576931
research-article2015
WHSXXX10.1177/2165079915576931Workplace Health & SafetyWorkplace Health & Safety
Workplace Health & Safety
ARTICLE
Occupational Stress Management and Burnout
Interventions in Nursing and Their Implications for
Healthy Work Environments
A Literature Review
Behdin Nowrouzi, PhD, OT Reg. (Ont.)1, Nancy Lightfoot, PhD1, Michael Larivière, PhD1, Lorraine Carter, PhD2, Ellen Rukholm, PhD1,
Robert Schinke, EdD1, and Diane Belanger-Gardner, RN3
Abstract: This article reports on a literature review
of workplace interventions (i.e., creating healthy work
environments and improving nurses’ quality of work life
[QWL]) aimed at managing occupational stress and burnout
for nurses. A literature search was conducted using the
keywords nursing, nurses, stress, distress, stress management,
burnout, and intervention. All the intervention studies
included in this review reported on workplace intervention
strategies, mainly individual stress management and burnout
interventions. Recommendations are provided to improve
nurses’ QWL in health care organizations through workplace
health promotion programs so that nurses can be recruited
and retained in rural and northern regions of Ontario. These
regions have unique human resources needs due to the
shortage of nurses working in primary care.
Keywords: workplace interventions, occupational stress,
nurses, quality of work life
O
ccupational stress is due to work situations that place
demands on workers; nurses’ inability to meet work
demands can lead to illness or psychological distress
(Edwards, 2003). Occupational stress is a major health problem
for both employees and organizations, and can lead to burnout,
illness, labor turnover, and absenteeism. Occupational stress can
also be a barrier to recruiting and retaining workers (Bartram,
Joiner, & Stanton, 2004).
Healthy work environments are vital to the retention and
recruitment of health care professionals and the sustainability of
health systems (Pino & Rossini, 2012). Health care organizations
must control costs and increase productivity while responding
to increasing demands from a growing aging population
(Schalk, Bijl, Halfens, Hollands, & Cummings, 2010). A clear
DOI: 10.1177/2165079915576931. From 1Laurentian University; 2Nipissing University; and 3Health Sciences North (Hospital). Address correspondence to: Behdin Nowrouzi, PhD, OT Reg. (Ont.),
Center for Research in Occupational Safety and Health, Laurentian University, 935 Ramsey Lake Road, Sudbury, Ontario, Canada P3E 2C6; email: bx_nowrouzi@laurentian.ca.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2015 The Author(s)
308
July 2015
understanding of the nursing workforce is essential prior to
developing recruitment and retention strategies.
According to the World Health Organization (2014), a
global shortage of 7.2 million health care workers exists. This
shortage is expected to increase to 12.9 million by 2035
(World Health Organization, 2014), and is especially
pronounced for the nursing profession, which is the largest
group of health care professionals in hospitals, one third of
the Canadian health care workforce; approximately 6 in 10
Canadian nurses work in hospitals (Canadian Federation of
Nurses Unions, 2013). Nurses’ work environments in Canada
have received attention due to high absenteeism and staff
shortages, augmented by dramatic cutbacks in funding and
restructuring of health care services in the 1990s (Schalk et al.,
2010). The Canadian Federation of Nurses Unions reported
that 86% of nurses found their workplaces stressful and
understaffed, 88% said they were under-resourced at work,
and 91% experienced heavy workloads (Greenslade &
Paddock, 2007).
In Canada, approximately 95% of the country’s land mass is
rural and remote (Fierlbeck, 2011). Registered nurses (RNs)
provide care to approximately 6.6 million (21.7% of
Canadians) individuals living in rural and remote areas
(Canadian Federation of Nurses Unions, 2013). However, the
nature of nurses’ clinical practice in rural, remote, and
northern regions of the country is poorly understood (Stewart
et al., 2011). RNs are often overworked (Canadian Federation
of Nurses Unions, 2013). Moreover, if the health needs of
Canadians continue to change based on current trends,
Canada will need an additional 60,000 full-time equivalent RNs
by 2022 (Canadian Nurses Association, 2012). However, little is
known about the determinants of a positive work environment
in rural and northern settings (Penz, Stewart, D’Arcy, &
Morgan, 2008).
vol. 63 ■ no. 7
Applying Research to Practice
Understanding and evaluating workplace interventions that
target the management of stress in the workplace is of
importance to nurses’ quality of work life (QWL). Moreover,
occupational stress affects not only job satisfaction, but also
satisfaction in other life domains including: leisure, family,
financial well-being, health, housing, friendships, education
attainment, community engagement, neighborhood
interactions, spiritual well-being, the environment, and
cultural and social status. Additional research is needed to
further examine the relationship between QWL and
occupational stressors, particularly in rural and northern
regions of Ontario, Canada. These may ultimately lead to the
development and implementation of QWL programs that are
tailored to meet the needs of employees and employers.
Regrettably, the constant undersupply of RNs, recruitment
challenges, and low retention rates limit northern and rural
residents’ access to health services (Dotson et al., 2011). Access to
services may even be eliminated in communities that do not have
sufficient RNs to deliver health services, or residents may have to
travel long distances to receive care (e.g., oncology services).
As the Canadian workforce ages, the overall health of nurses
may decline, challenging the profession to adequately care for
the health of the public. Today, Canadian nurses are often 30
years or older when they graduate from nursing programs and
begin their nursing careers (Canadian Institute for Health
Information, 2009). In 2009, most nurses practicing in Canada
were 40 to 59 years old; nurses in this age group constitute
57.1% of the RN workforce in Canada (Canadian Institute for
Health Information, 2009). In 2011, the average age of a
Canadian RN was 46 years (Canadian Federation of Nurses
Unions, 2013; Canadian Institute for Health Information, 2013).
To date, research has focused largely on occupational stress
(Malik, 2011; Opie et al., 2010; Schonfeld & Farrell, 2010; Wu,
Chi, Chen, Wang, & Jin, 2010), nurses’ health (Hayes, Douglas,
& Bonner, 2013; Smith, Fritschi, Reid, & Mustard, 2013), burnout
(Balevre, Cassells, & Buzaianu, 2012; Hanrahan, Aiken,
McClaine, & Hanlon, 2010; Jourdain & Chênevert, 2010),
work-related injuries (Witkoski & Dickson, 2010), and job
satisfaction (Bourbonnais, Brisson, Malenfant, & Vezina, 2005;
Eriksen, Tambs, & Knardahl, 2006; Marchand, 2007), issues
affecting the nursing shortage. It is clear that nurses continually
experience changes in their work roles and functions. A review
of nurses’ quality of work life (QWL) should evaluate
interventions to mitigate job stress, increase QWL and decrease
work absenteeism.
The aim of this review was to evaluate workplace
interventions, associated with work environments and QWL,
targeting nurses’ occupational stress and burnout. An
examination of the current literature focused on nurses’
occupational stress followed by a critical analysis of stress
Workplace Health & Safety
management interventions for nurses and their implications for
nurses’ QWL. Similarly, the authors present an overview of the
literature pertaining to nurses’ burnout, nurses’ work
environments, and prevention interventions.
Method
Databases, PUBMED and CINAHL, were searched to
examine workplace interventions, associated with work
environments and QWL, targeting occupational stress and
burnout for nurses. Primary search terms were “burnout,”
“stress,” “nurses,” “QWL,” and “nursing.” To be considered
relevant and included in the review, each study (a) evaluated an
intervention to mitigate stress or burnout, or bolster QWL; (b)
was published in English; (c) was published between 2002 and
2011; and (d) was conducted in a workplace.
Findings
Workplace Stress and Nursing
Occupational health risks, including the risk of
musculoskeletal injuries, related to nursing can stem from both
physical and mental stress. Furthermore, nurses experience
stress related to shift work and irregular hours, unremitting
exposure to disease and death, and for some, toxic chemicals
and pharmacological compounds (Clegg, 2001; Nelson, Lloyd,
Menzel, & Gross, 2003). Occupational stress involves the
interaction of work and worker characteristics as well as
personal stressors such as family responsibilities, lack of sleep,
and personal resources (e.g., conflict-resolution management,
health promotion practices) that influence nurses’ appraisal of
and coping with workplace situations (Zeller & Levin, 2013).
Concern about potential population health risks and
socioeconomic ramifications of a rural nursing shortage have
led to investigations about nurses’ intent to leave their positions
as an indicator of rural nursing workforce retention in the
United States (Dotson et al., 2011); however, similar research in
Canada is lacking except for two studies that have examined
rural northern Canadian nurses collectively rather than
investigating geographic differences (Penz et al., 2008; Stewart
et al., 2011).
In a 2011 study, researchers examined factors leading to
intent to leave a nursing position in rural remote Canada. Data
collected as part of a national cross-sectional mail survey of RNs
in rural and remote Canada showed that these nurses were
more likely to plan to leave their nursing position within the
next 12 months if they had higher self-reported occupational
stress, did not have children or relatives, had diminished job
satisfaction and less control over their work schedules, were
required to be on call and make clinical decisions, worked in
remote settings, were male, had higher levels of education, were
employed by their primary agency for a shorter time, and had
lower community satisfaction (Stewart et al., 2011). Such
findings may guide health policy and provide organizations with
strategies to augment recruitment and retention. Additional
research is warranted because studies often do not consider the
309
Workplace Health & Safety
geographic differences across rural regions and a single
definition of rurality has never been accepted.
Humphreys et al. (2009) developed a logic model for
delivering primary health care in small rural remote
communities (Daniels, VanLeit, Skipper, Sanders, & Rhyne,
2007). This model emphasized that workforce retention is
related to leadership, continuing education and professional
development, interdisciplinary teamwork, career opportunities
and advancement, effective recruitment, workforce succession
planning, and adequate infrastructure (Daniels et al., 2007).
Recruitment strategies and selection criteria are pivotal
factors in subsequent retention because the better the match
between workers and both their employing organization and
worker role, the longer workers are likely to remain,
independent of additional retention strategies (Thistlethwait
et al., 2007). Arnetz (2006) proposed a theoretical description of
the leadership–bottom line performance axis. In this model,
leadership was identified as the essential factor in organizational
health and employee well-being. Furthermore, resources,
including employee skills, motivation, and energy, were found
to be mediating variables.
Stress Management Interventions
Occupational stress is a serious threat to health care
providers’ QWL and can cause hostility, aggression,
absenteeism, and turnover and negatively affect productivity
(Mosadeghrad, Ferlie, & Rosenberg, 2011). In a 2005 study,
Shapiro and colleagues examined mindfulness-based stress
reduction (MBSR) as an intervention for health care
professionals. Thirty-eight health care professionals from the
United States participated in this randomized control study
(Shapiro, Astin, Bishop, & Cordova, 2005). Compared with
controls, the intervention (MBSR) group demonstrated a
significant mean reduction (27% vs. 7%, p = .04) in perceived
stress and an increase in self-compassion (3% vs. 22%, p =
.004; Shapiro et al., 2005). Eighty-eight percent of participants
in the MBSR group showed improvement in their stress
scores, and 90% demonstrated increases in self-compassion
(Shapiro et al., 2005). Compared with controls, intervention
participants reported greater satisfaction with life (19% vs. 0%,
p = .06), less job burnout (4% vs. 10%, p = .21), and less
distress (11% vs. 23%, p = .25; Shapiro et al., 2005). This
satisfaction with life finding demonstrated potential benefits
from a meditation-based intervention for health care
professionals (Shapiro et al., 2005). Future studies should use
a larger sample and also gather additional data at the 1- and
2-year marks to determine whether long-term benefits
occurred. Moreover, future studies should incorporate
measures of QWL and its relationship to occupational stress,
as well as how social supports outside of the workplace
influence work stress. Such undertakings should also better
elucidate the relationships between factors outside of the
workplace and their influences on workers’ job performance
and competencies.
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July 2015
Burnout Intervention Studies
Questions about type and location of employment have
prompted other researchers to examine job stress in rural and
small urban settings (Pinikahana & Happell, 2004; Tyson,
Pongruengphant, & Aggarwal, 2002). Some studies suggest that
geography may be a mitigating factor for occupational stress and
burnout (Pinikahana & Happell, 2004; Tyson et al., 2002). A
cross-sectional study of a convenience sample of RNs (n = 136)
working in two psychiatric hospitals in rural Australia revealed
that the nurses experienced less burnout on the emotional
exhaustion (EE), depersonalization (DP), and personal
accomplishment (PA) subscales of the Maslach Burnout Inventory
(Maslach, Jackson, & Leiter, 1996). Unlike nurses in urban
hospitals and independent of burnout, the majority (66.1%) of
rural psychiatric nurses stated they were satisfied with their jobs,
particularly with their current work situations, aspects of support
(e.g., support from management), and level of involvement in
decision-making on their units (Pinikahana & Happell, 2004).
These findings did not support the established relationship
between high levels of stress and job satisfaction in nurses.
Several explanations for why this relationship was not observed
in rural nursing could be hypothesized. Rural and northern
residents are unique in culture, health needs, and health behaviors
which may be both challenging and rewarding (Lightfoot, Strasser,
Maar, & Jacklin, 2008). The cross-sectional design of the study only
captured a snapshot of nurses’ views and may not accurately
reflect their work environments and occupational stress levels. In
addition, the cross-sectional, retrospective nature of the
questionnaire could not demonstrate causation. Finally, given the
cross-sectional design of the study and the non-rarity of outcomes,
multivariate inferential statistical findings may overestimate the
effect size compared with relative risk.
In another study, Psychosocial Intervention Training (PSI)
was evaluated in terms of its effect on the knowledge, attitudes,
and levels of clinical burnout in a group of forensic mental
health nurses. The researchers found that nurses in the
experimental group significantly gained knowledge and
changed attitudes about serious mental illness and significantly
decreased burnout (Ewers, Bradshaw, McGovern, & Ewers,
2002). Furthermore, 2 weeks after the intervention, scores
between the experimental and control groups showed
statistically significant differences on all three Maslach Burnout
Inventory subscales (i.e., emotional exhaustion,
depersonalization, personal achievement; Maslach et al., 1996).
This study suggests such interventions can affect nursing care
delivery, nurses’ health, and nurses’ QWL.
In another study, researchers examined the outcomes of a
psychosocial intervention for licensed and unlicensed nursing
staff working in a low-security mental health unit in the United
States (Redhead, Bradshaw, Braynion, & Doyle, 2011). Forty-two
nurses (21 nurses in each group) were randomly assigned to
experimental and control groups. Knowledge, attitudes, and
burnout were assessed before and after the intervention.
Furthermore, a random sample of 44 care plans written by the
vol. 63 ■ no. 7
Table 1. Summary of Study Findings
Study title
Workplace stress and
nursing: Stewart et al.
(2011)
Stress management
interventions: Shapiro,
Astin, Bishop, and Cordova
(2005)
Burnout and nursing: Ewers,
Bradshaw, McGovern, and
Ewers (2002)
Psychosocial intervention
training: Redhead,
Bradshaw, Braynion, and
Doyle (2011)
Note. RN = registered nurses; ITL = intent to leave; MBSR = mindfulness-based stress reduction; PSI = Psychosocial Intervention Training.
Methods
A national cross-sectional
mail survey of RNs in rural
and remote Canada
(n = 3,051) for the logistic
regression analysis of
predictors of ITL
Prospective randomized
controlled trial that
implemented a 2
(experimental [n = 18] vs.
wait-list control group
[n = 20]) × 2 (baseline,
post-treatment) study
design
Baseline assessments of
knowledge, attitude, and
burnout were compiled
for 33 nurses. A quasi-
experimental pretest–
posttest design was used
with participants (n =
20) randomly assigned
to either a waiting list
control condition or to the
psychosocial intervention
group.
Forty-two staff (21 qualified)
were randomly assigned
to an experimental training
group or a waiting list
control group. Pre–post
scores for knowledge,
attitudes, and burnout
were assessed. Moreover,
a random sample of 44
care plans written by
qualified nurses was
audited before and after
to examine evidence of
implementation of PSI in
practice.
Workplace Health & Safety
Results
RNs were more likely to
plan to leave their nursing
position within the next 12
months if they were male,
reported higher perceived
stress.
An 8-week MBSR
intervention may be
effective for reducing
stress and increasing
quality of life and self-
compassion in nurses.
Staff in the experimental
group showed significant
improvements in their
knowledge and attitudes
about serious mental
illness and a significant
decrease in burnout rates.
Qualified and unqualified
nurses in the experimental
group showed significant
improvements in
knowledge and attitudes
compared with the control
group. Care plans showed
a significant increase in
the implementation of
psychosocial interventions.
Conclusions
The importance of
community makes this
framework uniquely
relevant to the rural health
context. These findings
should guide policy
makers and employers
in developing retention
strategies.
MBSR offers a well-
established model for
providing a brief, cost-
effective program that can
be implemented easily in
hospitals and health care
settings.
The findings indicate that
providing nurses with a
better understanding of
serious mental illness and
training them in a broader
range of interventions
result in more positive
attitudes toward their
clients. In addition, nurses
experience less negative
effects of stress resulting
from their caring role.
Psychosocial intervention
training may result
in improvements in
knowledge, attitudes, and
practices of qualified and
unqualified nurses working
with patients. However,
the intervention did not
protect against burnout.
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Workplace Health & Safety
nurses was audited before and after the intervention to examine
the effect of the intervention on psychosocial intention in
clinical practice. The results demonstrated that licensed and
unlicensed nurses in the experimental group showed significant
gains in knowledge and changes in attitudes compared with
nurses in the control group. Similarly, care plans showed a
significant increase in the implementation of psychosocial
interventions. The only significant change in burnout was a
reduction in depersonalization for licensed nurses in the
experimental group. Table 1 summarizes all the study findings.
Discussion
The studies included in this review were all based in
workplaces and focused mainly on individual strategies.
Occupational stress research often lacks a comprehensive
theoretical framework and standardized measurement tools
(Webster, Beehr, & Love, 2011), which focus simultaneously on
individual and organizational factors (Carson & Kuipers, 1998;
Pino & Rossini, 2012).
Management style, incentives and career structures, educational
opportunities, salary scales, and recruitment and retention
practices were some of the organizational factors that can
influence the geographic distribution of health resources (Dussault
& Franceschini, 2006; Golubic, Milosevic, Knezevic, &
Mustajbegovic, 2009; Simon, Müller, & Hasselhorn, 2010). Any
retention strategy should be linked to health service providers’
structures and functions to take advantage of existing partnerships
and increase efficiencies. For example, health policy should be
directed at upgrading rural health facilities and improving the
work environment as part of a national health facility expansion
plan (McLean, 2013). This approach provides funding to support
the infrastructure that rural northern practitioners require to
provide quality clinical care. Conversely, a plan to expand
publically or privately funded health services in urban areas may
work against new strategies for attracting health care providers to
rural areas. Recruitment and retention of nurses may be more
successful when hospital administration has an understanding of
the perceptions of nurses in northern rural regions.
Recommendations
In Western countries, it is clear that occupational stress can
have serious health implications for nurses (Kroenke et al.,
2007; Mitchell et al., 2009; Simon et al., 2008). By industry, stress
levels are highest in education, health care, and social services
sectors (Jackson, 2009). Women are more likely than men to
report high stress levels (Jackson, 2009), and because nursing is
a female-dominated profession, this finding is of concern.
Therefore, properly planned intervention programs that include
aspects of both person-directed and organization-directed
prevention measures are expected to prevent burnout and
improve workers’ mental health. Positive effects can be
extended by refresher courses at appropriate intervals after the
end of the initial program (Awa, Plaumann, & Walter, 2010).
312
July 2015
Future studies should use better designed and evaluated
randomized controlled trials, with comparable participants,
appropriate baseline data, and at least two post-intervention
measurements points (Awa et al., 2010). Many of the studies
analyzed in this review had small samples, low retention rates,
and short intervention and monitoring durations. Furthermore,
they often focused on nurses in larger urban centers and in one
nursing specialty. It would be beneficial to examine intervention
strategies across nursing specialties and in both urban and rural
practice settings.
The authors hope this review fosters future studies
that incorporate random assignment to treatment and
control groups and report the results of all outcomes.
Furthermore, statistically significant findings should be
translated into nursing practice. In addition, the continued
use of meta-analytic techniques to synthesize research
findings should be pursued. As more primary studies are
conducted, systematic reviews should be updated to reassess
results.
Two issues are vital with respect to evaluating stress
management and burnout interventions. First, common
measurement approaches would permit investigators to
compare studies nationally and internationally. Second,
interventions should be more rigorously evaluated.
Effective health policy should incorporate health, cultural
and social contexts of occupational stress, and its
relationship to QWL. National recognition and support of
factors related to job satisfaction and quality work
environments may retain nurses working in both rural and
urban settings. In particular, identifying occupational barriers
that nurses working in rural and remote regions experience
is essential. Given the limited number of employment
opportunities in these regions, employers and employees
must work together to create a positive workplace that
fosters career advancement, supports job satisfaction, and
increases nurses’ QWL. In terms of policy implications, the
recruitment and retention of nurses to northern and rural
areas is a serious undertaking for decision makers and
planners. Building positive work environments is a crucial
component of retaining health care professionals in the
north and recruiting those from other regions to move to
rural areas for lifestyle and career opportunities.
Policy and practice changes, such as strategies to increase the
recruitment and retention of nurses, and organizational initiatives
to reduce stress due to staffing and workload issues are needed
to improve the quality of services that nurses provide. Canada
has many rural remote areas in which nurses are the only
professional health care providers. From an occupational health
and safety perspective, it is crucial that administrators and health
policy makers understand the realities of northern rural nursing
practice and the quality of work environments for RNs. National
recognition and support of factors related to job satisfaction, and
safe quality work environments may retain those RNs working in
northern rural communities.
vol. 63 ■ no. 7
Conclusion
The objective of this literature review was to evaluate
workplace interventions associated with healthy work
environments and QWL, targeting the management of
occupational stress and burnout for nurses. Beyond a
geographic lens, studies are needed to develop interventions
that respond to social and political changes, new health
policies, and economic factors, such as unemployment. The
viability of the nursing workforce depends on addressing
human resources issues associated with workplace stress and
job satisfaction (Stewart et al., 2011). The literature
demonstrates that the challenges of rural northern practice,
which initially attracts nurses, become a source of
occupational stress, job dissatisfaction, lower work ability
scores, and absenteeism (Nowrouzi et al., 2014). From a
recruitment and retention perspective, it is crucial that
administrators and health policy makers foster environments
that appreciate the realities of northern and rural nursing
practice and uniquely affect the quality of work environments
for nurses.
Conflict of Interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Behdin Nowrouzi is a postdoctoral fellow and occupational
therapist in the Centre for Research in Occupational Safety and
Health, Laurentian University, Sudbury, Ontario, Canada.
Nancy Lightfoot is an epidemiologist in the School of Rural and
Northern Health and in the Centre for Research in Occupational
Safety and Health, Laurentian University, Sudbury, Ontario,
Canada.
Michael Larivière is a clinical psychologist, associate professor in
the School of Human Kinetics and in the Centre for Research in
Occupational Safety and Health, Laurentian University,
Sudbury, Ontario, Canada.
vol. 63 ■ no. 7 Workplace Health & Safety

Lorraine Carter is an associate professor in the School of Nursing Robert Schinke is a professor in the School of Human Kinetics,
at Nipissing University, North Bay, Ontario, Canada. Laurentian University, Sudbury, Ontario, Canada.

Ellen Rukholm is a senior research fellow at the Centre for Diane Belanger-Gardner is the former (retired) administrative
Research in Rural and Northern Health, Laurentian University, director of the Family and Child Program at Health Sciences
Sudbury, Ontario, Canada. North, Sudbury, Ontario, Canada.

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