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.
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.
To evaluate the effectiveness of work- and person-directed interventions compared to no intervention or alternative interventions in preventing stress at work in healthcare workers.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2 and Web of Science up to November 2013.
Randomised controlled trials (RCTs) of interventions aimed at preventing psychological stress in healthcare workers. For organisational interventions, interrupted time-series and controlled before-and-after (CBA) studies were also eligible.
Two review authors independently extracted data and assessed trial quality. We used Standardised Mean Differences (SMDs) where authors of trials used different scales to measure stress or burnout. We combined studies that were similar in meta-analyses. We used the GRADE system to rate the quality of the evidence.
In this update, we added 39 studies, making a total of 58 studies (54 RCTs and four CBA studies), with 7188 participants. We categorised interventions as cognitive-behavioural training (CBT) (n = 14), mental and physical relaxation (n = 21), combined CBT and relaxation (n = 6) and organisational interventions (n = 20). Follow-up was less than one month in 24 studies, one to six in 22 studies and more than six months in 12 studies. We categorised outcomes as stress, anxiety or general health.There was low-quality evidence that CBT with or without relaxation was no more effective in reducing stress symptoms than no intervention at one month follow-up in six studies (SMD -0.27 (95% Confidence Interval (CI) -0.66 to 0.13; 332 participants). But at one to six months follow-up in seven studies (SMD -0.38, 95% CI -0.59 to -0.16; 549 participants, 13% relative risk reduction), and at more than six months follow-up in two studies (SMD -1.04, 95% CI -1.37 to -0.70; 157 participants) CBT with or without relaxation reduced stress more than no intervention.CBT interventions did not lead to a considerably greater effect than an alternative intervention, in three studies.Physical relaxation (e.g. massage) was more effective in reducing stress than no intervention at one month follow-up in four studies (SMD -0.48, 95% CI -0.89 to -0.08; 97 participants) and at one to six months follow-up in six studies (SMD -0.47; 95% CI -0.70 to -0.24; 316 participants). Two studies did not find a considerable difference in stress between massage and taking extra breaks.Mental relaxation (e.g. meditation) led to similar stress symptom levels as no intervention at one to six months follow-up in six studies (SMD -0.50, 95% CI -1.15 to 0.15; 205 participants) but to less stress in one study at more than six months follow-up. One study showed that mental relaxation reduced stress more effectively than attending a course on theory analysis and another that it was more effective than just relaxing in a chair.Organisational interventions consisted of changes in working conditions, organising support, changing care, increasing communication skills and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a four-week to a two-week schedule) reduced stress with SMD -0.55 (95% CI -0.84 to -0.25; 2 trials, 180 participants). Other organisational interventions were not more effective than no intervention or an alternative intervention.We graded the quality of the evidence for all but one comparison as low. For CBT this was due to the possibility of publication bias, and for the other comparisons to a lack of precision and risk of bias. Only for relaxation versus no intervention was the evidence of moderate quality.
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.
Background
In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID‐19), healthcare workers (HCW) are at much greater risk of ...infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.
Objectives
To evaluate which type of full‐body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.
Search methods
We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.
Selection criteria
We included all controlled studies that evaluated the effect of full‐body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.
Data collection and analysis
Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random‐effects meta‐analyses were appropriate.
Main results
Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi‐RCT and nine had a non‐randomised design.
Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups.
Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias.
Types of PPE
The use of a powered, air‐purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non‐compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low‐certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) −10.28, 95% CI −14.77 to −5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI −0.15 to 3.35) compared to more water‐repellent material but may have greater user satisfaction (MD −0.46, 95% CI −0.84 to −0.08, scale of 1 to 5).
Modified PPE versus standard PPE
The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown‐wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low‐certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31).
Donning and doffing
Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD −5.44, 95% CI −7.43 to −3.45). One‐step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double‐gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD −0.9, 95% CI −1.4 to −0.4) and to fewer contamination spots (MD −5, 95% CI −8.08 to −1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol‐based hand rub.
Training
The use of additional computer simulation may lead to fewer errors in doffing (MD −1.2, 95% CI −1.6 to −0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face‐to‐face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.
Authors' conclusions
We found low‐ to very low‐certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one‐step glove and gown removal, double‐gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face‐to‐face training in PPE use may reduce errors more than folder‐based training.
We still need RCTs of training with long‐term follow‐up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real‐life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.
Background
In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID‐19), healthcare workers (HCW) are at much greater risk of ...infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.
Objectives
To evaluate which type of full‐body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.
Search methods
We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.
Selection criteria
We included all controlled studies that evaluated the effect of full‐body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.
Data collection and analysis
Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random‐effects meta‐analyses were appropriate.
Main results
Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi‐RCT and nine had a non‐randomised design.
Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups.
Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias.
Types of PPE
The use of a powered, air‐purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non‐compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low‐certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) −10.28, 95% CI −14.77 to −5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI −0.15 to 3.35) compared to more water‐repellent material but may have greater user satisfaction (MD −0.46, 95% CI −0.84 to −0.08, scale of 1 to 5). According to three studies that tested more recently introduced full‐body PPE ensembles, there may be no difference in contamination.
Modified PPE versus standard PPE
The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown‐wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low‐certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31).
Donning and doffing
Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD −5.44, 95% CI −7.43 to −3.45). One‐step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double‐gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD −0.9, 95% CI −1.4 to −0.4) and to fewer contamination spots (MD −5, 95% CI −8.08 to −1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol‐based hand rub.
Training
The use of additional computer simulation may lead to fewer errors in doffing (MD −1.2, 95% CI −1.6 to −0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face‐to‐face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.
Authors' conclusions
We found low‐ to very low‐certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one‐step glove and gown removal, double‐gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face‐to‐face training in PPE use may reduce errors more than folder‐based training.
We still need RCTs of training with long‐term follow‐up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real‐life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.
Background
In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection ...than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed.
Objectives
To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self‐contamination or infection for HCW, and which training methods increase compliance with PPE protocols.
Search methods
We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH‐Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.
Selection criteria
We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non‐pathogenic virus.
We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes.
Data collection and analysis
Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta‐analyses but did not find sufficiently similar studies to combine their results.
Main results
We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non‐randomised controlled design. Two studies are awaiting assessment.
Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.
Evidence for all outcomes is based on single studies and is very low quality.
Different types of PPE
PPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) −0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD −0.46; 95% CI −0.84 to −0.08, scale of 1 to 5).
Gowns may protect better against contamination than aprons (MD large patches −1.36 95% CI −1.78 to −0.94).
The use of a powered air‐purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).
Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.
Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.
Different methods of donning and doffing procedures
Double gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).
Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches −5.44; 95% CI −7.43 to −3.45).
Alcohol‐based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).
Additional spoken instruction may lead to fewer errors in doffing (MD −0.9, 95% CI −1.4 to −0.4).
Different types of training
The use of additional computer simulation may lead to fewer errors in doffing (MD −1.2, 95% CI −1.6 to −0.7).
A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.
Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.
There were no studies on effects of training in the long term or on resource use.
The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants.
Authors' conclusions
We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face‐to‐face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.
We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.
Background
Shift work results in sleep‐wake disturbances, which cause sleepiness during night shifts and reduce sleep length and quality in daytime sleep after the night shift. In its serious form it ...is also called shift work sleep disorder. Various pharmacological products are used to ameliorate symptoms of sleepiness or poor sleep length and quality.
Objectives
To evaluate the effects of pharmacological interventions to reduce sleepiness or to improve alertness at work and decrease sleep disturbances whilst off work, or both, in workers undertaking shift work in their present job and to assess their cost‐effectiveness.
Search methods
We searched CENTRAL, MEDLINE, EMBASE, PubMed and PsycINFO up to 20 September 2013 and ClinicalTrials.gov up to July 2013. We also screened reference lists of included trials and relevant reviews.
Selection criteria
We included all eligible randomised controlled trials (RCTs), including cross‐over RCTs, of pharmacological products among workers who were engaged in shift work (including night shifts) in their present jobs and who may or may not have had sleep problems. Primary outcomes were sleep length and sleep quality while off work, alertness and sleepiness, or fatigue at work.
Data collection and analysis
Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We performed meta‐analyses where appropriate.
Main results
We included 15 randomised placebo‐controlled trials with 718 participants. Nine trials evaluated the effect of melatonin and two the effect of hypnotics for improving sleep problems. One trial assessed the effect of modafinil, two of armodafinil and one examined caffeine plus naps to decrease sleepiness or to increase alertness.
Melatonin (1 to 10 mg) after the night shift may increase sleep length during daytime sleep (mean difference (MD) 24 minutes, 95% confidence interval (CI) 9.8 to 38.9; seven trials, 263 participants, low quality evidence) and night‐time sleep (MD 17 minutes, 95% CI 3.71 to 30.22; three trials, 234 participants, low quality evidence) compared to placebo. We did not find a dose‐response effect. Melatonin may lead to similar sleep latency times as placebo (MD 0.37minutes, 95% CI ‐ 1.55 to 2.29; five trials, 74 participants, low quality evidence).
Hypnotic medication, zopiclone, did not result in significantly longer daytime sleep length compared to placebo in one low quality trial and we could not use the data from the study on lormetazepam.
Armodafinil taken before the night shift probably reduces sleepiness by one point on the Karolinska Sleepiness Scale (KSS) (MD ‐0.99, 95% CI ‐1.32 to ‐0.67; range 1 to 10; two trials, 572 participants, moderate quality evidence) and increases alertness by 50 ms in a simple reaction time test (MD ‐50.0, 95% CI ‐85.5 to ‐15.5) at three months' follow‐up in shift work sleep disorder patients. Modafinil probably has similar effects on sleepiness (KSS) (MD ‐0.90, 95% CI ‐1.45 to ‐0.35; one trial, 183 participants, moderate quality evidence) and alertness in the psychomotor vigilance test in the same patient group. Post‐marketing, severe skin reactions have been reported. Adverse effects reported by trial participants were headache, nausea and a rise in blood pressure. There were no trials in non‐patient shift workers.
Based on one trial, caffeine plus pre‐shift naps taken before the night shift decreased sleepiness (KSS) (MD ‐0.63, 95% CI ‐1.09 to ‐0.17).
We judged most trials to have a low risk of bias even though the randomisation method and allocation concealment were often not described.
Authors' conclusions
There is low quality evidence that melatonin improves sleep length after a night shift but not other sleep quality parameters. Both modafinil and armodafinil increase alertness and reduce sleepiness to some extent in employees who suffer from shift work sleep disorder but they are associated with adverse events. Caffeine plus naps reduces sleepiness during the night shift, but the quality of evidence is low. Based on one low quality trial, hypnotics did not improve sleep length and quality after a night shift.
We need more and better quality trials on the beneficial and adverse effects and costs of all pharmacological agents that induce sleep or promote alertness in shift workers both with and without a diagnosis of shift work sleep disorder. We also need systematic reviews of their adverse effects.
In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or SARS, healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact ...with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCWs use PPE as instructed.
To evaluate which type or component of full-body PPE and which method of donning or removing (doffing) PPE have the least risk of self-contamination or infection for HCWs, and which training methods most increase compliance with PPE protocols.
We searched MEDLINE (PubMed up to 8 January 2016), Cochrane Central Register of Trials (CENTRAL up to 20 January 2016), EMBASE (embase.com up to 8 January 2016), CINAHL (EBSCOhost up to 20 January 2016), and OSH-Update up to 8 January 2016. We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.
We included all eligible controlled studies that compared the effect of types or components of PPE in HCWs exposed to highly infectious diseases with serious consequences, such as EVD and SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or removing PPE, and the effects of various types of training in PPE use on the same outcomes.
Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We intended to perform meta-analyses but we did not find sufficiently similar studies to combine their results.
We included nine studies with 1200 participants evaluating ten interventions. Of these, eight trials simulated the exposure with a fluorescent marker or virus or bacteria containing fluids. Five studies evaluated different types of PPE against each other but two did not report sufficient data. Another two studies compared different types of donning and doffing and three studies evaluated the effect of different types of training.None of the included studies reported a standardised classification of the protective properties against viral penetration of the PPE, and only one reported the brand of PPE used. None of the studies were conducted with HCWs exposed to EVD but in one study participants were exposed to SARS. Different types of PPE versus each otherIn simulation studies, contamination rates varied from 25% to 100% of participants for all types of PPE. In one study, PPE made of more breathable material did not lead to a statistically significantly different number of spots with contamination but did have greater user satisfaction (Mean Difference (MD) -0.46 (95% Confidence Interval (CI) -0.84 to -0.08, range 1 to 5, very low quality evidence). In another study, gowns protected better than aprons. In yet another study, the use of a powered air-purifying respirator protected better than a now outdated form of PPE. There were no studies on goggles versus face shields, on long- versus short-sleeved gloves, or on the use of taping PPE parts together. Different methods of donning and doffing procedures versus each otherTwo cross-over simulation studies (one RCT, one CCT) compared different methods for donning and doffing against each other. Double gloving led to less contamination compared to single gloving (Relative Risk (RR) 0.36; 95% CI 0.16 to 0.78, very low quality evidence) in one simulation study, but not to more noncompliance with guidance (RR 1.08; 95% CI 0.70 to 1.67, very low quality evidence). Following CDC recommendations for doffing led to less contamination in another study (very low quality evidence). There were no studies on the use of disinfectants while doffing. Different types of training versus each otherIn one study, the use of additional computer simulation led to less errors in doffing (MD -1.2, 95% CI -1.6 to -0.7) and in another study additional spoken instruction led to less errors (MD -0.9, 95% CI -1.4 to -0.4). One retrospective cohort study assessed the effect of active training - defined as face-to-face instruction - versus passive training - defined as folders or videos - on noncompliance with PPE use and on noncompliance with doffing guidance. Active training did not considerably reduce noncompliance in PPE use (Odds Ratio (OR) 0.63; 95% CI 0.31 to 1.30) but reduced noncompliance with doffing procedures (OR 0.45; 95% CI 0.21 to 0.98, very low quality evidence). There were no studies on how to retain the results of training in the long term or on resource use.The quality of the evidence was very low for all comparisons because of high risk of bias in studies, indirectness of evidence, and small numbers of participants. This means that it is likely that the true effect can be substantially different from the one reported here.
We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. We also found very low quality evidence that double gloving and CDC doffing guidance appear to decrease the risk of contamination and that more active training in PPE use may reduce PPE and doffing errors more than passive training. However, the data all come from single studies with high risk of bias and we are uncertain about the estimates of effects.We need simulation studies conducted with several dozens of participants, preferably using a non-pathogenic virus, to find out which type and combination of PPE protects best, and what is the best way to remove PPE. We also need randomised controlled studies of the effects of one type of training versus another to find out which training works best in the long term. HCWs exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection.
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.
Background
Healthcare workers can suffer from work‐related stress as a result of an imbalance of demands, skills and social support at work. This may lead to stress, burnout and psychosomatic ...problems, and deterioration of service provision. This is an update of a Cochrane Review that was last updated in 2015, which has been split into this review and a review on organisational‐level interventions.
Objectives
To evaluate the effectiveness of stress‐reduction interventions targeting individual healthcare workers compared to no intervention, wait list, placebo, no stress‐reduction intervention or another type of stress‐reduction intervention in reducing stress symptoms.
Search methods
We used the previous version of the review as one source of studies (search date: November 2013). We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, CINAHL, Web of Science and a trials register from 2013 up to February 2022.
Selection criteria
We included randomised controlled trials (RCT) evaluating the effectiveness of stress interventions directed at healthcare workers. We included only interventions targeted at individual healthcare workers aimed at reducing stress symptoms.
Data collection and analysis
Review authors independently selected trials for inclusion, assessed risk of bias and extracted data. We used standard methodological procedures expected by Cochrane. We categorised interventions into ones that:
1. focus one’s attention on the (modification of the) experience of stress (thoughts, feelings, behaviour);
2. focus one’s attention away from the experience of stress by various means of psychological disengagement (e.g. relaxing, exercise);
3. alter work‐related risk factors on an individual level; and ones that
4. combine two or more of the above.
The crucial outcome measure was stress symptoms measured with various self‐reported questionnaires such as the Maslach Burnout Inventory (MBI), measured at short term (up to and including three months after the intervention ended), medium term (> 3 to 12 months after the intervention ended), and long term follow‐up (> 12 months after the intervention ended).
Main results
This is the second update of the original Cochrane Review published in 2006, Issue 4. This review update includes 89 new studies, bringing the total number of studies in the current review to 117 with a total of 11,119 participants randomised.
The number of participants per study arm was ≥ 50 in 32 studies. The most important risk of bias was the lack of blinding of participants.
Focus on the experience of stress versus no intervention/wait list/placebo/no stress‐reduction intervention
Fifty‐two studies studied an intervention in which one's focus is on the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (standardised mean difference (SMD) ‐0.37, 95% confidence interval (CI) ‐0.52 to ‐0.23; 41 RCTs; 3645 participants; low‐certainty evidence) and medium term (SMD ‐0.43, 95% CI ‐0.71 to ‐0.14; 19 RCTs; 1851 participants; low‐certainty evidence). The SMD of the short‐term result translates back to 4.6 points fewer on the MBI‐emotional exhaustion scale (MBI‐EE, a scale from 0 to 54). The evidence is very uncertain (one RCT; 68 participants, very low‐certainty evidence) about the long‐term effect on stress symptoms of focusing one's attention on the experience of stress.
Focus away from the experience of stress versus no intervention/wait list/placebo/no stress‐reduction intervention
Forty‐two studies studied an intervention in which one's focus is away from the experience of stress. Overall, such interventions may result in a reduction in stress symptoms in the short term (SMD ‐0.55, 95 CI ‐0.70 to ‐0.40; 35 RCTs; 2366 participants; low‐certainty evidence) and medium term (SMD ‐0.41 95% CI ‐0.79 to ‐0.03; 6 RCTs; 427 participants; low‐certainty evidence). The SMD on the short term translates back to 6.8 fewer points on the MBI‐EE. No studies reported the long‐term effect.
Focus on work‐related, individual‐level factors versus no intervention/no stress‐reduction intervention
Seven studies studied an intervention in which the focus is on altering work‐related factors. The evidence is very uncertain about the short‐term effects (no pooled effect estimate; three RCTs; 87 participants; very low‐certainty evidence) and medium‐term effects and long‐term effects (no pooled effect estimate; two RCTs; 152 participants, and one RCT; 161 participants, very low‐certainty evidence) of this type of stress management intervention.
A combination of individual‐level interventions versus no intervention/wait list/no stress‐reduction intervention
Seventeen studies studied a combination of interventions. In the short‐term, this type of intervention may result in a reduction in stress symptoms (SMD ‐0.67 95%, CI ‐0.95 to ‐0.39; 15 RCTs; 1003 participants; low‐certainty evidence). The SMD translates back to 8.2 fewer points on the MBI‐EE. On the medium term, a combination of individual‐level interventions may result in a reduction in stress symptoms, but the evidence does not exclude no effect (SMD ‐0.48, 95% CI ‐0.95 to 0.00; 6 RCTs; 574 participants; low‐certainty evidence). The evidence is very uncertain about the long term effects of a combination of interventions on stress symptoms (one RCT, 88 participants; very low‐certainty evidence).
Focus on stress versus other intervention type
Three studies compared focusing on stress versus focusing away from stress and one study a combination of interventions versus focusing on stress. The evidence is very uncertain about which type of intervention is better or if their effect is similar.
Authors' conclusions
Our review shows that there may be an effect on stress reduction in healthcare workers from individual‐level stress interventions, whether they focus one's attention on or away from the experience of stress. This effect may last up to a year after the end of the intervention. A combination of interventions may be beneficial as well, at least in the short term. Long‐term effects of individual‐level stress management interventions remain unknown. The same applies for interventions on (individual‐level) work‐related risk factors.
The bias assessment of the studies in this review showed the need for methodologically better‐designed and executed studies, as nearly all studies suffered from poor reporting of the randomisation procedures, lack of blinding of participants and lack of trial registration. Better‐designed trials with larger sample sizes are required to increase the certainty of the evidence. Last, there is a need for more studies on interventions which focus on work‐related risk factors.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To evaluate the effects of introducing, abolishing, or changing the period of self‐certification of sickness ...absence on:
the total or average duration (number of sickness absence days) of short‐term sickness absence periods;
the total or average number of short‐term sickness absence periods;
the associated costs (of sickness absence and (occupational) health care); and
social climate, supervisor involvement, and work load or presenteeism (
Figure 1
).
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