WK 8 DIS EPID

Literature Review

Interventions to Improve Mental Health, Well-Being, Physical Health, and Lifestyle Behaviors in Physicians and Nurses: A Systematic Review

Bernadette Mazurek Melnyk, PhD, RN1 , Stephanie A. Kelly, PhD, RN2, Janna Stephens, PhD, RN2, Kerry Dhakal, MAA, MLS3, Colleen McGovern, PhD, RN2,4 , Sharon Tucker, PhD, RN2, Jacqueline Hoying, PhD, RN2, Kenya McRae, PhD5, Samantha Ault, MS, RN2, Elizabeth Spurlock, BSN, RN2, and Steven B. Bird, MD6

Abstract

Objective: This systematic review focused on randomized controlled trials (RCTs) with physicians and nurses that tested interventions designed to improve their mental health, well-being, physical health, and lifestyle behaviors.

Data Source: A systematic search of electronic databases from 2008 to May 2018 included PubMed, CINAHL, PsycINFO, SPORTDiscus, and the Cochrane Library.

Study Inclusion and Exclusion Criteria: Inclusion criteria included an RCT design, samples of physicians and/or nurses, and publication year 2008 or later with outcomes targeting mental health, well-being/resiliency, healthy lifestyle behaviors, and/or physical health. Exclusion criteria included studies with a focus on burnout without measures of mood, resiliency, mindfulness, or stress; primary focus on an area other than health promotion; and non-English papers.

Data Extraction: Quantitative and qualitative data were extracted from each study by 2 independent researchers using a standardized template created in Covidence.

Data Synthesis: Although meta-analytic pooling across all studies was desired, a wide array of outcome measures made quantitative pooling unsuitable. Therefore, effect sizes were calculated and a mini meta-analysis was completed.

Results: Twenty-nine studies (N ¼ 2708 participants) met the inclusion criteria. Results indicated that mindfulness and cognitive- behavioral therapy-based interventions are effective in reducing stress, anxiety, and depression. Brief interventions that incorporate deep breathing and gratitude may bebeneficial. Visual triggers, pedometers, and health coachingwith texting increased physical activity.

Conclusion: Healthcare systems must promote the health and well-being of physicians and nurses with evidence-based inter- ventions to improve population health and enhance the quality and safety of the care that is delivered.

Keywords physicians, nurses, systematic review, mental health, physical health, lifestyle behaviors

Objectives

In 2017, the National Academy of Medicine (NAM)

launched the Action Collaborative on Clinician Well-being

and Resilience because of epidemic levels of burnout, depres-

sion, and suicide in physicians, nurses, and other healthcare

providers.1 Burnout is a syndrome characterized by a high

degree of emotional exhaustion and depersonalization along

with a low sense of personal accomplishment at work, which

has a high association with depression.2 The Action Colla-

borative’s primary goal is to decrease rates of clinician burn-

out in the United States in order to ultimately improve

1 The Ohio State University, Columbus, OH, USA 2 The Ohio State University College of Nursing, Columbus, OH, USA 3 The Ohio State University Office of Health Sciences, Columbus, OH, USA 4 University of North Carolina Chapel Hill College of Nursing, Chapel Hill,

NC, USA 5 Illinois Department of Health, Chicago IL, USA 6 University of Massachusetts Medical School, Worcester, MA, USA

Corresponding Author:

Bernadette Mazurek Melnyk, The Ohio State University, 145 Newton Hall,

1585 Neil Avenue, Columbus, OH 43210, USA.

Email: [email protected]

American Journal of Health Promotion 2020, Vol. 34(8) 929-941 ª The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0890117120920451 journals.sagepub.com/home/ahp

population health of clinicians and ensure health-care quality

and safety.2

Findings from a recent systematic review indicate that

over 50% of physicians and nurses are experiencing burn-

out. Another recent study with nearly 1800 nurses from 19

healthcare systems across the country found that over 50% of respondents reported suboptimal physical and mental

health.3 Depression affected 25% of this sample and was

the leading cause of medical errors, which are now the third

leading cause of death in America.4 Nurses with poor men-

tal and physical health were 26% to 71% more likely to

report making medical errors compared to those in better

health.

Although physicians and nurses do their best to provide

outstanding care to their patients, they often do not prioritize

their own self-care. As a result, participation in healthy

lifestyle behaviors are often given a low priority.4 Besides

personal factors, there are multiple healthcare system chal-

lenges that contribute to clinician burnout and depression,

including poor staffing patterns, ongoing challenges with elec-

tronic medical records that result in less time with patients, and

pressure to increase caseloads.5 Leaders must address these

healthcare system challenges in order to optimize clinician

well-being outcomes to ensure patient safety.

The fourth aim in healthcare quadruple is to improve the

work-life and well-being of clinicians.6 If clinicians are not

well, healthcare quality and safety may suffer. It is imperative

for healthcare systems to invest in an infrastructure that

includes providing evidence-based interventions that are

known to cultivate a culture that supports clinician health and

well-being in order to reach the quadruple aim in health care. A

model identifying factors affecting clinician well-being and

resilience has been created by NAM.7 In this model, external

and individual factors have been identified. External factors

include sociocultural factors, regulatory, business, and payer

environment, organizational factors, and learning/practice

environment. Individual factors include healthcare role,

personal factors, skills, and abilities. A wide array of

interventions have been designed to promote well-being in

clinicians primarily within the personal factors identified on

the model. Individual level interventions include a focus on

physical health, mental health, mindfulness, stress reduction,

resilience, and others. A website that contains a knowledge hub

has been created by the NAM to support clinician well-being

and resilience that includes many resources.8

There have been a number of systematic reviews completed

that have focused on a singular aspect of wellness for physicians

and/or nurses. However, this review is different than others in

that a wide array of experimental studies were included that

implemented a variety of interventions that sought to improve

mental health, well-being, lifestyle behaviors, and/or physical

health in order to identify evidence-based interventions to

improve population health in physicians and nurses. The objec-

tive of this study was to conduct a systematic review of inter-

ventions targeted to improve all of these outcomes.

Methods

Data Source

The Institute of Medicine guidelines for completing systema-

tic reviews were used and reporting of findings followed

PRISMA guidelines.9,10 Prior to beginning the review, a pro-

tocol was developed and registered with PROSPERO

(#CRD42018098869). A research librarian conducted the lit-

erature search. Electronic databases searched for studies pub-

lished between 2008 through May of 2018 included PubMed,

CINAHL, PsycINFO, SPORTDiscus, and Cochrane Library

(see Online Appendix A). All aspects of the review process

were completed by 2 researchers. Titles and abstracts of all

articles were screened for applicability. If the article appeared

to meet the review’s inclusion criteria, the full article was

reviewed and assessed to ensure that it met the criteria for

inclusion. All discrepancies were reviewed by the same 2

researchers and consensus was met regarding the eligibility

of the study. For each article included in this review, all refer-

ences were reviewed for inclusion criteria. Additionally, cita-

tions for all included studies were identified through Google

Scholar and reviewed for inclusion criteria.11

Inclusion and Exclusion Criteria

Inclusion criteria for this review included a randomized con-

trolled trial (RCT) design, samples of physicians and/or nurses,

and publication year 2008 or later with outcomes targeting

mental health (ie, stress, anxiety, depression, and negative

mood), well-being/resiliency, healthy lifestyle behaviors, and/

or physical health. Exclusion criteria included studies with a

focus on burnout without measures of mood (ie, depression/

anxiety), resiliency, mindfulness, or stress; primary focus on an

area other than health promotion (eg injury prevention and

weight loss); and non-English papers.

Data Extraction

Quantitative and qualitative data were extracted from each

study by 2 independent researchers using a standardized tem-

plate created in Covidence™.11 Data extracted included study

author, location, population demographics, sample size, inter-

vention details, quality details, and outcomes. Critical appraisal

of studies was performed using Cochrane Collaboration’s tool

for assessing the risk of bias.12

Data Synthesis

Although meta-analytic pooling across all the studies was desired,

a wide variety of outcome measures was used to make quantitative

pooling unsuitable. However, Cohen’s deffect sizes were calcu-

lated on studies reporting means and standard deviations. For

studies measuring similar concepts, effect sizes were assessed

with a mini meta-analysis using a fixed-effect approach.13 A Z-

score was calculated based on the mean effect size and its standard

930 American Journal of Health Promotion 34(8)

error with the corresponding P-value identified. Additionally,

studies were summarized descriptively and assessed qualitatively.

Results

Due to a broad search that was conducted, a wide array of

studies were identified with most not meeting inclusion cri-

teria. Eleven thousand five hundred forty references were iden-

tified for screening. Duplicates were removed (n ¼ 1175). One

hundred eighty-seven studies appeared to meet inclusion cri-

teria and were assessed for full-text eligibility. One hundred

fifty-eight studies were excluded for various reasons, including

no intervention, the study involved students, and non-RCT

design. This process resulted in 29 studies being included in

this review (see Figure 1).14-42 These 29 studies had sample

sizes of 22 to 557. Six studies included physicians; 6 included

nurses; and 17 included physicians, nurses, and/or other allied

health-care professionals. Ten studies had attention-control

groups, 11 studies used wait-list control groups, 6 studies had

no-attention control groups, and 2 studies had cross-over

designs.

Instrumentation

Multiple instruments were used to measure a variety of mental

health outcomes in the included studies. Seven studies mea-

sured anxiety, which was captured with the Generalized Anxi-

ety Disorder-7 Scale, the Smith anxiety scale, the Symptoms

Checklist-90-Revised, and the Depression, Anxiety, and Stress

Scale (DASS-21).18,25,31,32,34,37,38 Tools to measure mood in 8

studies included the Profile of Mood States, symptoms of dis-

tress, the Brief Symptom Index, the DASS, and mental health

questions from the Short Form 36.15,19,20,23,24,26,29,30 Stress was

most commonly measured with the Perceived Stress Scale and

the DASS 12-item stress subscale. Other stress tools included

the Coping with Stress Scale, the Nursing Stress Scale, and the

Post-traumatic Diagnostic Scale.17,18,22,23,25,27-29,31-33,36-38,42

The most common instruments used to assess mindfulness were

Records iden�fied through database searching

(n = 11,513) Sc re en

in g

In clu

de d

El ig ib ili ty

noitacifitnedI

Addi�onal records iden�fied through other sources

(n = 27)

Number of duplicate records removed (n = 1175)

Records screened (n = 10,365)

Records excluded (n = 10,185)

Full-text ar�cles assessed for eligibility

(n = 187)

Full-text ar�cles excluded (n = 158)

53 Healthcare Student 29 One Group Design 14 Two Group non RCT

11 No interven�on 11 Published prior to 2008 6 Wrong outcomes 6 Wrong popula�on 6 Duplicate study 5 Abstract 4 Qualita�ve outcome 4 Non-English 4 Resident/junior physician 3 Treatment Study 2 Disserta�on 2 Studies not published yet 1 Book

Studies included in qualita�ve synthesis

(n =29)

Figure 1. PRISMA flow diagram. From: Moher D, Liberati A, Tetzlaff J, Altman DG; The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;6(7): e1000097. doi:10.1371/journal.pmed1000097.

Melnyk et al. 931

the Five Facets of Mindfulness Questionnaire and the Mindful

Attention Awareness Scale.14,15,18,35,36,38,41

Nine studies measured depression, which was assessed with

the Center for Epidemiologic Studies Depression Scale, the

DASS-21, the Beck Depression Inventory-II, the Symptom

Checklist 90 Revised-Depression, the 2-item Primary Care Eva-

luation of Mental Health, and a 2-question screen.17,25,29-34,42

Well-being measures included the Work Ability Index Score,

the Self Compassion Scale; the World Health Organisation-

Five (WHO-5) Well-Being Index, Work Engagement, Empow-

erment at Work, and the Quality of Life: Linear Analog

Self-Assessment Scale.20,21,24,25,29,32,37-39

Three studies measured physical activity with a pedometer

or reported physical activity.19,28,40 Six studies included either

body mass index (BMI) or weight.16,19,26,28,30,40 Three studies

included a measure of percent body fat.16,30,40 Two studies

measured blood pressure16,19and 2 studies measured oxygen

uptake during peak exercise ( _V O2) peak.16,30

Type and Length of Interventions Delivered

Twelve studies provided a mindfulness-based stress reduction

(MBSR) type intervention (see Table 1).14,15,20,31-36,39,41,42 The

duration of studies was between 4 weeks to 9 months with total

time in intervention sessions ranging from 10 to 53 hours plus

home practice. The typical number of sessions in these MBSR

interventions were 8 weekly sessions plus home practice. Eight

studies provided stress reduction programs that included a vari-

ety of interventions, such as journaling, web-based stressed

management, breathing exercises, and yoga.17,18,22,23,27,29,37,38

Duration of interventions in these studies were between

4 weeks and 12 to 18 months with time ranging between 1 and

12 hours. Seven studies targeted improvement of lifestyle

behaviors, including physical activity and/or healthy

eating.16,18,24,26,28,30,40 The duration of these studies was

between 4 and 40 weeks with time ranging between 12 and

92 hours. Two studies targeted overall well-being with inter-

ventions that included an eMental Health program utilizing

cognitive behavior therapy (CBT) components and an online

10-week intervention that included asking physicians to com-

plete microtasks designed to cultivate professional satisfaction

and well-being.21,25

Studies varied widely in the variables evaluated and find-

ings of significance reached postintervention (see Table 2).

Authors reported either within group significance, between-

group significance, or both. Significant findings were identified

for many variables, but not consistently across all studies.

Interventions That Improved Mental Health Outcomes

Seven studies assessed a mindfulness outcome (see Table 2).

Six (86%) studies reported significant differences between

groups, with sample sizes ranging from 22 to 127 and duration

between 1.5 and 53 hours.14,15,18,35,36,38,41 One study reported

only a correlation of mindfulness with subscales of the DASS

and the Maslach’s Burnout Inventory.20

Sixteen studies assessed a measure of stress, 2 of which

assessed post-traumatic stress.17,18,20,22,23,25,27-29,31-33,36-41

Seven (44%) studies identified a between-group difference

with sample sizes ranging from 26 to 120 and duration between

1.5 and 17 hours. The focus of the interventions included

MBSR (n ¼ 1, 14%),36 stress and resiliency (n ¼ 3,

43%),23,37,38 and other (n ¼ 3, 43%).22,17,29

Eight studies assessed a general mood mea-

sure.15,19,20,23,24,26,29,30 Three (37.5%) studies identified a

significant between-group with sample sizes ranging between

40 and 98 and length of intervention was between 12 and 28

hours. The emphasis of the interventions varied and included

MBSR,15 cardiovascular risk reduction,19 and benefits of rela-

tional groups.29

Seven studies assessed a measure of anxiety.18,25,31,32,34,37,38

Three (43%) studies identified a significant between-group dif-

ference with sample sizes ranging between 26 and 40, and dura-

tion was between 1.5 and 25 hours. One study focused on

MBSR,34 while the other 2 studies37-38 used the same intervention

focusing on decreasing stress and enhancing resiliency.

Nine studies assessed a measure of depression.17,25,29-34,42

Four (44%) studies identified a significant between-group dif-

ference. Sample sizes ranged from 29 to 102 and duration

between 11.5 and 27 hours of MBSR plus exercise, counseling,

and journaling. Emphasis of the interventions included mind-

fulness (n¼ 2, 50%),31,34 gratitude (n¼ 1, 25%),17and benefits

of a relational group (n ¼ 1, 25%).29

Interventions That Improved Well-Being/Resilience and Sleep

Five studies assessed a measure of resilience;18,31,36-38 however,

only 1 study identified a significant between-group difference.37

This study had a sample size of 40 and included a brief stress

management and resiliency training intervention (1.5 hours).

Nine studies assessed a measure of well-being.20,21,24,25,29,32,37,39

Five (56%) studies identified a significant between-group dif-

ference. Sample sizes ranged between 26 and 557 and the inter-

vention duration was between 1.5 and 12 hours. Emphasis of the

interventions included eMental Health (n¼ 1, 20%),25 decreas-

ing stress and enhancing resiliency (n¼ 2, 40%),37,38 exercise (n

¼ 1, 10%),24 benefits of a relational group (n ¼ 1, 20%).29

Eight studies assessed a measure of sleep or fati-

gue.19,21,22,25,29,32,35,37 Two (25%) studies identified a signifi-

cant between-group difference. Sample sizes ranged between

120 and 127 and duration of the intervention was between 7

weeks and 6 months (length of time not reported). Emphasis of

the interventions included MBSR22 and mindfulness-based

CBT.35

Interventions That Improved Lifestyle Behaviors/Physical Health

Six studies assessed a measure of body mass, including BMI or

weight.16,19,26,28,30,40 One (17%) study identified a significant

between-group difference with sample size 118 and

932 American Journal of Health Promotion 34(8)

Table 1. Study Details.

Author, Year, Country, Name and Focus Design and Control Group; Sample, Setting, N Intervention Details

Mindfulness Focused Interventions Amutio, 2015, Spain, MBSR RCT; wait-list CG; physicians; public or private

practice; N ¼ 42 18 sessions þ retreat; FU 12 mo.; TT: 53 hours þ

home practice Asuero, 2014, Spain, MBSR RCT; wait-list CG; physicians, nurses, social workers,

& clinical psychologist; primary health care; N¼ 68 8 wkly sessions þ retreat; mindfulness based coping

strategies & yoga; TT 28 hours þ home practice Duchemin, 2015, USA, MBSR RCT; wait-list CG; Nurses & other; Surgical ICU;

N ¼ 32 8 wkly sessions; Mindfulnes, yoga, mindful eating &

music; TT: *26 hours Mealer, 2014, USA, MBSR; PA;

counselling; journally RCT; no attention CG; ICU nurses; hospital; N ¼ 29 multimodal intervention; duration 12 wks;TT: 27 hours

MBSR, exercise,þ 2 day training & counselling (CBT) Mistretta, 2018, USA, MBRT 3 group RCT; attention CG; health-care workers at

Mayo Clinic; N ¼ 60 6 wkly sessions; duration 6 wks; FU at 3 mo. Resilience

trainngMBRTorSmartphone;TT: MBRT12 hoursþ home practice; smartphone not specified

Moody, 2013, Israel & USA, MBSR

RCT; no attention CG; nurses, social workers, physicians, nurse practitioners, psychologists, & child-life specialists; hospital; N ¼ 47

8 wkly sessions; FU at postintervention: mindfulness concepts; TT: 15 hoursþ 9 to 18 hours of practice

Pipe, 2009, USA, MBSR RCT with attention CG; nursing leaders from a health-care system; N ¼ 32

5 sessions; duration 4 wks; MBSR &/or educational classes; TT: 10 hours þ 15 hours daily practice

Querstret, 2017, United Kingdom, MBSR; MBCT

RCT; wait-list CG; Dietitians, physiotherapists, nurses, & physicians; health-care workers across the United Kingdom; N ¼ 127

10 online sessions; duration * 7 wks; FU at 6 mo.; formal meditation skills & informal mindfulness techniques; TT: varied

Schroeder, 2016, USA, MBSR RCT; wait-list CG; Primary care physicians; N ¼ 33 weekend training þ 2 FU sessisions: duration 4 wks; FU at 3 mo.; TT: 17 hours

Steinberg, 2016, USA, MBSR RCT; wait-list CG; Nurses, patient care assistant, family support coordinator, chaplain, janitor, pharmacist, & unit clerk; hospital; N ¼ 32

9 sessions; duration 8 wks; mindfulness; yoga, & music; TT: 10 hours þ 13.3 hours home practice

Valley, 2017, USA, MBSR RCT; wait-list CG; Nurses, nurse practitioner, & paramedics, hospital health-care system; N ¼ 22

8 wkly session þ one full day; duration 8 wks; FU at 6 mo.; MBSR & yoga; TT 27 hoursþ home practice

West, 2014, USA, MBSR RCT; attention CG; Internal medicine physician; outpt clinic; N ¼ 74

biwkly sessions; duration 9 mo.; FU at 12 mo.; mindfulness, reflection, & shared experience or 1 hour of protected time; TT 19 hours

Well-being focused interventions Dyrbye, 2016, USA, Promote

satisfaction & well-being RCT; attention CG; Physicians at Mayo Clinic;

N ¼ 290 10 e-mails; duration 10 wks; FU at 3 mo.; wkly

microtasks to promote professional satisfaction & well-being; TT: not specified

Ketelaar, 2014, Netherlands, Mental Vitality @ Work eMental Health vs OP

3 group Cluster RCT; wait-list CG; nurses & allied health professionals (physiotherapists & radiotherapists) in one academic hospital; N ¼ 557

variable sessions; duration not specified; FU at 6 mo.; eMental health interventions or in-person occupational physician consultation; TT: not specified

Stress Reduction & Resilence Interventions Cheng, 2015, Hong Kong,

Gratitude journally 3-group RCT; No attention CG; Physicians, nurses,

physiotherapists, & occupational therapists in 5 public hospitals; N ¼ 102

8 sessions; duration 4 wks; FU at 3 mo; write about gratitude experiences or feeling annoyed/angry; TT: not reported, journals done in evening

Chesak, 2015, USA, SMART Stress reduction & enhance resiliency

RCT; attention CG; new nurses; academic medical center; N ¼ 55

2 sessions; duration 4 wks; FU at 12 wks; enhance resiliency; brief Stress Management & Resiliency Training (SMART) program; Control: lecture r/t stress, reality shock & work-life connectedness; TT: 2.5 hours

Fang, 2015, China, Yoga RCT; no attention CG; Nurses; hospital, N ¼ 120 > 2X/week for 50-60 minutes after work hours; Duration 6 mo.; yoga. TT: varied

Hersch, 2016, USA, Stress Management

RCT; wait-list CG; Nurses, advance practice nurses, clinical nurse managers; hospital; N ¼ 104

7 modules (nurses) þ 1 nurse managers. Access for 3 mo.; stress management; TT: ave. logged on 1-3X for ave. of 43 minutes

Linzer, 2015, USA, Healthy Work Place Study Improve work environment

Cluster RCT; no attention CG; Primary care clinicians (physicians, nurse practitioners, & physician assistant); health-care clinics; N ¼ 166

1 facilitated session by research staff to help customize a list of ways to address work conditions; duration 12-18 mo.; FU at postintervention. TT: not specified

Luthar, 2017, USA, Authentic Connections Groups; benefit of relational group program

RCT; attention CG; physicians, PhD’s in clinical pratice, nurse practitioners & physician assistant who are also mothers; outpatient clinic; N ¼ 40

12 wkly session; duration 12 wks; wkly sessions regarding respect, empathy & empowerment or 1 hour of wkly protected time; TT: 12 hours

(continued)

Melnyk et al. 933

intervention duration 40 weeks (*80 hours).16 The emphasis

of the intervention was soccer or Zumba for exercise with the

Zumba group having the significant effect. Three studies

assessed a measure of fat.16,30,40 None identified a significant

between-group difference. Three studies assessed a measure of

physical activity of which none had a significant between-

group difference.19,28,40 Blood pressure was measured in 2

studies with none identifying a significant between-group

difference.16,19

Risk of Bias

All 29 studies were assessed using the Cochrane Bias Tool (see

Table 3). Two studies scored low risk of bias for all 7

domains.24,35 The 2 binding domains were predominantly

unclear or high risk of bias. The domain primarily judged as

low risk was selective outcome reporting. Two domains had 5

studies judged as high risk for bias and included incomplete

outcomes data and other sources of bias. Reporting of the

randomization method was fairly high with 20 studies being

judged as low risk. Six additional items of interest were

extracted. Sixteen (55%) studies reported baseline comparabil-

ity on key factors. Fifteen (52%) studies described drop-outs or

withdrawals. Twenty-three (79%) studies had more than 80% of participants with measures at postintervention. Fourteen

(48%) studies reported using intention to treat analysis. Only

2 (7%) studies reported fidelity assessment of the interventions.

Eighteen (62%) studies indicated dose received by participants.

Effect Sizes and Mini Meta-Analysis

Effect sizes were calculated for 16 outcome variables (see

Table 4). Effect sizes for stress were small, medium, and large

almost equally divided. Mindfulness effect sizes were medium

to large. Two effect sizes for mood were large with one being

less than small. Effect sizes for anxiety ranged between less

than small to large. Effect sizes for depression were less than

small to small. Resilience effect sizes were medium to large

Table 1. (continued)

Author, Year, Country, Name and Focus Design and Control Group; Sample, Setting, N Intervention Details

Sood, 2011, USA, SMART stress reduction & enhance resiliency

RCT; wait-list CG; General internal medicine physicians; N ¼ 40

2 sessions (1 optional); FU at 8 wks; enhance resiliency; brief Stress Management & Resiliency Training (SMART) program; TT: 1.5 hours þ optional .5 to 1 hour

Sood, 2014, USA, SMART stress reduction & enhance resiliency

RCT; wait-list CG; Physicians or scientists in radiology; Department of Radiology; N ¼ 26

2 sessions (1 optional) þ 2 phone calls; FU at 12 wks; enhance resiliency; brief Stress Management & Resiliency Training (SMART) program; TT: 1.5 hours þ optional .5 to 1 hour & 2 calls

Lifestyle Behavior Barene, 2014, Norway, PA

Soccer or Zumba 3 group RCT; no attention CG; Nurses, nurse

assistants, & other professions; hospital; N ¼ 118 2-3/wk in first 12 wks, 2/wk in wks 12 to 40; duration

40 wks; soccer or zumba; TT 80-92 hours Doran, 2018, USA, WHHIP CV

risk reduction Cluster RCT; attention CG; Long-term care staff; N ¼ 98

I: Multimodal intervention; C: 30 min educational session; duration 9 mo.; FU at 18 mo.; CV health; TT: not specified

Jakobsen, 2017, Denmark, PA Cluster RCT; attention CG; Female health-care workers hospital; N ¼ 200

5�/week; duration 10 wks; exercise at work or at home; TT: 12-15 hours

Leedo, 2017, Denmark, Meals at work

RCT; Cross-over design; Physicians, nurses, nursing assistants; hospital; N ¼ 60

4 wks of cold meal, water, & snack on all workday shifts. Duration 4 wks; TT: not specified

Low, 2015, USA, CV risk reduction

RCT; attention CG; Female employees at hospital; N ¼ 62

I: wkly contact (phone or e-mail); C: variable & optional; duration 6 mo.; FU at 1 year; I: goal setting & overcoming obatacles; all received CV risk reduction type classes; TT: not specified

Matsugaki, 2017, Japan, Work vs home PA

RCT; attention CG; nurses; recruited nurses organization; N ¼ 30

24 sessions; duration 12 wks; FU at postintervention; Home versus supervised by PT exercise; TT: 16 hours

Tucker, 2016, USA, NEAT PA RCT; cross-over design; Nurses & medical assistants; ambulatory nursing clinic; N ¼ 42

"activity by 1 hour each day. Duration 6 mo.; All received environmental NEATþ intervention; I: text messages daily mo 1-3; C: text messages daily mo. 4 to 6; TT: not specified

Abbreviations: CBT, cognitive behavioral therapy; CG, control group; CV, cardiovascular; FU, follow-up; MBCT, mindfulness-based cognitive therapy; ICU, intensive care unit; MBSR, mindfulness-based stress reduction; mo, months; MBRT, mindfulness-based resilience training; OP, occupational physician; PA, physical activity; SMART, Stress Management & Resiliency Training; RCT, randomized controlled trial; TT, total time of intervention; WHHIP, Worksite Heart Health Improvement Project; NEAT, non-exercise activity thermogenesis.

934 American Journal of Health Promotion 34(8)

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936 American Journal of Health Promotion 34(8)

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with one being small in favor of the control group. The WHO 5

Well-Being Index and the Work Ability scales had an effect

size of less than small to small. Distress and the work engage-

ment scales had small effects. Quality of life effect sizes was

less than small and medium. Measures of sleep and fatigue had

effect size of less than small, small, and large. The effect size

for a measure of fat was large. The effect size for physical

activity was medium and large. The effect size for a measure

of mass was less than small for 2 studies and large for 1 study.

The mean effect size for variables ranged from �0.87 to 0.85.

Significant Z-scores for the mini-meta analysis were found for

stress, mindfulness, mood, anxiety, resilience, Who-5 Well-

Being Index, sleep, and fatigue.

Conclusions

There have been several published systematic reviews that

focus on 1 specific dimension of wellness for physicians and/

or nurses. This review is different and extends the science in

that it focused on a wide array of interventions so that findings

could reveal which types of interventions are the most effective

in improving mental health, well-being, lifestyle behaviors,

and/or physical health of physicians and nurses.

Studies in this review evaluated a variety of different types of

interventions for decreasing stress, increasing mindfulness and

resilience, and improving mood, anxiety, sleep, and fatigue.

Many of the studies that incorporated mindfulness techniques

had significant positive effects on stress, anxiety, and/or depres-

sion and were typically comprised of interventions that included

8 weekly 1- to 2.5-hour sessions led by a mindfulness-trained

instructor followed by at least 9 hours of practice at home.

Although effective, mindfulness-based interventions are usually

time-intensive and require clinicians to attend lengthy sessions

followed by several hours of practice that may be difficult to

arrange with their schedules. Many hospitals also do not have

qualified mindfulness trainers to deliver these interventions.

Three studies included CBT principles or therapy and had

positive effects on mindfulness, sleep, fatigue, depression, and

work engagement.25,31,35 A recent RCT of an 8-session man-

ualized CBT-based intervention entitled MINDSTRONG©

delivered by a nurse to new nurse residents also demonstrated

decreases in depression, anxiety, and stress as well as improve-

ments in job satisfaction up to 6 months following the

intervention.43,44

Three studies that used a program called Stress Management

and Resiliency Training, comprised of a brief 90-minute session

that focused on attention and interpretation therapy that aimed to

decrease stress and increase resiliency along with the use of deep

breathing techniques, was found to lessen physician anxiety.37,38

A focus on helping clinicians to use gratitude practice also was

effective on stress and depression.17 Only 1 study measuring

physical parameters, such as BMI, fat, or blood pressure, found

a significant difference highlighting the difficulty in changing

healthy lifestyle behaviors to a significant degree.16

Strengths and Limitations

Strengths of this body of studies include RCT designs and

several studies had 6- to 12-month follow-up. However, several

weaknesses in methodological design were apparent. Most of

the studies did not measure intervention fidelity, which is crit-

ical in determining the impact of the interventions on out-

comes. Many studies did not have attention-control groups

that controlled for time spent with the experimental groups,

which threatens their internal validity. Many studies did not

report if participants or research staff were blinded. Some stud-

ies combined a variety of interventions, which make it difficult

to determine what specifically impacted the outcomes. Addi-

tionally, the studies assessed outcomes using a variety of dif-

ferent measures, which inhibited pooling of the data across

studies. Many studies used self-report measures rather than

objective measures. The sample size in many studies also was

small and attrition was higher than desirable.

Findings from RCTs are considered high-quality evidence.

However, our rating was downgraded due to methodological

weaknesses of several studies due to inadequate attention-

control groups, lack of blinding or reporting of blinding of

participants or research staff, or lack of information regarding

handling of missing data. Therefore, the overall quality of this

body of evidence appears to be moderate when considering the

methodological weaknesses identified.45,46

There are limitations in the conduct of this review. Only

English manuscripts have been included with 4 non-English

studies identified through the literature search. Studies reported

outcomes measured with a variety of tools limiting our ability

to pool findings. Effect sizes were only calculated based on

data reported in the published manuscripts for each study.

Finally, as we wanted to include a large breadth of studies,

we limited the study publication dates to the prior 10 years.

Individual and group evidence-based interventions that

focus directly on clinicians are important to positively impact

their health and well-being outcomes. However, without build-

ing a culture of well-being in healthcare systems that makes

healthy choices, the norm or the easy choices for clinicians to

make, those behaviors are not likely to sustain.47 It is also

important to target system-based interventions that are known

to adversely affect clinician well-being (eg, short staffing, long

work hours, and alarm fatigue). Healthcare systems must

invest in the well-being of their clinicians to enhance their

outcomes and ultimately improve the quality and safety of

care. Prior studies have shown that, for every dollar invested

in employee wellness, the return on investment is $3 to $4.48

Value of investment also increases as clinicians who perceive

they practice in a healthcare system that is supportive of their

well-being tend to be in better physical and mental health, more

engaged, and have higher levels of job satisfaction.3

Findings from this systematic review indicate an urgent

need for more rigorously designed RCTs with attention-

control groups that evaluate the efficacy of interventions to

improve the health and well-being outcomes of physicians and

nurses. Studies should implement interventions that can be

938 American Journal of Health Promotion 34(8)

easily reproduced and scaled across the United States. It is

critical that fidelity and dose response of interventions be

assessed, and similar outcomes be measured so that data can

be pooled to conduct meta-analyses. Sample size should be

sufficient and long-term follow-up is important. Reliable

objective measures provide greater confidence in study

results.

Authors’ Note

This systematic review was conducted as part of the work of the NAM

Action Collaborative on Clinician Well-Being and Resilience. All

authors had access to the data and a role in writing the manuscript.

All authors contributed to the development of the selection criteria,

search strategy, risk of bias assessment strategy, and data extraction

criteria. All authors read, provided feedback, and approved the final

manuscript.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest

with respect to the research, authorship, and/or publication of this

article: Bernadette Mazurek Melnyk is the creator of the MINDBO-

DYSTRONG program referenced in this paper.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

ORCID iD

Bernadette Mazurek Melnyk https://orcid.org/0000-0002-4704-

1198

Colleen McGovern https://orcid.org/0000-0002-4616-5121

Supplemental Material

Supplemental material for this article is available online.

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What is already known on this topic?

A broad range of interventions have been tested to address physician and nurse mental health, well-being, and physical health with modest improvements.

What does this article add?

Our findings indicated that mindfulness and cognitive- behavioral therapy-based interventions are effective in reducing stress, anxiety, and depression. Brief interven- tions that incorporate deep breathing and gratitude may be beneficial. Visual triggers, pedometers, and health coaching with texting increased physical activity.

What are the implications for health promotion practice or research?

Healthcare systems need to provide wellness cultures and rapidly translate evidence-based interventions into clinical settings to improve the mental health, healthy lifestyle behaviors, and physical health outcomes of their clinicians, which should lead to improvements in the quality and safety of care. There is a need for more RCTs with rigorous methods and use of similar outcome measures.

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