect was sustainable, although the
downward trend in reducing the average burnout score had not continued.
AAQ-II: Acceptance and Action Questionnaire-II; AUDIT: Alcohol Use Disorders Identification Test; BDI: Beck Depression Inventory; Brief-COPE: Coping Orientation to Problems
Experienced Inventory; CAMS-R: Cognitive and Affective Mindfulness Scale – Revised; CBI: Copenhagen Burnout Inventory; CD-RISC2: Connor-Davidson Resilience Scale-2; DASS-21:
Depression, anxiety, and stress scale; DTA: Distress Thermometer Assessment; EQ-5D: EuroQol; GAD-7: Generalized Anxiety Disorder Scale; GHQ: General Health Questionnaire;
HADS: Hospital Anxiety and Depression Scale; HPQ: The World Health Organization Health and Work Performance Questionnaire; ISI: Insomnia Severity Index; MBI: Maslach Burnout
Inventory; MSHS: Multidimensional Sense of Humor Scale; PHQ-2: Patient Health Questionnaire; PRIME-MD: Primary Care Evaluation of Mental Disorder; ProQOL: Professional
Quality of Life Scale; PSS: Perceived Stress Scale; QoL: Quality of Life; SCS: Self-Compassion Scale; STAI: State and Trait Anxiety Inventory; STCI-S: State-Trait Cheerfulness Inventory;
SUD: Subjective Units of Distress Scale; SWLS: Satisfaction With Life Scale; WHOQOL-BREF: WHO Quality of Life-BREF; WSS: Work Stress Scale.
Medicina 2023, 59, 1866 8 of 17

Table 2. Studies focused on individual level using relaxing techniques.

First Author Outcome Measures of

Type of Study (Country) Treatment Arms Intervention Results
(Publication Year) Effectiveness
Training on the technique of
Randomized 46 nurses The mean change in the scores from baseline to
Calder Calisi C. the Relaxation Response (RR) STAI; semantic
Controlled Trial (24 intervention group; post assessment did not differ significantly
(2017) [55] and practice the RR over an differential scales
(USA) 22 control group) between groups.
8-week period
Caregivers in both interventions demonstrated
improvements across all psychological outcomes
Two brief art-making PANAS; PSS; GSE; SSCS; (creative agency, p < 0.001; self-efficacy, p = 0.015;
34 professional (n = 25)
Clinical Trial interventions: open studio art PROMIS; MBI; cortisol, positive affect, p < 0.001; negative affect, p < 0.001;
Kaimal G. (2019) [53] and informal (n = 9)
(USA) therapy or the active control IL-6 and CRP levels in perceived stress, p < 0.001; anxiety, p = 0.002;
caregivers
coloring session saliva samples burnout, p = 0.041). There was no evidence of
change in any of the biomarkers (cortisol, IL-6,
and CRP) measured.
In the intervention group, there was a statistically
72 nurses caring for On-line brief single-session significant reduction in stress levels (p < 0.001),
Randomized Controlled
COVID-19 patients group intervention utilizing anxiety levels (p < 0.001), and burnout levels
Dincer B. (2020) [56] Trial SUD; STAI; Burnout Scale
(35 intervention group; Emotional Freedom (p < 0.010). No differences between pre- and
(Turkey)
37 control group) Techniques (EFT) post-intervention tests were found in the
control group.
There was a statistically significant decrease in
state anxiety scores following the retreat
Cunningham T. Clinical Trial 106 healthcare Ten group sessions of 19-item survey developed (p < 0.001). Brief resilience retreats can reduce
(2021) [61] (USA) professionals daylong resilience retreats by the research team perceived anxiety and facilitate engagement in
contemplative practices, which are associated
with a decrease in the risk of burnout.
The data from this randomized controlled trial did
34 health science faculty
Randomized Controlled not demonstrate a change in burnout symptoms
Kavanaugh J. and medical resident Guided forest bathing session
Trial OLBI; Mini-Z from participating in a single Shinrin-Yoku walk
(2022) [62] (24 intervention group; (Shinrin-Yoku)
(USA) when compared to baseline burnout scores or
10 control group)
when compared to a control group.
GSE: General Self-Efficacy Scale; MBI: Maslach Burnout Inventory; Mini-Z: Work-related burnout symptoms questionnaire modified from Minimizing Error Maximizing Outcome; OLBI:
Oldenburg Burnout Inventory; PANAS: Positive and Negative Affect Schedule; PROMIS: Patient-Reported Outcomes Measurement Information System; PSS-10: Perceived Stress Scale;
SSCS: Short Scale of Creative Self; STAI: State and Trait Anxiety Inventory; SUD: Subjective Units of Distress Scale.
Medicina 2023, 59, 1866 9 of 17

Table 3. Studies focused on organizational level.

First Author Outcome Measures of

Type of Study Treatment Arms Intervention Results
(Publication Year) Effectiveness
No statistically significant differences
PJSS; EWS; QOL single were seen in mean changes in
Randomized 123 physicians
Self-facilitated physician question; MBI; PRIME-MD; burnout scale scores, meaning, or
West C.P. (2021) [50] Controlled Trial (61 control group;
small-group meetings SPS; PROMIS Social Isolation social support, although numeric
(USA) 62 intervention group)
Short form 4a Scale differences generally favored
the intervention.
Individual and organizational-level
Results reflected the potency of both
initiatives, including mindfulness-based
64 trainees (residents MBI, PSS, PHQ-2, AUDIT, social support and affective regulation
Clinical Trial affective regulation training, advanced
Lebares C.C. (2021) [47] and clinical fellows) in STAI, CAMS-R, MHC-SF, skills in their ability to mitigate
(USA) scheduling of time off, wellness half-days,
Department of Surgery DCSQ negative emotional influences on
and the creation of a resident-driven
trainee work satisfaction.
well-being committee
AUDIT: Alcohol Use Disorders Identification Test; CAMS-R: Cognitive and Affective Mindfulness Scale – Revised; DCSQ: Demand-Control-Support Questionnaire; EWS: Empowerment
at Work Scale; MBI: Maslach Burnout Inventory; MHC-SF: Mental Health Continuum–Short Form; PHQ-2: Patient Health Questionnaire; PJSS: Physician Job Satisfaction Scale
PRIME-MD: Primary Care Evaluation of Mental Disorder; PROMIS: Patient-Reported Outcomes Measurement Information System; PSS-10: Perceived Stress Scale; QoL: Quality of Life;
SPS: Social Provisions Scale; STAI: State and Trait Anxiety Inventory.
Medicina 2023, 59, 1866 10 of 17

Table 4. Assessment tools used for each study. Copenhagen Burnout Inventory (CBI); The Swedish Demand -Control -Support Questionnaire (DCSQ); Early
Warning Score—EWS; General Self-Efficacy scale (GSE); Health professional questionnaire (HPQ); Maslach Burnout Inventory (MBI); oldenburg burnout inventory
(OLBI); Physician Job Satisfaction Scale (PJSS); Work Stressors Scale (WSS); General Health Questionnaire-28 (GHQ-28); Mental Health Continuum Short Form
(MHC-SF); Professional Quality of Life (proQOL); Satisfaction With Life Scale (SWLS); Beck Depression Inventory (BDI); Depression Anxiety Stress Scales Short
Version (DASS-21); General Anxiety Disorder-7 (GAD-7); Hamilton Depression Rating scale (HAD-S); Insomnia severity index (ISI); Patient Health Questionnaire
(PHQ-2); Perceived Stress Scale (PSS); The State-Trait Anxiety Inventory (STAI).

Group I Group II Group III

Haghighinejad (2022) [60]

Cunningham (2021) [61]

Calder Calisi (2017) [55]

Kavanaugh (2022) [62]

León-Pérez (2021) [57]
dos Santos (2015) [46]

Luzarraga (2019) [59]

Montaner (2021) [49]

Tarquinio (2021) [58]

Watanabe (2019) [45]
Sullivan (2019) [52]

Lebares (2021) [47]

Rinaldi (2019) [54]

Kaimal (2019) [53]

Dincer (2020) [56]

Luton (2021) [48]
Axisa (2019) [51]

West (2021) [50]

Burnout assessment
19 item survey +
Burnout scale +
CBI +
DCSQ +
EWS +
GSE +
HPQ +
MBI + + + + + +
Mini-Z +
OLBI +
PJSS +
WSS +
 Medicina 2023, 59, 1866

Psychiatric assessment
Quality of life assessment

AUDIT

STAI
ISI
BDI

GAD-7

SUD
PSS
PRIME-MD
PHQ-2
HADS
DTA
DASS-21
WHOQOL-BREF
SWLS
QOL single question
Pro-QOL
MHC-SF
GHQ-28
EQ-5D
Table 4. Cont.

+
+
+
+
+
dos Santos (2015) [46]

+
+
+
Axisa (2019) [51]

+
Luzarraga (2019) [59]

+
Rinaldi (2019) [54]
+

Sullivan (2019) [52]

+
+
+
+
+

Watanabe (2019) [45]

Group I

León-Pérez (2021) [57]

+
+
+ Luton (2021) [48]

+
+

Montaner (2021) [49]

+
+

Tarquinio (2021) [58]

+

Haghighinejad (2022) [60]

+

Calder Calisi (2017) [55]

+

Kaimal (2019) [53]

+
+

Dincer (2020) [56]

Group II

Cunningham (2021) [61]

Kavanaugh (2022) [62]

+
+

West (2021) [50]

Group III

+
+
+
+

Lebares (2021) [47]

11 of 17
 Other
Medicina 2023, 59, 1866

Psychological assessment
AAQ-II

Cortisol, IL-6, CRP

Breath rate
STCI-S
SSCS
SPS
Semantic scale
SCS
PROMIS
PANAS
MSHS
CD-RISC2
CAMS-R
Brief-COPE
Table 4. Cont.

+
dos Santos (2015) [46]

Axisa (2019) [51]

+
Luzarraga (2019) [59]

Rinaldi (2019) [54]

+
+

Sullivan (2019) [52]

Watanabe (2019) [45]

Group I

+
+

León-Pérez (2021) [57]

+

Luton (2021) [48]

+

Montaner (2021) [49]

Tarquinio (2021) [58]

Haghighinejad (2022) [60]

+

Calder Calisi (2017) [55]

+
+
+
+

Kaimal (2019) [53]

Dincer (2020) [56]

Group II

Cunningham (2021) [61]

Kavanaugh (2022) [62]

+
+

West (2021) [50]

Group III

Lebares (2021) [47]

12 of 17
Medicina 2023, 59, 1866 13 of 17

4. Discussion
Work-related stress is a growing concern for healthcare professionals. In fact, more
than 20% of European workers report suffering from stress related to the workplace. More-
over, work-related stress has been associated with a number of negative health outcomes,
including cardiovascular diseases, musculoskeletal disorders (particularly back problems),
and absenteeism. Work-related stress develops because a person is unable to cope with
work demands [63]. Factors causing work stress include poor communication or coop-
eration within the organization and lack of control over work pace or work processes.
Protective factors for reducing work-related stress have also recently been identified, in-
cluding resilience and sense of coherence (SOC). In particular, people reporting high levels
of SOC have an opinion on reality and their environment that is more comprehensive,
manageable, and meaningful [64].
Work-related stress can have a negative impact on the workers themselves, patients,
communities, and the general population at large. Furthermore, burnout and work-related
stress in healthcare professionals is associated with work-to-family conflict and unre-
alistic expectations of patients, which are factors that have been worsened during the
pandemic [65].
The selected articles highlight that high levels of work-related stress and burnout can
cause a significant reduction in life and job satisfaction, worsening quality of life, and can
lead to the onset of psychiatric disorders such as depression. In fact, many authors use
assessment tools for quality of life, job satisfaction, and depressive symptoms to evaluate
the effectiveness of interventions aimed at reducing work-related stress.
Therefore, the implementation and dissemination of preventive interventions for
work-related stress represents an urgent priority from a public health perspective [66–68].
Based on the present systematic review, different interventions are currently available
for addressing work-related stress in healthcare professionals. Studies included in this
review are very heterogeneous in terms of assessment tools, target populations, and types
of interventions, thus limiting the generalizability of the findings.
Among interventions focused on the individual level using CBT or other psychother-
apeutic approaches, our findings confirm the effectiveness of mindfulness techniques in
reducing work-related stress [46,54,59,60], which was already shown in healthy adults and
children [69,70]. Specific features of mindfulness can be beneficial for preventing stress
in the workplace: it can be easily practiced after a short training and it does not require
particular tools nor settings, and it is usually well accepted by participants. The appar-
ently conflicting data by Watanabe et al., could be due to the peculiarities of the specific
interventions (techniques, duration, environment) and the different study design [45].
The main limitations of the included interventions are related to the extreme hetero-
geneity and to the short-term evaluation of their effectiveness. Therefore, it should be
needed to promote further rigorous longitudinal studies, aiming to assess the preventive
and protective effects of these interventions in the long-term. Encouraging results in re-
ducing stress, anxiety, and depressive symptoms, as well as emotional exhaustion, are
seen with other psychotherapeutic approaches, such as ESRT, EMDR, and ACT [48,49,58].
Also, referring to these latter approaches, there is not a specific protocol of intervention
that is work-related stress oriented. Although CBT-based techniques may be useful in
mitigating stress and promoting coping and resilience, further research to investigate the
effects of SOC-strengthening interventions may be useful, since SOC has been shown to be
a work-related stress-specific protective factor. [64]
As regards relaxation techniques, a promising intervention carried out by Dincer and
Inangil utilizing Emotional Freedom Techniques (EFT) led to a significant reduction in
stress, anxiety, and burnout levels [56]. EFT had already been shown to be effective in
reducing depressive symptoms [71] and in improving stress-related conditions such as
tension-type headaches [72]. Instead, Cunningham and Çayir, while reporting an efficacy
in reducing the anxiety at group sessions of daylong resilience retreats, did not use any
validated tools but a self-produced questionnaire [61]. On the other hand, Kaimal et al.
Medicina 2023, 59, 1866 14 of 17

measured the effectiveness of art-based relaxation techniques in reducing stress, but these
data were not supported by changes in biomarkers, suggesting a potential placebo effect
and suggesting that further studies are needed [53]. Similarly, two RCTs [55,62] found a
small effectiveness for interventions based on relaxation techniques that seek to reduce and
prevent burnout. Overall, relaxation techniques can be considered effective in reducing
stress and can be easily applied in the workplace; in particular, they are simple techniques
that do not require special training conducted by qualified personnel, are cost-effective,
and can be repeated over time. On the other hand, the need to repeat the interventions
several times with the same people in the workplace could represent a limitation in itself.

Limitations
The present review has some limitations which must be acknowledged. First, the
search strategy has been limited to healthcare professionals in general, without a specific
comparison among the different professional roles of participants. In fact, it could be
that protective and risk factors for specific groups of professionals, such as early career
professionals or nurses, are completely different from those relevant for senior medical
doctors. Furthermore, the work environment, the type of patients, the tasks required,
the level of responsibility, and the career opportunities available significantly change for
each category and can play a role in determining the risk of developing workplace-related
stress or burnout symptoms. Another limitation is due to the extreme heterogeneity of
the assessment tools used for measuring the levels of workplace-related stress. This could
be due to the fact that “workplace-related stress” is a complex phenomenon, including
both structural and organizational factors as well as personal dimensions, such as coping
strategies, temperament traits, and cognitive styles. Therefore, a complex phenomenon
cannot be measured by a unique assessment tool. Finally, most of the interventions were
conducted with volunteers and control groups not clearly defined. This may have led to a
selection bias and to a “placebo” effect. However, the difficulty in selecting participants
among healthcare professionals may explain the lack of RCTs on the subject, despite the
growing interest of the scientific community.

5. Conclusions
The findings of the present systematic review clearly highlight the complexity of the
management and prevention of work-related stress, which requires a multicomponent and
multilevel approach. Despite the growing interest in the topic, it is not possible to draw
definite conclusions on the “best practice” to adopt in order to prevent work-related stress
among healthcare workers. It can be useful to run randomized controlled trials examining
the most promising intervention techniques (such as mindfulness), which need to be well-
structured and reliable. Interventions should be carried out on restricted categories of
healthcare professionals, taking into account age, tasks, and type of treated patients. It is
also necessary to define which assessment tools shall be used in order to compare more
objectively the results and to investigate all the dimensions of burnout [73,74].

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/medicina59101866/s1, Table S1. Risk of bias assessment in non-
randomized studies of intervention (NRSI). Table S2. Risk of bias assessment in randomized clinical
trials (RCTs).
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Upon request to the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.
Medicina 2023, 59, 1866 15 of 17

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