Stress reduction is a key employee health challenge, and intuitively one would think that any of the common approaches would help de-stress healthcare workers. It turns out to be surprisingly difficult to quantify the effects of the various interventions.

It’s widely known that stress can affect the cardiovascular system, raising blood pressure and the risk of heart attack. What’s less discussed is that stress affects an astonishing number of body systems and organs, so many that the American Institute of Stress concludes, “it’s hard to think of any disease in which stress cannot play an aggravating role or any part of the body that is not affected.”

To make matters very much worse, healthcare workers are the most stressed-out employees in the country. A recent survey of 3,211 workers found healthcare workers at the very white-knuckled pinnacle, with an astounding 86% of workers reporting that they feel “stressed” (69%) or “highly stressed” (17%).1

“Often this is because healthcare workers face high expectations and they may not have enough time, skills and social support at work,” the authors of a recent Cochrane review report.2 “This can lead to severe distress, burnout or physical illness. In the end, healthcare workers may be unable to provide high quality healthcare services. Stress and burnout can also be costly because affected healthcare workers take sick leave and may even change jobs.”

It goes without saying that stressful, burned-out nurses may put themselves and their patients at greater risk than those who are coping better and using interventions to reduce stress.

Unfortunately, when subjected to the rigorous standards of a Cochrane review, the actual evidence supporting the various approaches is scant. Researchers found that cognitive-behavioral training as well as mental and physical relaxation all reduce stress moderately. Changing work schedules can also reduce stress, but other organizational interventions have no clear effects.

The review evaluated how well person-directed or organizational interventions prevent stress or burnout in healthcare workers. The authors included 58 studies that included 7,188 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 (i.e., mindfulness, self-talk) was 13% better than no intervention at all in seven studies, the authors report. 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, they note. The results were similar when cognitive-behavioral training was combined with relaxation. In addition, 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 a 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.

The authors found fewer studies on organizational interventions, and surprisingly the introduction of a social support program did not lead to a considerable reduction of stress levels in workers at less than six months follow-up in four studies with 2,476 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, the authors reported. 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,” they concluded. “[We] recommend conducting evaluations of organizational interventions that better focus on improving specific working conditions associated with stress. [C]ognitive-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.”

Given these rather discouraging results, we reached out via email to lead author Jani H. Ruotsalainen, MSc, managing editor of the Cochrane Occupational Safety and Health Review Group at the Finnish Institute of Occupational Health in Kuopio.

HEH: Do you have any opinion on why the data do not show a greater benefit to cognitive-behavioral training (CBT) as well as mental and physical relaxation to reduce stress?

Ruotsalainen: “Given the nature of systematic reviews in trying to overcome the problems of individual studies and trying to extract an overall ‘truth’ regarding the magnitude of effect for a particular intervention, such as how much on average does CBT reduce stress, it would be going beyond the data to conjecture how and why the effect size is what it is. Of course we can make educated guesses based on obvious shortcomings in the included studies, such as problems in keeping intervention and control groups truly separate and following up people for long periods of time after the intervention. But unfortunately this type of research is not the best way to answer any questions beginning with why.”

HEH: Based on your findings, would it be fair to say it is better to have such programs than not?

Ruotsalainen: “Absolutely. We can say without any doubt that healthcare workers’ stress can be reduced with CBT and relaxation programs. However, to say if they would help in any given particular context, one would first need to know the current situation, i.e. magnitude/prevalence of the stress/burnout problem. If, for example, a particular hospital/care facility had tackled the issue with vigour and had already achieved significant results over time then it would be silly to expect much further improvement.”

HEH: Would the moderate benefits reported be worth the resources needed for such programs — in other words, would they be cost-effective?

Ruotsalainen: “Generally speaking, I would be willing to bet that CBT and relaxation interventions would not be very expensive to set up and therefore even a modest improvement would mean a healthy cost/benefit ratio. Sadly very few stress management intervention studies address cost-effectiveness directly so anything I state on this is conjecture and not based on the review.”

HEH: You and co-authors conclude that shorter vs. longer working schedules can also reduce stress — can you elaborate on that point in terms of what changes have shown effective in stress reduction?

Ruotsalainen: “[One study] in 20113 compared a work schedule with weekend breaks to a continuous schedule among intensive care staff, and another in 20124 compared a two-week with a four-week schedule among resident physicians. We combined the results of the two studies because the interventions had a similar objective and they both measured emotional exhaustion as an outcome, even though it was measured in different ways. The results showed that the shorter schedules reduced stress.”


  1. The Hiring Site. America’s most stressful jobs: What are they? Feb. 10, 2014:
  2. Ruotsalainen RH, Verbeek JH, Mariné A, et al. Preventing occupational stress in healthcare workers. Cochrane Occupational Safety and Health Group. April 7, 2015
  3. Continuity of care in intensive care units: A cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med 2011;184(7):803-808.
  4. Lucas BP, Trick WE, Evans AT. Inpatient Rotations on Unplanned Patient Revisits, Evaluations by Trainees, and Attending Physician Burnout: A Randomized Trial JAMA. 2012;308(21):2199-2207.