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Musker M, Othman S. Effective interventions to reduce burnout in nurses: A meta-analysis. Complement Ther Clin Pract 2024; 54:101827. [PMID: 38181650 DOI: 10.1016/j.ctcp.2023.101827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/29/2023] [Accepted: 12/29/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND To examine the effectiveness of interventions to ameliorate burnout, secondary traumatic stress, and emotional exhaustion in nurses and midwives. The systematic review was completed with all available studies that reported data on the effect of interventions that targeted burnout using the outcome measures of the Professional Quality of Life scale (ProQOL), or the Maslach Burnout Inventory (MBI). METHODS We used a systematic review methodology, which included a meta-analysis. A total of 2103 articles resulted from the systematic search; 688 were removed as duplicates, and 1415 articles were reviewed by the title and abstract, of which 255 were eligible for full-text screening. Only 66 met the inclusion criteria and were included in the analysis. The final meta-analysis consisted of 33 reports divided into 12 studies for ProQOL and 21 studies for the MBI. RESULTS The results provide an overall effect in studies using the ProQOL measurement was Z = 2.07 (P = 0.04) and a positive improvement mean difference of 9.32. The overall effect in studies using MBI was Z = 3.13 (P = 0.002) and a positive improvement mean difference of 6.58. CONCLUSIONS Whilst most studies indicated a positive difference, the most effective interventions included clinical supervision or activities that addressed the personal physical and mental well-being of nurses. Less effective interventions were managerial interventions or ones that used a strictly educational approach.
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Affiliation(s)
- Mike Musker
- UniSA, Clinical & Health Sciences, Mental Health and Suicide Prevention Research and Education Group, University of South Australia, Adelaide, SA, 5000, Australia.
| | - Shwikar Othman
- Wardliparingga Aboriginal Health Equity, Population Health, South Australian Health and Medical Research Institute (SAHMRI), North Terrace, Adelaide, SA, 5000, Australia; Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia.
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Norouzinia R, Yarmohammadian MH, Ferdosi M, Masoumi G, Ebadi A. Development and psychometric evaluation of the emergency nurses' professional resilience tool. PLoS One 2022; 17:e0269539. [PMID: 35671289 PMCID: PMC9173641 DOI: 10.1371/journal.pone.0269539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is no specific tool for measuring the professional resilience of emergency nurses. Therefore, the present study aimed to design and psychometrically evaluate a new tool named the emergency nurses' professional resilience tool. METHOD This mixed-method sequential exploratory study was conducted in two phases: (1) item generation using literature review and evaluation of the results of a qualitative study and (2) psychometric evaluation of the developed scale. The face, content, and construct validity (exploratory and confirmatory factor analysis), reliability (internal consistency, relative, and absolute), and accountability were assessed in the population of Iranian nurses (N = 465) during March 2019-June 2020. RESULTS The tool designed for assessing the professional resilience of Iranian nurses included 37 items. The average scale content validity index (S-CVI/Ave) was equal to 0.94. The exploratory factor analysis revealed five factors, including professional competencies, emotional-cognitive characteristics, external support, in addition to behavioral and cognitive strategies, and explained 75.59% of the whole variance. Cronbach's alpha and intraclass correlation were 0.915 and 0.888, respectively. Construct validity for five factors was established with acceptable model fit indices [Chi-square/df = 1336.56/619, p < .001]; [Comparative Fit Index [CFI] = 0.96]; [Non-Normed Fit Index [NNFI] = 0.96]; [Root Mean Square Error of Approximation (RMSEA) = 0.074 and 90 Percent Confidence Interval = (0.069; 0.080)]; and [SRMR = 0.095]. CONCLUSIONS According to the findings of the current study, the emergency nurses' professional resilience tool can be used by healthcare managers as a valid and reliable scale to evaluate the professional resilience of nurses to designate them as nurses working in emergency and disaster situations.
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Affiliation(s)
- Roohangiz Norouzinia
- Social Determinants of Health Research Center, Alborz university of Medical Sciences, Karaj, Iran
| | | | - Masoud Ferdosi
- Health Management and Economics Research Centre, Isfahan university of Medical Sciences, Isfahan, Iran
| | - Gholamreza Masoumi
- Emergency Management Research Centre, Iran University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioural Sciences Research Centre, Life style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Di Nota PM, Bahji A, Groll D, Carleton RN, Anderson GS. Proactive psychological programs designed to mitigate posttraumatic stress injuries among at-risk workers: a systematic review and meta-analysis. Syst Rev 2021; 10:126. [PMID: 33910641 PMCID: PMC8079856 DOI: 10.1186/s13643-021-01677-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 04/15/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Public safety personnel and frontline healthcare professionals are at increased risk of exposure to potentially psychologically traumatic events (PPTE) and developing posttraumatic stress injuries (PTSI, e.g., depression, anxiety) by the nature of their work. PTSI are also linked to increased absenteeism, suicidality, and performance decrements, which compromise occupational and public health and safety in trauma-exposed workers. Evidence is lacking regarding the effectiveness of "prevention" programs designed to mitigate PTSI proactively. The purpose of this review is to measure the effectiveness of proactive PTSI mitigation programs among occupational groups exposed to PPTE on measures of PTSI symptoms, absenteeism, and psychological wellness. METHODS Five electronic databases were searched per PRISMA guidelines for English or French peer-reviewed studies from 2008 to 2019 evaluating PTSI and psychological wellness in adults exposed to occupational PPTE. The risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS We identified 42 studies evaluating 3182 public safety and frontline healthcare professionals, PPTE-exposed educational staff, and miners. Significant overlap was found across program themes that included mindfulness, psychoeducation, resilience promotion, and stress management strategies. Post-program effect sizes were small (SMD < 0.5) to moderate (SMD < 0.8) for reductions in PTSI symptoms and for promoting measures of well-being as indicated by a meta-analysis on 36 studies. There was no evidence for significant reductions in substance use, absenteeism, or biomarkers of distress except for heart rate. Subgroup analyses indicated that multimodal programs effectively improved general psychological health, while resilience programs improved measures of depression, burnout, coping, and resilience. Effect sizes for resilience, depression, and general psychological health improvements were greatest immediately or 1-month post-training, while improvements in PTSD symptoms and coping were larger at longer follow-up. Studies were of moderate quality and risk of bias. CONCLUSIONS The current results showcase modest evidence for time-limited reductions in PTSI following participation in holistic programs that promote resilience, stress, and emotion regulation among at-risk workers. Implications for organizational implementation of proactive PTSI mitigation programs and areas of future research are discussed. SYSTEMATIC REVIEW REGISTRATION PROSPERO (CRD42019133534).
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Affiliation(s)
- Paula M Di Nota
- Department of Psychology, University of Toronto, Toronto, Canada
| | - Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Canada
| | - Dianne Groll
- Department of Psychiatry, Queen's University, Kingston, Canada
| | | | - Gregory S Anderson
- Faculty of Science, Thompson Rivers University, TRU Way, Kamloops, BC, V2C 0C8, Canada.
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Mihandoust S, Pati D, Lee J, Roney J. Exploring the Relationship Between Perceived Visual Access to Nature and Nurse Burnout. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2021; 14:258-273. [PMID: 33678050 DOI: 10.1177/1937586721996302] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study aims to investigate the relationship between perceived visual access to nature views in nurse work and break environments and scores for subscales of Maslach Burnout Inventory among nurses. BACKGROUND Burnout is a severe problem among nurses. Literature shows a relationship between stress and burnout and between nature exposure and stress. However, the possible consequent relationship between connection to nature and nurse burnout needs further study. METHODS This cross-sectional study explored the relationship between the subscales (Emotional Exhaustion, Depersonalization, and Personal Accomplishment [EE, DP, and PA]) of the Maslach Burnout Inventory as "outcome variables" and perception of view duration, frequency of exposure to views, view content and artwork content as "explanatory variables" in a subset regression model. The study model also included organizational stressors, environmental design factors, unit type, workload, and personal factors as control variables. Fifty-one nurses working in six units in a large tertiary care hospital participated in the study. RESULTS Percentage of perceived nature views and organizational stressors were the top two best predictors correlating with EE (37% of the EE variance; p < .05). Percentage of perceived nature views, organizational stressors, and environmental design were the top three predictors correlating with DP (43% of variance for DP; p < .05). No significant relationship was found between study variables and PA. CONCLUSIONS The results of this study recommend perceiving nature views as an independent or integrated intervention to meditation and relaxation techniques. From a design standpoint, this study suggests that a unit and breakroom design with access to nature views could work as a consistent preventive intervention for burnout.
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Woo T, Ho R, Tang A, Tam W. Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. J Psychiatr Res 2020; 123:9-20. [PMID: 32007680 DOI: 10.1016/j.jpsychires.2019.12.015] [Citation(s) in RCA: 299] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 12/06/2019] [Accepted: 12/27/2019] [Indexed: 11/25/2022]
Abstract
WHO recently declared burnout as a "occupational phenomenon" in the International Classification of Diseases 11th revision (ICD-11), recognizing burnout as a serious health issue. Amongst healthcare workers, nurses are known to struggle with burnout symptoms the most, carrying serious consequences for patients, other healthcare professionals and healthcare organisations. Evidence has suggested that burnout symptoms in nurses is high across specialties and countries, but no meta-analysis have been performed to investigate burnout symptoms prevalence in nurses globally. We conducted a systematic review and meta-analysis to examine burnout symptoms prevalence in nurses worldwide using 8 academic research databases. Risk of bias, heterogeneity and subgroup analyses were further conducted in the meta-analysis. 113 studies were included for systematic review and 61 studies for the meta-analysis, consisting 45,539 nurses worldwide in 49 countries across multiple specialties. An overall pooled-prevalence of burnout symptoms among global nurses was 11.23%. Significant differences were noted between geographical regions, specialties and type of burnout measurement used. Sub-Saharan African region had the highest burnout symptoms prevalence rate while Europe and Central Asia region had the lowest. Paediatric nurses had the highest burnout symptoms prevalence rates among all specialties while Geriatric care nurses had the lowest. This study is the first study to synthesize published studies and to estimate pooled-prevalence of burnout symptoms among nurses globally. The findings suggest that nurses have high burnout symptoms prevalence warranting attention and implementation. This study serves as an impetus for intervention studies and policy change to improve nurses' work conditions and overall healthcare quality.
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Affiliation(s)
- Tiffany Woo
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore
| | - Roger Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Biomedical Global Institute of Healthcare Research & Technology (BIGHEART), National University of Singapore, Singapore; Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Viet Nam
| | - Arthur Tang
- Department of Software, Sungkyunkwan University, Suwon, Republic of Korea.
| | - Wilson Tam
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore; Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Viet Nam
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Stanulewicz N, Knox E, Narayanasamy M, Shivji N, Khunti K, Blake H. Effectiveness of Lifestyle Health Promotion Interventions for Nurses: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 17:E17. [PMID: 31861367 PMCID: PMC6981404 DOI: 10.3390/ijerph17010017] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 12/15/2019] [Accepted: 12/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prior research has investigated various strategies to improve health, wellbeing and the job-related outcomes of nurses. However, the scope of this evidence is not clear and the types of intervention most likely to have positive outcomes are unknown. OBJECTIVE To provide an overview and synthesis of the effectiveness of interventions conducted with the goal of improving health, wellbeing and the job-related outcomes of nurses. METHODS A systematic database search was conducted from January 2000 to December 2018, with pre-defined criteria (Cochrane Central Register of Controlled Trials; MEDLINE and PubMed; EMBASE; CINAHL; PsycINFO; and BioMed Central). In total, 136 intervention studies with a total sample of 16,129 participants (range 9-3381) were included and evaluated. Data extraction, quality assessment and risk of bias analyses were performed. RESULTS Studies included randomised controlled trials (RCTs; n = 52, 38%), randomised crossover design studies (n = 2, 1.5%) and non-randomised pre-post studies with a control group (n = 31, 23%) and without a control group (n = 51, 37.5%). The majority of interventions focused on education, physical activity, mindfulness, or relaxation. Thirty-seven (27%) studies had a multimodal intervention approach. On average, studies had relatively small samples (median = 61; mode = 30) and were conducted predominantly in North America (USA/Canada, n = 53). The findings were mixed overall, with some studies reporting benefits and others finding no effects. Dietary habits was the most successfully improved outcome (8/9), followed by indices of body composition (20/24), physical activity (PA) (11/14), and stress (49/66), with >70% of relevant studies in each of these categories reporting improvements. The lowest success rate was for work-related outcomes (16/32). Separate analysis of RCTs indicated that interventions that focus solely on education might be less likely to result in positive outcomes than interventions targeting behavioural change. CONCLUSIONS Interventions targeting diet, body composition, PA, or stress are most likely to have positive outcomes for nurses' health and/or wellbeing. The methodologically strongest evidence (RCTs) is available for body composition and stress. Interventions relying solely on educational approaches are least likely to be effective. Organisational outcomes appear to be more challenging to change with lifestyle intervention, likely requiring more complex solutions including changes to the work environment. There is a need for more high-quality evidence since many studies had moderate or high risk of bias and low reporting quality.
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Affiliation(s)
- Natalia Stanulewicz
- School of Applied Social Sciences, De Montfort University, Leicester LE1 9BH, UK
| | - Emily Knox
- Infant Nutrition and Metabolism, University of Granada, 52005 Granada, Spain;
| | - Melanie Narayanasamy
- School of Health Sciences, University of Nottingham, Nottingham NG7 2RD, UK; (M.N.); (H.B.)
| | - Noureen Shivji
- School of Primary, Community and Social Care, Keele University, Staffordshire ST5 5BG, UK;
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester LE1 7RH, UK;
| | - Holly Blake
- School of Health Sciences, University of Nottingham, Nottingham NG7 2RD, UK; (M.N.); (H.B.)
- NIHR Nottingham Biomedical Research Centre, Nottingham NG7 2UH, UK
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Luo YH, Li H, Plummer V, Cross WM, Lam L, Guo YF, Yin YZ, Zhang JP. An evaluation of a positive psychological intervention to reduce burnout among nurses. Arch Psychiatr Nurs 2019; 33:186-191. [PMID: 31753226 DOI: 10.1016/j.apnu.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/27/2019] [Accepted: 08/18/2019] [Indexed: 11/28/2022]
Abstract
This quasi-experimental study aimed to evaluate the positive psychological intervention of recording three good things on alleviating nurses' burnout. Eighty-seven nurses with burnout were recruited. Nurses in the study group recorded three good things using communication tool WeChat for six months, no records were made in the control group. After intervention, the score of exhaustion decreased considerably for nurses in the study group. Nurses recording three good things on average twice a week returned the lowest score of exhaustion. This intervention combined with appropriate surveillance and encouragement is recommended to reduce nurses' burnout and create a positive work environment.
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Affiliation(s)
- Yuan-Hui Luo
- School of Nursing, The University of Hong Kong, Hong Kong SAR, China; Nursing Psychology Research Centre of Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Hui Li
- Nursing Psychology Research Centre of Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Virginia Plummer
- School of Nursing and Midwifery, Monash University, Victoria, Australia; Peninsula Health, PO Box 52, Frankston 399, Australia
| | - Wendy M Cross
- School of Nursing and Healthcare Professions, Federation University Australia, Victoria, Australia
| | - Louisa Lam
- School of Nursing and Midwifery, Monash University, Victoria, Australia; School of Nursing and Healthcare Professions, Federation University Australia, Victoria, Australia
| | - Yu-Fang Guo
- College of Nursing, Hebei University, Baoding, Hebei, China
| | - Yi-Zhen Yin
- Nursing Psychology Research Centre of Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Jing-Ping Zhang
- Nursing Psychology Research Centre of Xiangya School of Nursing, Central South University, Changsha, Hunan, China.
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López Gómez MA, Sabbath E, Boden L, Williams JAR, Hopcia K, Hashimoto D, Sorensen G. Organizational and Psychosocial Working Conditions and Their Relationship With Mental Health Outcomes in Patient-Care Workers. J Occup Environ Med 2019; 61:e480-e485. [PMID: 31651598 PMCID: PMC10898241 DOI: 10.1097/jom.0000000000001736] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between both psychosocial and organizational working conditions with self-reported mental health and mental health expenditures. METHODS This study used worker survey and medical claims data from a sample of 1594 patient-care workers from the Boston Hospital Workers Health Study (BHWHS) to assess the relationship of psychosocial (job demands, decision latitude, supervisor support, coworker support) and organizational (job flexibility, people-oriented culture) working conditions with mental health outcomes using validated tools RESULTS:: People-oriented culture and coworker support were negatively correlated with psychological distress and were predictive of lower expenditures in mental health services. Job demands were positively correlated with psychological distress. CONCLUSIONS Working conditions that promote trustful relationships and a cooperative work environment may render sustainable solutions to prevent ill mental health.
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Affiliation(s)
- María Andrée López Gómez
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Dr López Gómez, Dr Williams, and Dr Sorensen); Boston College, School of Social Work, Boston, Massachusetts (Dr Sabbath); Boston University School of Public Health, Boston, Massachusetts (Dr Boden); Department of Health Policy and Management, University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, Kansas (Dr Williams); Workplace Health and Wellbeing, Partners HealthCare System, Boston, Massachusetts (Dr Hopcia); Partners HealthCare, Inc., Boston, Massachusetts (Dr Hashimoto); Boston College Law School, Boston, Massachusetts (Dr Hashimoto); Dana-Farber Cancer Institute, Center for Community-Based Research, Boston, Massachusetts (Dr Williams and Dr Sorensen)
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Slater PJ, Edwards RM, Badat AA. Evaluation of a staff well-being program in a pediatric oncology, hematology, and palliative care services group. J Healthc Leadersh 2018; 10:67-85. [PMID: 30532609 PMCID: PMC6241860 DOI: 10.2147/jhl.s176848] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Challenges experienced by staff in the Oncology Services Group at Queensland Children's Hospital led to issues with staff retention, well-being, and stress on team culture. Therefore, a customized program was developed through a needs analysis to improve the well-being and resilience of oncology staff, enabling them to cope with stressors and critical incidents inherent in their everyday work and to flourish. The program included education, on-site counselors, mindfulness sessions, debriefing, well-being resources, and improved engagement, support, and communication. METHODS Evaluation of the program in the first year examined program participation, staff feedback following education workshops and mindfulness sessions, staff retention rates, and the results of an annual organizational staff survey and a program outcome survey. RESULTS Approximately 76% of staff attended the Introduction to Well-being workshop, and 98% of responses to survey questions were positive. Staff also provided positive feedback on the other well-being workshops and sessions embedded within existing education programs. Employee Assistance Program counseling sessions had an 81% uptake, with a wide variety of presenting issues, 62% related to work. All participants in mindfulness sessions agreed that it was a valuable tool to improve clinical practice, 94% said it had an immediate positive impact on their well-being, and 70% agreed that they were applying mindfulness principles outside the sessions. Staff retention and turnover improved. Staff reported a positive effect on awareness of self-care, addressing risks to resilience, seeking support from trusted colleagues, coping with critical incidents, and the ability to interact positively with patients and families. CONCLUSION The evaluation showed a positive impact on staff well-being. Although there was a wide variety of successful interventions reported in the literature, sustainability needs to be considered. Feedback on this program found that staff appreciated being listened to, valued, and supported through the strategies, and the ongoing program will continue to monitor staff needs and be responsive in building their resilience and well-being.
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Affiliation(s)
- Penelope J Slater
- Oncology Services Group, Queensland Children's Hospital, Brisbane, QLD, Australia,
| | - Rachel M Edwards
- Nursing Learning and Workforce Development, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Ashraf A Badat
- Oncology Services Group, Queensland Children's Hospital, Brisbane, QLD, Australia,
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Schneider A, Hilbert S, Hamann J, Skadsem S, Glaser J, Löwe B, Bühner M. The Implications of Psychological Symptoms for Length of Sick Leave. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:291-297. [PMID: 28530171 DOI: 10.3238/arztebl.2017.0291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 10/17/2016] [Accepted: 01/16/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND In this cross-sectional study, we aimed to determine the relation between sick leave duration, burnout symptoms, depression, anxiety, and somatization in a primary care setting. METHODS Patients receiving a sickness certificate in one of 14 participating primary care practices were consecutively asked by their primary care physician to fill in a questionnaire comprising the Maslach Burnout Inventory-General Survey (MBI-GS) and the Patient Health Questionnaire (PHQ) containing the depression (PHQ-9), somatization (PHQ-15), and anxiety (GAD-7) scales. The main diagnosis on the sickness certificate was documented by the issuing physician. A quasi-Poisson regression analysis was performed to estimate the influence of burnout symptoms, depression, and anxiety on length of sick leave. RESULTS 225 patients participated, 122 (54.2%) were female; the mean age was 39.5 years. Length of sick leave correlated with emotional exhaustion (p = 0.005), depersonalization (p = 0.013), depression (p = 0.006), anxiety (p = 0.023), and somatization (p = 0.001). However, regression analysis revealed that the only predictors for length of sick leave were anxiety (exp[0.081] = 1.084; p = 0.013), age (exp[0.017] = 1.017; p = 0.041) and education (exp[- 0.508] = 0.602; p = 0:029). The pseudo R2 of the model was 0.25. CONCLUSION The impact of anxiety on burnout symptoms and sick leave days might have been underestimated so far. A holistic approach in patient centered communication should comprise the evaluation of psychosomatic comorbidity under consideration of the established concepts of depression and anxiety disorder to ensure adequate diagnostic and therapeutic management.
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Affiliation(s)
- Antonius Schneider
- Institute of General Practice, Klinikum rechts der Isar der Technischen Universität München; Institute of Psychological Methods and Diagnostics, Department of Psychology, Ludwig-Maximilians-Universität München; Faculty for Psychology, Pedagogy and Sport Science, University of Regensburg; Clinic and Polyclinic for Psychiatry and Psychotherapy, Technische Universität München; Institute of Psychology, University of Innsbruck, Austria; Department of Psychosomatic Medicine and Psychotherapy, Center for Internal Medicine, Universitätsklinikum Hamburg Eppendorf
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Weenink JW, Kool RB, Bartels RH, Westert GP. Getting back on track: a systematic review of the outcomes of remediation and rehabilitation programmes for healthcare professionals with performance concerns. BMJ Qual Saf 2017; 26:1004-1014. [DOI: 10.1136/bmjqs-2017-006710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/19/2017] [Accepted: 07/18/2017] [Indexed: 11/04/2022]
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12
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Duhoux A, Menear M, Charron M, Lavoie-Tremblay M, Alderson M. Interventions to promote or improve the mental health of primary care nurses: a systematic review. J Nurs Manag 2017; 25:597-607. [PMID: 28782168 DOI: 10.1111/jonm.12511] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2017] [Indexed: 11/30/2022]
Abstract
AIM To synthesize the evidence on the effectiveness of interventions aiming to promote or improve the mental health of primary care nurses. BACKGROUND Primary care nurses have been found to have high levels of emotional exhaustion and to be at increased risk of suffering from burnout, anxiety and depression. Given the increasingly critical role of nurses in high-performing primary care, there is a need to identify interventions that can effectively reduce these professionals' mental health problems and promote their well-being. EVALUATION We conducted a systematic review on the effectiveness of interventions at the individual, group, work environment or organizational level. KEY ISSUES Eight articles reporting on seven unique studies met all eligibility criteria. They were non-randomized pre-post intervention studies and reported positive impacts of interventions on at least some outcomes, though caution is warranted in interpreting these results given the moderate-weak methodological quality of studies. CONCLUSIONS This systematic review found moderate-weak evidence that primary, secondary and combined interventions can reduce burnout and stress in nurses practising in community-based health care settings. IMPLICATIONS FOR NURSING MANAGEMENT The results highlight a need for the implementation and evaluation of new strategies tailored for community-based nurses practising in primary care.
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Affiliation(s)
- Arnaud Duhoux
- Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada.,Centre de recherche de l'hôpital Charles Lemoyne, Quebec, Canada
| | - Matthew Menear
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec, Canada.,CHU de Québec Research Centre, Quebec, Canada
| | - Maude Charron
- Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada
| | | | - Marie Alderson
- Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada.,Centre de Recherche de l'Institut Universitaire de Gériatrie de Montréal, Quebec, Canada.,Institut de Psychodynamique du Travail du Québec, Quebec, Canada.,Association Internationale des Spécialistes de Psychodynamique du Travail, Quebec, Canada
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Andresen IH, Hansen T, Grov EK. Norwegian nurses’ quality of life, job satisfaction, as well as intention to change jobs. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/2057158516676429] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With the expected future nurse shortage we need knowledge on nurses’ life and work situation. The aim of this study is to examine 498 nurses’ satisfaction with life (SwL) and job (SwJ), and intention to change job (IchJ), and to compare this with a control group of non-nurses ( n = 3,714). With data from a Norwegian population-based survey, we analysed associations between socio-demographic and work-related variables. In order to study SwL, SwJ and IchJ we performed bivariate and multivariate statistical analyses. The results show that nurses reported significantly higher SwL and SwJ than non-nurses. For nurses, high SwL was significantly associated with lower age, higher SwJ and appreciative leaders. Significant predictors of higher SwJ were: intention to stay in current job, autonomy, appreciative leader, less monotonous tasks and less stressful work. Intention to change job was associated with low age, nagging colleagues, temporary position and low SwJ. The conclusion is that nurses reported high SwL and SwJ; however, leaders should aim to promote permanent positions, and to minimize stressful work conditions and nagging coworkers.
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Affiliation(s)
- Ida Hellum Andresen
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo and Akershus University College of Applied Sciences, Norway
| | - Thomas Hansen
- Norwegian Social Research, Oslo and Akershus University College of Applied Sciences, Norway
| | - Ellen Karine Grov
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo and Akershus University College of Applied Sciences, Norway
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Abstract
BACKGROUND 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. OBJECTIVES 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. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013. SELECTION CRITERIA 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. DATA COLLECTION AND ANALYSIS 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. MAIN RESULTS 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.
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Affiliation(s)
- Jani H Ruotsalainen
- Finnish Institute of Occupational HealthCochrane Occupational Safety and Health Review GroupPO Box 310KuopioFinland70101
| | - Jos H Verbeek
- Finnish Institute of Occupational HealthCochrane Occupational Safety and Health Review GroupPO Box 310KuopioFinland70101
| | - Albert Mariné
- Corporacio Sanitaria Parc Tauli de SabadellPrevention ServiceParc Tauli s/nSabadellCataloniaSpain08208
| | - Consol Serra
- Pompeu Fabra UniversityCiSAL ‐ Centre for Occupational HealthPRBB BuildinngDr Aiguader, 88BarcelonaSpain08003
- Parc de Salut MAROccupational Health ServicePasseig Marítim de la Barceloneta, 25‐29BarcelonaSpain08003
- CIBER Epidemiología y Salud Pública (CIBERESP)Spain
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15
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Abstract
BACKGROUND Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work. which may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision. OBJECTIVES 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. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013. SELECTION CRITERIA 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. DATA COLLECTION AND ANALYSIS 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. MAIN RESULTS 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.
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Affiliation(s)
- Jani H Ruotsalainen
- Cochrane Occupational Safety and Health Review Group, Finnish Institute of Occupational Health, PO Box 310, Kuopio, 70101, Finland.
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16
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Abstract
Background Healthcare workers can suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work.which may lead to distress, burnout and psychosomatic problems, and deterioration in quality of life and service provision.Objectives 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.Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL,NIOSHTIC-2 and Web of Science up to November 2013.Selection criteria 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.Data collection and analysis 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.Main results 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.
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Blanca-Gutiérrez JJ, Jiménez-Díaz MDC, Escalera-Franco LF. Intervenciones eficaces para reducir el absentismo del personal de enfermería hospitalario. GACETA SANITARIA 2013; 27:545-51. [DOI: 10.1016/j.gaceta.2012.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 09/14/2012] [Accepted: 09/14/2012] [Indexed: 10/27/2022]
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Voltmer E, Wingenfeld K, Spahn C, Driessen M, Schulz M. Work-related behaviour and experience patterns of nurses in different professional stages and settings compared to physicians in Germany. Int J Ment Health Nurs 2013; 22:180-9. [PMID: 22713110 DOI: 10.1111/j.1447-0349.2012.00855.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Working in a health-care profession is correlated with high levels of stress and potential burnout that are likely to increase over time. Few studies differentiate psychosocial stress between nurses in different clinical settings or professional stages. In this cross-sectional study, we compared the work-related behaviour and experience of nurses (n=389) and physicians (n=344) and of nurses across different career stages and clinical settings in Germany. Nurses had the lowest proportion of a healthy behaviour and experience pattern (11.6%) compared with student nurses (32.6%), senior nurses (25%), and physicians (16.7%). They also had the highest proportion of a burnout-related behaviour and experience pattern (32.8% vs 26.1% of student nurses, 18.3% of senior nurses, and 27.3% of physicians). In comparison with medical nurses, psychiatric nurses presented a significantly (P<0.01) lower proportion with a healthy (10.6% vs 21.8%) and burnout-related behaviour pattern (23.5% vs 29.6%), and a higher proportion showing a low commitment to work (61.4% vs 34.4%). Differences in health-related dimensions were primarily observed in the domains of professional commitment and stress resistance. The observed differences in behaviour and experience patterns as a function of health-care settings and career stages emphasize the need for specific interventions.
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Affiliation(s)
- Edgar Voltmer
- Department of Health and Behavioural Sciences, Friedensau Adventist University, Friedensau, Germany.
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19
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Gärtner FR, Ketelaar SM, Smeets O, Bolier L, Fischer E, van Dijk FJH, Nieuwenhuijsen K, Sluiter JK. The Mental Vitality @ Work study: design of a randomized controlled trial on the effect of a workers' health surveillance mental module for nurses and allied health professionals. BMC Public Health 2011; 11:290. [PMID: 21569282 PMCID: PMC3112124 DOI: 10.1186/1471-2458-11-290] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 05/10/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Employees in health care service are at high risk for developing mental health complaints. The effects of mental health complaints on work can have serious consequences for the quality of care provided by these workers. To help health service workers remain healthy and productive, preventive actions are necessary. A Workers' Health Surveillance (WHS) mental module may be an effective strategy to monitor and promote good (mental) health and work performance. The objective of this paper is to describe the design of a three arm cluster randomized controlled trial on the effectiveness of a WHS mental module for nurses and allied health professionals. Two strategies for this WHS mental module will be compared along with data from a control group. Additionally, the cost effectiveness of the approaches will be evaluated from a societal perspective. METHODS The study is designed as a cluster randomized controlled trial consisting of three arms (two intervention groups, 1 control group) with randomization at ward level. The study population consists of 86 departments in one Dutch academic medical center with a total of 1731 nurses and allied health professionals. At baseline, after three months and after six months of follow-up, outcomes will be assessed by online questionnaires. In both intervention arms, participants will complete a screening to detect problems in mental health and work functioning and receive feedback on their screening results. In cases of impairments in mental health or work functioning in the first intervention arm, a consultation with an occupational physician will be offered. The second intervention arm offers a choice of self-help e-mental health interventions, which will be tailored based on each individual's mental health state and work functioning. The primary outcomes will be help-seeking behavior and work functioning. Secondary outcomes will be mental health and wellbeing. Furthermore, cost-effectiveness in both intervention arms will be assessed, and a process evaluation will be performed. DISCUSSION When it is proven effective compared to a control group, a WHS mental module for nurses and allied health professionals could be implemented and used on a regular basis by occupational health services in hospitals to improve employees' mental health and work functioning. TRIAL REGISTRATION NTR2786.
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Affiliation(s)
- Fania R Gärtner
- Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Sarah M Ketelaar
- Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Odile Smeets
- Innovation Center of Mental Health & Technology (I.COM), Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - Linda Bolier
- Innovation Center of Mental Health & Technology (I.COM), Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - Eva Fischer
- Innovation Center of Mental Health & Technology (I.COM), Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - Frank JH van Dijk
- Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Karen Nieuwenhuijsen
- Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Judith K Sluiter
- Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, the Netherlands
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